Novel Therapeutic Approaches to Elevate HDL-C and Modulate HDL Functionality

Daniel J. Rader, MD Perelman School of Medicine University of Pennsylvania Philadelphia, PA Novel HDL Therapeutics

• Elevate plasma HDL-C • Enhance cholesterol efflux and reverse cholesterol transport Novel HDL Therapeutics

• Elevate plasma HDL-C – CETP inhibition CETP as a Therapeutic Target Cholesteryl Ester Transfer Protein

CETP is a 74 kDa plasma protein that circulates in plasma mainly associated with HDL It is a member of the LPS-binding and lipid transport protein family It is expressed mainly in liver and adipose tissue CETP exchanges neutral lipids (cholesteryl esters and triglycerides) among lipoprotein particles CETP has a net effect of transferring CE out of HDL in exchange for TG

Hayek T, et al. JCI 1995;96:20714. Okamoto H, et al. Nature 2000;406:2037. Jiang XC, et al. JBC 1993;268:2740612. Mechanism of action of CETP

Two hypotheses have been proposed for the mechanism by which CETP transfers neutral lipids between plasma lipoproteins.

(i) a shuttle mechanism that involves CETP collecting cholesteryl esters from one lipoprotein and delivering them through the aqueous phase to another lipoprotein.

(ii) a tunnel mechanism in which CETP bridges two lipoproteins to form a ternary complex, with lipids flowing from the donor to acceptor lipoprotein through the CETP molecule

Barter et al; Biochem J. 1982; 208:1. Ihm et al. J. Lipid Res.1982;23:1328. Swenson et al. J. Biol. Chem. 1988; 263:5150. Tall. J. Lipid Res.1993;34:1255. Zhang et al. Nature Chem Biol. 2012; 8:342. Shuttle Mechanism

HDL TRL CETP CETP

CE CE CE CE TG TG TG TG

CE TG CETP

CE TG CETP

CE TG LDL

Barter et al; Biochem J. 1982; 208:1. Swenson et al. J. Biol. Chem. 1988; 263:5150. Tall. J. Lipid Res.1993; 34:1255. Tunnel Mechanism

HDL CE CETP HDL CE CE

VLDL/LDL Tunnel Binary CE complex CE CE Ternary VLDL/LDL complex

CE

Ihm et al. J. Lipid Res.1982; 23, 1328. Zhang et al. Nature Chem Biol. 2012; 8:342. Role of CETP in the Remodelling of HDL TGR-LP HDL

TG CE CETP TG CE CE

Lipid-free/poor apoA-I Excretion through kidney HDL

CETG TG CE TG FFA CECE Small, dense HDL HL

Rye et al Atherosclerosis, 1999,145:227. Rye et al Arterioscler Thromb Vasc Biol, 2004, 24: 421. Evidence that Activity of CETP Impacts on Plasma Lipoprotein Concentrations The first genetic deficiency of CETP was identified in Japan in 1989 in patients with markedly elevated HDL-C 57% of Japanese subjects with levels of HDL-C > 100 mg/dL have mutations of the CETP gene 37% of Japanese subjects with levels of HDL-C between 75- 100 mg/dL have mutations of the CETP gene CETP mutations have also been identified outside Japan in association with elevated HDL Common variants at the CETP locus are strongly associated with variation in HDL-C levels

Brown ML, Inazu A, Hesler CB, et al. Nature. Nov 23 1989;342(6248):448-451. Maruyama T, Sakai N, Ishigami M, et al. Atherosclerosis. Jan 2003;166(1):177-185. Nagano M, Yamashita S, Hirano K, et al. J Lipid Res. Jul 2002;43(7):1011-1018. Ritsch A, et al. Arterioscler Thromb Vasc Biol. Dec 1997;17(12):3433-3441. Teh EM, Dolphin PJ, Breckenridge WC, Tan MH. J Lipid Res. Feb 1998;39(2):442-456. Relationship of CETP and Atherosclerosis CETP and Atherosclerosis Human epidemiology

Honolulu Heart Study 7-year prospective data There was no statistically significant relation between heterozygous mutations of CETP and CHD or stroke However, it was concluded that a deficiency of CETP is athero-protective, so long as it is accompanied by an HDL-C level > 60 mg/dL

Moriyama et al. Prev Med. 1998;27:659–667. CETP Polymorphisms and Cardiovascular Risk in Humans • A meta-analysis has been conducted of studies investigating relationships between CETP polymorphisms and cardiovascular disease in humans

• 46 studies had data on 27,196 coronary cases and 55,338 controls.

• Those polymorphisms that were associated with lower CETP mass and lower CETP activity had higher levels of HDL-C and a significantly reduced coronary risk.

Thompson et al JAMA2008;299:2777-2788. CETP Genotypes and CHD in Humans

A prospective cohort of 18,245 initially healthy American women

Polymorphisms near or in the CETP gene were associated with both HDL cholesterol concentration and risk of myocardial infarction

It was concluded that decreased CETP activity is associated with an increased level of HDL-C and a decreased risk of myocardial infarction.

