4. Agents to Raise HDL-C

Agents to Raise HDL (Do We Have the Right Biomarker of HDL Function?)

Khalid Al-Rasadi, BSc, MD, FRCPC Head of Biochemistry Department, SQU Head of Lipid and LDL-Apheresis Unit, SQUH President of Oman society of Lipid & Atherosclerosis (OSLA) Disclosures

• Honoraria for Speakers Bureau (Pharma) AstraZeneca, Sanofi, Pfizer

• Advisory Boards: Sanofi, Aegerion, AstraZeneca

• Research Funding: Pfizer Coronary heart disease and HDL

3.5 N = 302,430 3.0 Emerging Risk Factors Adjusted for age and gender Collabration) 2.5 Adjusted for multiple factors long trem, prospective, population based study, 2.0 association between CVD outcomes and 1.5 circulating lipids and

inflammatory markers HazardRatio

1.0

0.8 30 40 50 60 70 80 HDL-C (mg/dL)

The Emerging Risk Factors Collaboration. JAMA 2009;302:1993-2000. Low HDL-C Predicts Residual CVD Risk After Optimal Statin Rx: TNT Study LDL-C ≤70 mg/dL on Statina,b (Treating to New Targets (TNT) Study) 10 Case: HDL-C 32; LDL-C 67 on statin 8

2 Year Risk of Major CVD Events, % - 5 0 HDL-C Quintiles,a Q1 Q2 Q3 Q4 Q5 mg/dL <37<38 3837 toto <42 <43 4342 toto <47<48 4847 to to <55 >=55≥55 Hazard Ratio Versus Q1* 0.85 0.57 0.55 0.61 aOn-treatment level (3 months statin therapy); n = 2661 bMean LDL-C, 58 mg/dL; mean TG, 126 mg/dL *P=.03 for differences among quintiles of HDL-C Barter P et al. New Engl J Med. 2007;357:1301-1310. HDL-C Risk Factor vs Risk Marker?

• Low HDL-C predicts high CVD Risk • High HDL-C predicts anti-atherogenic effects: – Anti-inflammatory – Antioxidant – Antithrombotic – Pro-endothelial • But clinical trials have not yet proven that: – HDL is a causal factor vs biomarker of risk, or – Raising HDL-C reduces CVD risk HDL Subpopulations

Particle Shape Apolipoprotein Content

Discoidal

Spherical A-I HDL A-I/A-II HDL Globular +other apos: A-IV, C, D, E, etc. +non-apo proteins: inflam, thromb, etc.

HDL Particle Size/Electrophoretic Mobility

Lipid-poor apoA-I

Globular Discoidal HDL2b HDL2a HDL3a HDL3b HDL3c ------Alpha-migrating------Pre-beta-migrating--

Adapted from Barter PJ. Atheroscler Suppl. 2002;3:39-47. Potential Antiatherogenic Actions of HDL

HDL inhibits expression of endothelial cell adhesion molecules and MCP-1 Monocyte Vessel Lumen LDL

MCP-1 Endothelium Adhesion LDL molecule HDL inhibits oxidation of LDL-C

Cytokines Oxidized LDL Intima

Foam Macrophage cell HDL promotes efflux of cholesterol from foam cells

MCP-1 = monocyte chemoattractant protein-1 Adapted from Barter PJ et al. Circ Res. 2004;95:764-772. Should High-density Lipoprotein Be a Target of Therapy ?

• ATP III Guidelines on HDL-C: “Current documentation of risk reduction through controlled clinical trials is not sufficient to warrant setting a specific goal value for raising HDL-C” (Grundy SM et al. Circulation. 2004;110:227-239) • Failure of ACCORD, FIELD, AIM-HIGH and the experience with torcetrapib have increased doubts as to the value of raising HDL-C • Recent clinical trial data from next generation investigational CETP inhibitors has refueled hope that this approach may increase HDL-C and improve clinical outcomes

Lifestyle Modifications to Raise HDL-C Levels

• Smoking Cessation − HDL-C levels are 7-20% lower in smokers, but return to normal 1-2 months after smoking cessation • Whole Food Plant Based Diet • Weight Reduction − For every 3 kg (7 lb) of weight loss, HDL-C levels increase about 1 mg/dL (~2-4% increase) • Exercise − Aerobic exercise (40 min, 3-4 times weekly) increases HDL-C by about 2.5 mg/dL (~5-10% increase)

Rössner S et al. Atherosclerosis. 1987;64:125-130. Cullen P et al. Eur Heart J. 1998;19:1632-1641. Wood PD et al. N Engl J Med. 1988;319:1173-1179. Kokkinos PF et al. Arch Intern Med. 1995;155:415-420. Ornish D et al. JAMA. 1998;280:2001-2007. Kodama S et al. Arch Intern Med. 2007;167:999-1008. Available Agents for HDL-C Raising Agent HDL-C ↑ Primary Use Nicotinic acid 15-35% HDL ↑ Fibrates 5-20% TG ↓ Statins 5-15% LDL ↓ Prescription Om-3* 2-10% TG ↓ Bile-acid resins* 2-5% LDL ↓ Ezetimibe* 1-3% LDL ↓ Pioglitazone* 5-20% Glucose ↓ Estrogens* 10-25% Hot flashes a-blockers* 10-20% BPH Alcohol* 5-15% Social, etc. *Lacking FDA-approved indication for HDL-raising. Belalcazar LM, Ballantyne CM. Prog Cardiovasc Dis. 1998;41:151-174. Insull W et al. Mayo Clin Proc. 2001;76:971-982. McKenney JM et al. Pharmacother. 2007;27:715-728.