Ridker et al. Circ Cardiovasc Genet 2009; 2: 26. CETP and Atherosclerosis in Rodents

Rodents naturally deficient in CETP

Rodents naturally resistant to development of atherosclerosis

Expression of CETP in transgenic mice and rats increases atherosclerosis in most (but not all) models

Marotti et al. Nature.1993;364:73. Plump et al. ATVB.1999;19:1105. CETP and Atherosclerosis in Rabbits

Rabbits have high level of activity of CETP

Rabbits naturally highly susceptible to the development of atherosclerosis

Inhibition of CETP in rabbits decreases atherosclerosis in all models, including genetic manipulation to inhibit CETP, use of an anti- CETP vaccine or by administration of small molecule CETP inhibitors (including dalcetrapib and torcetrapib)

Sugano et al. J Biol Chem.1998;273:5033. Rittershaus et al. ATVB. 2000;20:2106. Okamoto et al. Nature. 2000;406:203. Morehouse et al. J Lipid Res. 2007;48:1263. CETP inhibition in Humans Effect of CETP Inhibition on Plasma Cholesterol Transport Liver LDL-R CE CE SR-B1 SR-B1 VLDL/LDL FC CETP

CE Extrahepatic Tissues LCAT (including the artery wall HDL FC Free Cholesterol Bile CETP Inhibitors

Torcetrapib Anacetrapib Dalcetrapib Evacetrapib

O F O O O N S F3C O O N H N O N O

O CF3

F3C CF3 F3C

Cao et al. J Lipid Res 2011; 52:2169. Lipid efficacy of CETP inhibitors (% change from baseline)

CETP Dose HDL-C LDL-C TG inhibitor mg/d % % % Torcetrapib 60 61 -24 -9

Adapted from Cannon C, JAMA 306:2154; 2011 Torcetrapib

Torcetrapib was an effective CETP inhibitor that was shown in humans to increase the concentration of HDL-C by more than 60% while reducing the concentration of LDL-C by more than 20% over and above the changes achieved by using high doses of statins.

Torcetrapib was the first CETP inhibitor to be tested in human imaging trials and in a large cardiovascular clinical end point trial

Barter et al, NEJM 2007;357:2109. Coronary IVUS Trial - ILLUSTRATE

• 910 patients with angiographic coronary artery disease treated with torcetrapib 60 mg or placebo in addition to background atorvastatin for 24 months • Change in coronary atheroma burden was determined in matched arterial segments by intravascular ultrasound • Relationship between changes in biochemical parameters and plaque burden with treatment was determined

Nissen et al. NEJM. 2007;356:1304. Nicholls et al. Circulation 2008;118:2506. ILLUSTRATE: Primary Efficacy Parameter Change in Percent Atheroma Volume 0.35 † 0.3 p = 0.72

0.25 Change 0.19 in percent 0.2 atheroma 0.15 volume 0.12 0.1

0.05

0 Atorvastatin Torcetrapib- monotherapy atorvastatin

Nissen et al. NEJM. 2007;356:1304. ILLUSTRATE: Secondary Efficacy Parameters

Change in Normalized Change in 10 mm Most Atheroma Volume (mm3) Diseased Segment (mm3)

Nissen et al. NEJM. 2007;356:1304. Atheroma Regression at Highest HDL-C Levels with Torcetrapib in the ILLUSTRATE trial 0.75

0.50 P=0.004 for trend

0.25

0.00

-0.25 Atheroma Volume -0.50 LS Mean Change Percent

-0.75 Q1 Q2 Q3 Q4 (<56) (56-69) (69.5-86) (>86) Quartiles of Achieved HDL Cholesterol (mg/dL)

Nicholls et al. Circulation 2008; 118:2506. ILLUSTRATE Conclusions

• Torcetrapib 60 mg in combination with atorvastatin increased HDL-C by 61% and lowered LDL-C by 20%, compared with atorvastatin monotherapy.

• However, torcetrapib also increased systolic blood pressure by an average of 4.6 mmHg.

• Torcetrapib-atorvastatin did not reduce the progression of coronary atherosclerosis for the primary efficacy parameter, compared with atorvastatin alone.

• More regression was observed with greater torcetrapib- induced elevations of HDL-C Carotid IMT trials: RADIANCE 1 and 2

B-mode ultrasound every 6 months S C R Torcetrapib/atorvastatin E Atorvastatin only run-in E Target: LDL-C to goal N Atorvastatin I Dose titration (mg): 10 20 40 80 N G 24-month double-blind treatment

Study Name Clinical Sites Subject Population N RADIANCE 8 countries HeFH; eligible for statin treatment 904 1 (US, CAN, FRA, RADIANCE ITA, NL, FIN, CZ, Mixed hyperlipidemia; eligible for 752 2 S.AFR) statin treatment

Kastelein et al. NEJM, 2007; 356:16; Bots et al. Lancet. 2007; 370:153. RADIANCE 1 Lipids

HDL-C (mg/dL) LDL-C (mg/dL)

80 140

70 T/A T/A A 130 60 A 120 50 40 110 024487296 024487296

Weeks of treatment Weeks of treatment

T/A: torcetrapib plus atorvastatin A: atorvastatin alone

Kastelein et al. NEJM, 2007; 356:16. RADIANCE 1 Imaging primary Endpoint Maximum Carotid Intima-Media Thickness (mm)

Average Over 12 Carotid Segments Combined 2 T/A A 1.5 1.152 1.150 1.149 1.162 1.163 1 1.133 1.134 1.126 1.132 1.148

0.5 Max Carotid IMT (mm) Max Carotid IMT Means +/- SD 0 0 6 12 18 24

Months of Treatment

Kastelein et al. NEJM, 2007; 356:16. RADIANCE 1 Systolic Blood Pressure (mmHg)

130

125 121.7

120 116.0 119.0 115 116.6 T/A 110

Systolic BP (mmHg) Systolic BP A 105

100 0 1 3 6 9 12 15 18 21 24 Months of treatment

Kastelein et al. NEJM, 2007; 356:16. RADIANCE 1 Conclusions

• In heterozygous FH, T/A, when compared to A alone – Did not result in regression of atherosclerosis as assessed by a combined measure of carotid arterial wall thickness – Caused progression of disease in the common carotid segment • These effects occurred despite a 52% increase in HDL-C and a 21% decrease in LDL-C

Kastelein et al. NEJM, 2007; 356:16 . RADIANCE 2 Lipids

HDL-C (mg/dL) LDL-C (mg/dL)

80 110

70 100 T/A T/A A A 60 90

50 80

40 70 0 1 6 12 18 24 0 1 6 12 18 24 Months of treatment Months of treatment

T/A: torcetrapib plus atorvastatin A: atorvastatin alone

Bots et al. Lancet. 2007; 370:153. RADIANCE 2 Imaging Primary Endpoint Maximum Carotid Intima-Media Thickness (mm) Average Over 12 Carotid Segments Combined T/A 1.80 A 1.60

1.3319 1.3469 1.3680 1.40 1.3002 1.3079 1.3592 1.3634 1.20 1.3150 1.3260 1.3210

1.00 Max Carotid IMT (mm) Max Carotid IMT 0.80 Means +/- SD 0.60 0 6 12 18 24

Months of Treatment

Bots et al. Lancet. 2007; 370:153. RADIANCE 2 Systolic Blood Pressure

130 128.7 127.7 127.3 126.8 126.9 126.2 126.7 125.5

125 123.7

121.2 122.9 122.1 122.2 121.2 121.3 120 120.8 120.8 120.8

Systolic BP (mmHg) Systolic BP 119.6 119.5 T/A A 115 0 1 3 6 9 12 15 18 21 24 Months of Treatment

Bots et al. Lancet. 2007; 370:153. RADIANCE 2 Conclusions

• In mixed dyslipidemia, torcetrapib plus atorvastatin, when compared to atorvastatin alone did not result in regression of atherosclerosis as measured by carotid arterial wall thickness • These effects occurred despite a 63% increase in HDL-C and an 18% decrease in LDL-C

Bots et al. Lancet. 2007; 370:153. ILLUMINATE: Investigation of Lipid Level Management to Understand its Impact in Atherosclerotic Events

Torcetrapib 60 mg + titrated atorvastatin dose 15 067 patients . Men and women . Aged 45-75 years Titrated atorvastatin dose . 250 sites in 7 countries . CHD or risk equivalent, any HDL-C level, statin eligible Planned 4.5-year follow-up or 1820 Primary End Point events whichever is . Composite of fatal CHD, nonfatal MI, stroke (fatal and non-fatal and unstable later angina requiring hospitalization

Barter et al, NEJM 2007;357:2109. On Trial Lipid Levels By Study Month Atorvastatin only Group (Post Run-In)

140 128 127 128 130 129 TG 120

100 79.9 79.3 80.5 80.5 80.7 LDL-C 80 48.9 49.2 48.9 Lipids (mg/dL) 60 48.5 48.2 HDL-C 40

20 0 Baseline 1 3 6 12 Study Month

Barter et al, NEJM 2007;357:2109. ILLUMINATE: On Trial Lipid Levels Torcetrapib/ Atorvastatin Group (Post Run-In)

140 127 115 120 112 112 112 TG -9% (-27,+13)* 100 82.9 79.7 77.5 80.9 HDL-C 80 71.8 +72.1% (34.7) †

Lipids (mg/dL) 60 48.6 LDL-C 59.7 59.3 58.2 58.3 -24.9% (28.5) † 40

20

0 Baseline 1 3612 Study Month

Barter et al, NEJM 2007;357:2109. ILLUMINATE: Primary Endpoint: Time to First MCVE*: Kaplan-Meier Plot

*Major cardiovascular event: CHD death, non-fatal MI, stroke or hospitalization for unstable angina

Barter et al, NEJM 2007;357:2109. ILLUMINATE: Secondary Endpoint Time to Death: Kaplan-Meier Plot

Barter et al, NEJM 2007;357:2109. Causes of Death

Atorvastatin Torcetrapib/ (n=59 ) Atorvastatin (n=93) Any cardiovascular death 35 49 Sudden cardiac death 25 26 Fatal MI - not procedure related 6 8 Fatal stroke 0 6 Other cardiac death 1 4 Fatal heart failure 1 2 Other vascular death/procedure related MI 2 3 Any non-cardiovascular 20 40 Cancer 14 24 Infection 0 9 Other non-cardiovascular 2 4 Trauma/suicide/homicide 4 3 Reason unknown 4 4

Barter et al, NEJM 2007;357:2109. What was the Reason for the Adverse Outcome with Torcetrapib in the ILLUMINATE Trial? Possible explanations • Inhibiting CETP is pro-atherogenic

• Inhibiting CETP generates dysfunctional HDL

• Torcetrapib had an adverse off-target pharmacology unrelated to CETP What was the Reason for the Adverse Outcome with Torcetrapib in the ILLUMINATE Trial? Possible explanations

• Inhibiting CETP is pro-atherogenic

• Inhibiting CETP generates dysfunctional HDL

• Torcetrapib had an adverse off-target pharmacology unrelated to CETP Off-target Pharmacological Effects of Torcetrapib

In patients receiving torcetrapib in the ILLUSTRATE, RADIANCE 1 & 2 and ILLUMINATE studies there was a significant:

• Increase in blood pressure • Decrease in serum potassium • Increase in serum bicarbonate • Increase in serum sodium • Increase in serum aldosterone

Barter et al, NEJM 2007;357:2109. Nissen et al. NEJM. 2007;356:1304. Kastelein et al. NEJM, 2007; 356:16. Bots et al. Lancet. 2007; 370:153. ILLUMINATE: On-Trial Blood Pressure By Study Month Torcetrapib plus Atorvastatin Group Atorvastatin Group

140 128.2* 123.0 123.9 122.9 120

100 73.9 73.7 75.7* 80 73.7

60 Blood Pressure (mmHg) Blood Pressure 40 0136912 0136912 Study Month * p<0.001 vs atorvastatin at month 12

Barter et al, NEJM 2007;357:2109. Off-target Pharmacological Effects of Torcetrapib Unrelated to CETP Inhibition

Torcetrapib increases blood pressure in rats, a species that does not have CETP.

Analogues of torcetrapib that do not inhibit CETP raise blood pressure to an extent similar to that observed with torcetrapib

Other CETP inhibitors such as dalcetrapib, anacetrapib and evacetrapib do not raise blood pressure

Forrest et al. Br J Pharmacol. 2008;154:1465. Hu et al. Endocrinology 2009;150:2211. Nicholls et al. JAMA. 2011; 306:2099. Off-target Pharmacological Effects of Torcetrapib Unrelated to CETP Inhibition Torcetrapib induces synthesis and secretion of both aldosterone and cortisol from human adrenal cells in tissue culture.

Torcetrapib reduces expression of endothelial nitric oxide synthase mRNA and protein, reduces nitric oxide release, increases expression of endothelin-1 and induces endothelial dysfunction animals independent of CETP inhibition

Other CETP inhibitors such as dalcetrapib and anacetrapib do not have these off-target effects

Forrest et al. Br J Pharmacol. 2008;154:1465-1473. Hu et al. Endocrinology 2009;150:2211-2219. Capponi et al. Circulation 2008;118:S:452. Connelly et al. J Cardiovasc Pharmacol 2010; 55:459. Simic et al. Eur Heart J. 2012 [In Press]. Effects on Diabetic Control in ILLUMINATE There were 6101 patients with type 2 diabetes in the ILLUMINATE trial

Treatment with torcetrapib resulted in a highly significant improvement in diabetic control

Barter et al. Circulation 2011; 124:555. Effects of Atorvastatin (A) vs Atorvastatin Plus Torcetrapib (T/A) in Diabetics in ILLUMINATE (N = 6661) Glucose

8.4 (p<0.0001 for all)

8.2 A A 8.0 (ns) A T/A 7.8 A T/A T/A 7.6 T/A Plasma glucose (mmol/L) 7.4 0136 Months of treatment

Barter et al. Circulation 2011; 124:555. Effects of Atorvastatin (A) vs Atorvastatin Plus Torcetrapib (T/A) in Diabetics in ILLUMINATE (N = 6661) HbA1C (p<0.0001 for all) A 7.3 A

7.2 (ns)

A T/A A 7.1 T/A

7.0 T/A

HbA1C (%) T/A

6.9

6.8 0136 Months of treatment

Barter et al. Circulation 2011; 124:555. Effects of Atorvastatin (A) vs Atorvastatin Plus Torcetrapib (T/A) in Diabetics in ILLUMINATE (N = 6661) Insulin (ns) (p=0.0007) 145 A A T/A 140

U/ml 135

 T/A

130 Insulin 125

120 03 Months of treatment

Barter et al. Circulation 2011; 124:555. Effects of Atorvastatin (A) vs Atorvastatin Plus Torcetrapib (T/A) in Diabetics in ILLUMINATE (N = 6661) HOMA-IR 52 A (ns) A 51 (p<0.0001)

50 T/A

49 HOMA-IR

48 T/A

47

46 03 Months of treatment

Barter et al. Circulation 2011; 124:555. Lipid efficacy of CETP inhibitors (% change from baseline)

CETP Dose HDL-C LDL-C TG inhibitor mg/d % % % Torcetrapib 60 61 -24 -9

Dalcetrapib 600 31 -2 -3

Adapted from Cannon C, JAMA 306:2154; 2011 dal-HEART Program: dalcetrapib HDL Evaluation, Atherosclerosis & Reverse Cholesterol Transport

Double-blind, randomized, placebo-controlled studies

dal- dal-VESSEL dal-PLAQUE dal-PLAQUE 2 dal-ACUTE dal- OUTCOMES OUTCOMES 2 476 patients 130 patients 906 patients 300 patients 15,872 with CHD or with CHD with CAD hospitalized 20,000 patients patients CHD risk for ACS with stable recently equivalent inflammation, on <1 week after CHD, CHD risk hospitalized plaque size atherosclerotic ACS equivalents or for ACS endothelial and burden, disease at elevated risk function and measured by progression, treatment for CVD CV outcomes blood PET/CT and assessed by initiated within pressure MRI imaging 1 week of an CV outcomes ACS Fully Completed Completed Fully Fully FPI (Feb recruited recruited recruited 2012)

1. Schwartz et al. Am Heart J. 2009;158:896–901. 2. Kastelein et al. Curr Med Res Opin. 2011;27:141–150. 3. http://clinicaltrials.gov/ct2/show/NCT00655473; Accessed 21st April 2009. 4. http://clinicaltrials.gov/ct2/show/NCT01059682; Accessed February 2nd 2010. 5. Roche, data on file. Dal-PLAQUE

dal-PLAQUE was the first multicentre study using novel non- invasive multimodality imaging to assess structural and inflammatory indices of atherosclerosis as primary endpoints.

Co-primary endpoints were MRI-assessed indices (total vessel area, wall area, wall thickness, and normalised wall index [average carotid]) after 24 months and 18F-fluorodeoxyglucose PET/CT assessment of arterial inflammation within an index vessel (right carotid, left carotid, or ascending thoracic aorta) after 6 months, with no-harm boundaries established before unblinding of the trial.

Fayad et al. Lancet, 2011;378:1547. dal-PLAQUE Trial

130 patients (men Dalcetrapib 600 mg and women) aged Therapy to LDL-C 18–75 years, with <100 mg/dL CHD or CHD equivalent Placebo

24 Month follow-up Co-primary endpoints were MRI-assessed indices (total vessel area, wall area, wall thickness, and normalised wall index [average carotid]) after 24 months and 18F-fluorodeoxyglucose PET/CT assessment of arterial inflammation within an index vessel (right carotid, left carotid, or ascending thoracic aorta) after 6 months

Fayad et al. Lancet, 2011;378:1547. Dal-PLAQUE- Results

189 patients were screened and 130 randomly assigned to placebo (66 patients) or dalcetrapib (64 patients).

There was no evidence of harm in dalcetrapib treated subjects, with a possible beneficial vascular effects as evidenced by a reduction in total vessel enlargement over 24 months.

Dalcetrapib did not increase blood pressure and the frequency of adverse events was similar between groups.

It was concluded that these results provided comfort with a decision to proceed with a longer and much larger clinical endpoint trial.

Fayad et al. Lancet, 2011;378:1547. Dal-VESSEL

This trial investigated the effects of dalcetrapib on endothelial function, blood pressure, inflammatory markers and lipids in patients with, or at risk of, coronary heart disease (CHD) in a double-blind randomised placebo- controlled trial

Luscher et al. European Heart J, 2012;33:857. dal-VESSEL Trial

Dalcetrapib 600 mg 476 patients with Therapy to LDL-C CHD or equivalent <100 mg/dL HDL-C < 50 mg/dL Placebo

36 week follow-up

The primary outcome measures were change from baseline of flow-mediated dilatation of the right brachial artery at 12 weeks and the 24- hour ambulatory blood pressure at week 4.

Luscher et al. European Heart J, 2012;33:857. Dal-VESSEL- Results

476 patients were randomised. Change in FMD was not significantly different from placebo after 12 and 36 weeks of treatment with dalcetrapib.

After 4, 24 and 36 weeks of treatment with dalcetrapib, CETP activity decreased by 51, 53 and 56% while at weeks 4, 12 and 36 HDL-C increased by 25, 27 and 31%. Dalcetrapib had no effect on LDL-C levels

Ambulatory blood pressure was unaffected by dalcetrapib up to 36 weeks.

Biomarkers of inflammation, oxidative stress and coagulation were

unaffected by dalcetrapib up to 36 weeks, although Lp-PLA2 levels increased by 17%.

Luscher et al. European Heart J, 2012;33:857. Objective of the dal‐OUTCOMES trial

• To compare the effects of dalcetrapib with placebo, added to evidence‐based background therapy, on cardiovascular risk in patients with recent acute coronary syndrome dal-OUTCOMES Trial

15,600 patients Dalcetrapib 600 mg 4-12 weeks Statin therapy to optimal after an index LDL-C level ACS event Placebo

2.5-year follow-up (Likely to report at Primary End Point ACC in 2013) CHD death, non-fatal MI, atherothrombotic stroke, unstable angina requiring hospitalization or resuscitated cardiac arrest

Schwartz et al. Am Heart J. 2009;158:896. Entry criteria

• Age 45 years • Acute coronary syndrome • Evidence‐based management of LDL‐C • No restriction on entry level of HDL‐C • Key exclusions: Triglycerides >400 mg/dl; treatment with niacin, fibrates, or bile acid sequestrants. Outcome measures

• Primary outcome composite (time to first occurrence): – Coronary heart disease death – Non-fatal MI – Ischemic stroke – Hospitalization for unstable angina (with objective evidence of acute myocardial ischemia) – Cardiac arrest with resuscitation

• Secondary outcome measures: – All cause mortality – Coronary revascularization Flow of patients in the trial

• 19,005 entered single blind run-in • 15,871 patients randomized • Withdrawal of consent or loss to follow-up: dalcetrapib 3.9%, placebo 3.3% • At the 2nd pre-specified interim analysis, including 1135 (71% of projected) primary endpoint events, the DSMB recommended termination of the trial for futility. • At termination, median follow-up 31 mo. Baseline characteristics (all balanced between treatment groups) Mean age (years) 60 Female 19% Caucasian 88% Region Europe or Israel 50% North America 32% Cardiovascular risk factors Hypertension 68% Metabolic syndrome 63% Diabetes 24% Current smoker 21% Cardiac biomarker‐positive qualifying (index) event 87% Time from index event to randomization (days) 61 Concurrent treatments (all balanced between treatment groups)

PCI or CABG for index event (before randomization) 91%

Statin 97%

Aspirin 97%

Clopidogrel, ticlopidine or prasugrel 89%

Beta blocker 88%

ACE inhibitor or ARB 79% Baseline lipids (mean) (all balanced between treatment groups)

mg/dl mmol/L

LDL cholesterol 76 1.96

HDL cholesterol 42 1.09

Triglycerides 134 1.51 HDL‐C and LDL‐C by treatment group

Placebo Dalcetrapib HDL cholesterol (mg/dl) HDL

Placebo Dalcetrapib

Data are cholesterol (mg/dl) LDL mean ± 95% CI Primary outcome* by treatment group

Hazard ratio 1.04 (95% CI 0.93-1.16)

* Coronary heart disease death, non‐fatal MI, ischemic stroke, hospitalization for unstable angina, resuscitated cardiac arrest Risk of primary and secondary outcomes Event Dalcetrapib Placebo Hazard Ratio (95% CI) (% at 3 years) (% at 3 years) P‐value Primary composite 9.2 9.1 1.04 (0.93‐1.16) 0.52 CHD death 1.6 1.8 0.94 (0.73‐1.21) 0.66 Non‐fatal MI 5.9 6.0 1.02 (0.89‐1.17) 0.80 Unstable angina 1.3 1.3 0.91 (0.68‐1.22) 0.54 Resuscitated 0.2 0.1 1.41 (0.63‐3.18) cardiac arrest 0.40 Ischemic Stroke 1.4 1.0 1.25 (0.92‐1.70) 0.16 All cause mortality 3.1 3.4 0.99 (0.82‐1.19) 0.90 Coronary 9.5 9.6 1.00 (0.87‐1.11) revascularization 0.97 Systolic blood pressure and hs‐CRP were slightly higher with dalcetrapib than placebo

With dalcetrapib, compared with placebo: •Mean systolic blood pressure was 0.6 mm Hg higher (P<0.001) •No effect on plasma aldosterone, bicarbonate, or potassium •No difference in number of anti- hypertensive medications

•At 3 months of assigned treatment, median hs-CRP was 0.2 mg/L higher (P<0.001, based on ANOVA after log transformation) Conclusions • In patients with recent ACS, the CETP inhibitor dalcetrapib raised HDL‐C by ~30% with minimal effect on LDL‐C and had no effect on the risk of major cardiovascular events. • HDL‐C concentration did not predict risk in this study population. • Slightly higher systolic blood pressure and C‐reactive protein with dalcetrapib might reflect an adverse effect of inhibiting CETP. Why did Dalcetrapib fail to Reduce CV Events? The two most obvious explanations are:

(i) The increase in HDL-C concentration induced by dalcetrapib is not accompanied by an enhancement of the protective functions of HDL or

(ii) that the inverse relationship between HDL-C concentration and cardiovascular risk observed in population studies is an epiphenomenon rather than being reflective of an ability of HDL to protect against cardiovascular disease. Lipid efficacy of CETP inhibitors (% change from baseline)

CETP Dose HDL-C LDL-C TG inhibitor mg/d % % % Torcetrapib 60 61 -24 -9

Dalcetrapib 600 31 -2 -3

Anacetrapib 100 138 -40 -7

Adapted from Cannon C, JAMA 306:2154; 2011 DEFINE Trial Determining the EFficacy and Tolerability of CETP INhibition with AnacEtrapib

Anacetrapib 100 mg 1620 patients with CHD or CHD risk Statin therapy equivalents to achieve LDL-C <100 mg/dL

Placebo

76 week follow-up

Primary End Point Lipid efficacy and the safety

Cannon et al. NEJM. 2010; 363:2406. DEFINE Trial LDL-C (mg/dL) HDL-C (mg/dL) 100 120 Placebo 100 80 Anacetrapib 80 60 60 40 Anacetrapib 40 Placebo 20 20

0 0 02476 O24 76

Study Week Study Week

Cannon et al. NEJM. 2010; 363:2406. DEFINE Trial ApoB (mg/ml) ApoA-I (mg/ml)

100 Placebo 240 Anacetrapib

80 200 160 60 Anacetrapib 120 Placebo 40 80 20 40

0 0 02476 O24 76

Study Week Study Week

Cannon et al. NEJM. 2010; 363:2406. DEFINE Trial TG (mg/dL) Non-HDL-C (mg/dL)

150 Placebo 120 Placebo 120 100 80 90 Anacetrapib 60 60 Anacetrapib 40 30 20

0 0 02476 O24 76

Study Week Study Week

Cannon et al. NEJM. 2010; 363:2406. DEFINE Trial

Lp(a) (nmol/L) CRP (mg/L) 50 3.0

40 2.5 Placebo 2.0 Anacetrapib 30 1.5 20 Placebo 1.0 10 Anacetrapib 0.5

0 0 02476 O24 76

Study Week Study Week

Cannon et al. NEJM. 2010; 363:2406. Anacetrapib had no Effect on BP

200 160 120 SBP

mmHg 80 40 Anacetrapib 0 Placebo 0 6 12 18 24 30 38 46 54 62 70 76 120

80 DBP mmHg 40

0 0 6 12 18 24 30 38 46 54 62 70 76 Week

Cannon et al. NEJM. 2010; 363:2406. Adjudicated CV Events and Death

Anacetrapib Placebo Hazard ratio P value N=808 N=804 (95% CI) n (%) n (%)

Pre-specified adjudicated 16 (2.0) 21 (2.6) 0.76 (0.39, 1.45) 0.40 CV Safety endpoint

Cardiovascular Death 4 (0.5) 1 (0.1) Non-fatal MI 6 (0.7) 9 (1.1) Unstable Angina 1 (0.1) 6 (0.7) Non-fatal Stroke 5 (0.6) 5 (0.6) Death from any Cause 11 (1.4) 8 (1.0) Revascularization 8 (1.0) 28 (3.5) 0.29 (0.13, 0.64) 0.001 Death or major CV event 27 (3.3) 43 (5.3) 0.62 (0.38, 1.01) 0.048 (Death/MI/UA/S/Revasc)**

Cannon et al. NEJM. 2010; 363:2406. DEFINE trial

Primary Bayesian analysis revealed that the event distribution in DEFINE indicates a 94% predictive probability of dismissing a torcetrapib type increase in CV Events

Cannon et al. NEJM. 2010; 363:2406. ILLUMINATE Trial 2007 (torcetrapib)1 DEFINE Trial 2010 (anacetrapib)2

ILLUMINATE Trial (2007) N=15,067 (torcetrapib)

Primary endpoint: MCVE

Revascularization

DEFINE trial (2010) N = 1,623 (anacetrapib)

Primary endpoint: MCVE

Revascularization

0.25 0.50.75 1.01.25 1.5

1. Barter et al, NEJM 2007;357:2109. CETP-I Better CETP-I worse 2. Cannon et al. NEJM. 2010; 363:2406. REVEAL Trial Randomized Evaluation of the Effects of Anacetrapib through Lipid-modification

Anacetrapib 100 mg 30,000 patients Atovastatin to aged > 50 with achieve LDL-C with occlusive target arterial disease Placebo

Sites in North America, Europe and Asia 4 year follow-up

Primary End Point Coronary death, myocardial infarction or Planned completion coronary revascularization in 2017

www.revealtrial.org Lipid efficacy of CETP inhibitors (% change from baseline)

CETP Dose HDL-C LDL-C TG inhibitor mg/d % % % Torcetrapib 60 61 -24 -9

Dalcetrapib 600 31 -2 -3

Anacetrapib 100 138 -40 -7

Evacetrapib 500 129 -36 -17

Adapted from Cannon C, JAMA 306:2154; 2011 Study Design

• Subjects with elevated LDL-C or low HDL-C

• Up to 8 week dietary lead-in period and withdrawal of lipid-modifying therapies

• 12 week treatment period

– Evacetrapib (30, 100 or 500 mg) or placebo

– Evacetrapib 100 mg or placebo in combination with statin therapy (simvastatin 40 mg, atorvastatin 20 mg, rosuvastatin 10 mg)

• Co-primary endpoints: Percent change in HDL-C and LDL-C

Nicholls et al. JAMA. 2011; 306:2099. Percent Change in HDL-C and LDL-C

* P<0.001 compared with placebo Nicholls et al. JAMA. 2011;306:2099. Percent Change in HDL-C: Evacetrapib Plus Statin

* P<0.001 compared with placebo Nicholls et al. JAMA. 2011;306:2099. Percent Change in LDL-C: Evacetrapib Plus Statin

Nicholls et al. JAMA. 2011;306:2099. * P<0.001 compared with placebo Evacetrapib Conclusions

• Evacetrapib monotherapy produced a dose-dependent increase in HDL-C up to 128.8% and decrease in LDL-C up to 35.9%.

• Significant incremental HDL-C and LDL-C changes were observed when evacetrapib 100 mg was administered in combination with statins.

• Evacetrapib was well tolerated with no evidence of adverse blood pressure or mineralocorticoid effects.

• The impact of evacetrapib on cardiovascular events remains to be determined.

Nicholls et al. JAMA. 2011; 306:2099. Future of CETP Inhibition as a Strategy to Reduce CV Risk

• There is still a compelling case for further testing the hypothesis that inhibiting CETP by will be anti- atherogenic in humans so long as the hypothesis is tested using potent CETP inhibitors that more than double the level of HDL-C and reduce LDL-C by more than 30%.

• This hypothesis is currently being tested in large CV clinical endpoint trials. CETP Inhibition: Effect on RCT?

Bile A-I A-I ABCG1 FC CE LCAT CE FC SR-BI ABCA1 Liver LDLR CETPX Macrophage CETP inhibitor CE B TG

VLDL/LDL Novel HDL Therapeutics

• Elevate plasma HDL-C • Enhance cholesterol efflux and reverse cholesterol transport Anti-atherogenic HDL functions HDL

Anti-oxidant NO- promoting Anti- Anti- inflammatory thrombotic Anti-atherogenic HDL functions HDL

Anti-oxidant NO- promoting Anti- Anti- inflammatory thrombotic Cholesterol efflux and reverse cholesterol transport Reverse Cholesterol Transport

Bile A-I A-I FC ABCG1 CE FC LCAT CE FCFC SR-BI ABCA1 Liver Macrophage Quantitation of macrophage reverse cholesterol transport in vivo

Genetic and pharmacologic interventions

Feces 3H-BA 3H-FC 3H-Chol

Bile 3H-BA 3H-FC

3H-BA Macrophage 3H-FC Plasma 3 3H-chol H-cholesterol, AcLDL Measuring HDL Cholesterol Efflux Capacity

3H‐Cholesterol

MACROPHAGES

cAMP

HDL % cholesterol efflux

After George Rothblat, et al Promoting Cholesterol Efflux and Reverse Cholesterol Transport

Bile A-I A-I FC ABCG1 CE FC LCAT CE FCFC SR-BI ABCA1 Liver • apoA-I infusion Macrophage Normal Apo A1 and Apo A1 Milano Dimer Lipid Binding In Vivo Catabolism 35 143 187 99 243 A1 1

25 209 220 66 121 165 A1=apolipoprotein A1 LCAT Activation“Receptor” A1m=apolipoprotein A1 Milano Cholesterol Binding LCAT=lecithin cholesterol acyl- Efflux transferase 243 243

A1m/A1m 173 173 1 ss 1

Franceschini G. Eur J Clin Invest 1996;26:733–746. Can reconstituted HDL remove cholesterol from plaque? Recombinant apoA-I Milano Produced Regression of Coronary Atherosclerosis

ETC-216: apoA-I milano/phospholipids Nissen SE, et al. JAMA. 2003;290(17):2292-2300. Copyright © 2003 American Medical Association. Reconstituted HDL: The ERASE Trial Percent Change in Atheroma Volume from Baseline to 6 weeks

Tardif JC et al. JAMA 2007;297:1675–1682. Plasma Selective Delipidation: LS-001 Study

Waksman et al. JACC. 2010:55;2727. Effects of apoA-I vs LDL Interventions on Coronary Atherosclerosis by IVUS

+5.00 apoA-I Milano Intensive Statin Treatment or r-HDL Up to 53% reduction LDL-C for 2 years for 4-5 weeks REVERSAL +2.50 pravastatin 40 mg 540 days VS Progression 0 apoA-I milano REVERSAL JAMA 2003 atorvastatin 80 mg 540 days -2.50 Delipidated HDL ASTEROID rosuvastatin 40 mg ERASE JAMA 2007 720 days -5.00 50 60 70 80 90 100 110 120 Median Change in % Atheroma Volume in % Atheroma Median Change Mean LDL-C

Nissen SE, et al. JAMA. 2003;290(17):2292-2300. Tardif JC, et al. JAMA. 2007;297(15):1675-1682. Nissen SE, et al. JAMA. 2006;295(13):1556-1565. Courtesy of Dr. Jan Johansson Nissen SE, et al. JAMA. 2004;291(9):1071-1080. Promoting Cholesterol Efflux and Reverse Cholesterol Transport

Bile A-I A-I FC ABCG1 CE FC LCAT CE FCFC SR-BI ABCA1 Liver • apoA-I infusion Macrophage • apoA-I upregulation Efficacy of RVX-208 Time Course of Changes in HDL and Large Particle HDL

HDL Cholesterol Large HDL Particles 10 25 * ** 8 20 * 6 15 4 10 2 5 0 0 -2 -5 Median Percent Change Median Percent Change Median Percent

Placebo **P < 0.001 RVX-208 50 mg *P < 0.01 RVX-208 100 mg RVX-208 150 mg

Nicholls SJ, et al. J Am Coll Cardiol. 2011;57(9):1111-1119. Copyright © 2011 American College of Cardiology Foundation. Regulation of Macrophage Cholesterol Efflux

PPAR PPAR PPAR A1 Oxysterols FC LXR/RXR ABCA1 FC

ABCA1=ATP-binding cassette transporter A1; A1=apolipoprotein A1; FC=free cholesterol; LXR=liver X receptor; RXR=retinoid X receptor; PPAR= peroxisome proliferator- activated receptor; TZD=thiazolidinedione Promoting Cholesterol Efflux and Reverse Cholesterol Transport

Bile A-I A-I FC ABCG1 CE FC LCAT CE FCFC SR-BI ABCA1 Liver • apoA-I infusion Macrophage • apoA-I upregulation • LXR agonism Targeting LXR

PPAR PPAR PPAR A1 FC LXR/RXR ABCA1 New agents

ABCA1=ATP-binding cassette transporter A1; A1=apolipoprotein A1; FC=free cholesterol; LXR=liver X receptor; RXR=retinoid X receptor; PPAR= peroxisome proliferator- activated receptor; TZD=thiazolidinedione Effect of LXR Agonist on Macrophage to Feces Reverse Cholesterol Transport

LXR agonist Feces 3H-BA 3H-FC

Bile 3H-BA 3H-FC 3H cholesterol

3H-BA 3H-FC

3 Plasma H cholesterol, 3H cholesterol AcLDL

LXR=liver X receptor; BA=bile acid; FC=free cholesterol; AcLDL=acetylated low-density lipoprotein Adapted from Naik SU, et al. Adapted fromNaik SU, An LXR Agonist Significantly Increased An LXR

% CPM Injected Macrophage-to-Feces Reverse Cholesterol Transport 0.0 0.5 1.0 1.5 2.0 2.5 Circulation. 2006;113(1):90-97. * P < 0.05vsvehicle-treatedgroup Control LXR Agonist in vivo * Promoting Cholesterol Efflux and Reverse Cholesterol Transport

Bile A-I A-I FC ABCG1 CE FC LCAT CE FCFC SR-BI ABCA1 Liver • apoA-I infusion Macrophage • apoA-I upregulation • LXR agonism • miR-33 antagonism Targeting miR-33

A1 FC LXR/RXR ABCA1 Anti- miR-33 miR-33 Promoting Cholesterol Efflux and Reverse Cholesterol Transport

Bile A-I A-I FC ABCG1 CE FC LCAT CE FCFC SR-BI ABCA1 Liver • apoA-I infusion Macrophage • apoA-I upregulation • LXR agonism • miR-33 antagonism • LCAT infusion/activation The HDL flux hypothesis

Bile A-I A-I ABCG1 FC CE LCAT FCFC CE ABCA1 SR-BI HL, EL LDLR CETP Macrophage

CE B TG

VLDL/LDL