Rationale for using niacin

• Niacin increases the level of HDL-C by up to 25%

• It also reduces the level of LDL-C by about 15%

• Given as monotherapy, niacin reduces CV events

• Given in combination with a statin, niacin promotes regression of atherosclerosis as assessed by measuring carotid intima-media thickness

Schachter M. Br J Cardiol 2003;10:462-8. CDP Research Group. JAMA 1975;231:360-81. Taylor et al. NEJM 2009; 361:2113-2122 Meta-Analysis: Effects of Nicotinic Acid Major Coronary Events, Pre-AIM-HIGH Trials

Treatment Control Peto OR Peto OR Study n/N n/N 95% Cl 95% Cl ARBITER-6-HALTS 2/187 9/176 0.25 (0.08, 0.84) Guyton JR et al 1/676 1/272 0.35 (0.02, 7.56) AFREGS 0/71 1/72 0.14 (0.00, 6.92) ARBITER-2 2/87 2/80 0.92 (0.13, 6.65) HATS 1/38 5/38 0.24 (0.05, 1.26) UCSF_SCOR 0/48 1/49 0.14 (0.00, 6.96) STOCKHOLM 72/279 100/276 0.61 (0.43, 0.88) CLAS 1/94 5/94 0.25 (0.05, 1.29) CDP 287/1119 839/2789 0.81 (0.69, 0.94) Total Test for heterogeneity: P = 0.24, I2 = 23.0% 0.75 (0.65, 0.86) Test for overall effect: P < 0.0001 Subtotal excluding CDP 0.53 (0.38, 0.73)

0.1 0.2 0.5 1 2 5 10 Log scale Many of these trials were tests of drug combinations that included niacin Bruckert E et al. Atherosclerosis. 2010;210:353-361. Meta-Analysis: Effects of Nicotinic Acid Carotid Intima Media Thickness

Treatment Control WMD (fixed) WMD (fixed) Study N N Mean (SD) Mean SD 95% Cl 95% Cl ARBITER-6-HALTS 97 -12 (36) 111 -1 (31) -12 (-21, -2) Thoenes M et al 30 -5 (11) 15 9 (12) -14 (-21, -7) ARBITER-2 78 14 (104) 71 44 (100) -30 (-63, -3) CLAS 39 -12 (20) 39 12 (20) -25 (-34, -16) Total -17 (-22, -12) Test for heterogeneity: P = 0.13, I2 = 47.4% Test for overall effect: P < 0.0001 -100 -50 0 50 100 Annual change, µm/y

E. Bruckert et al, Atherosclerosis 210 (2010) 353-361 Niacin Reduces CVD Events Coronary Drug Project Event Rate (%) • Subjects: men with prior MI 35 –14 • Treatment arms, 5 lipid meds: 30 Placebo Niacin – IR Niacin, 1 g TID (n=1119) 25 estrogen (2 arms), 20 dextrothyroxine, clofibrate –27 15 –26 – Niacin lipid effects: TC ¯ 10%, TG ¯ 27% (HDL-C not meas.) 10 –47

• Results (6 yrs, end-study): benefit 5 only seen in Niacin arm (¯ MI 27%, no ¯ 1o endpoint=total mortality) 0 Nonfatal Nonfatal Stroke/ CV • Post-study f/u 15 yrs: 4% absolute ¯ MI/CHD Death MI TIA Surgery total mortality (NNT = 25)

Coronary Drug Project. JAMA. 1975;231:360-381. Canner PL et al. J Am Coll Cardiol. 1986;8:1245-1255. Niacin promotes regression of atherosclerosis

ARBITER-6 HALTS

This trial in statin treated patients compared the effects of ezetimibe (added to the statin to achieve further lowering of LDL-C) with those of niacin (added to the statin to achieve not only additional lowering of LDL-C but also raising of HDL-C)

Taylor et al. NEJM 2009; 361:2113-2122 ARBITER-6 HALTS

HDL-Cholesterol LDL-Cholesterol 0 Niacin 20

-10 Niacin 10

P<0.001 -20 P<0.01 0 Ezetimibe

%Change from Baseline from %Change Baseline from %Change Ezetimibe

-10 -30 0 2 4 6 8 10 12 14 0 2 4 6 8 10 12 14 Months Months

Taylor et al. NEJM 2009; 361:2113-2122 Change from Baseline in Mean cIMT

0.06 Ezetimibe 0.00

P=0.003 Niacin -0.01 Mean(mm) Carotid IMT Change from Baseline inChange from

-0.02 0 8 14 Months

Taylor et al. NEJM 2009; 361:2113-2122 AIM HIGH: Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides and Impact on Global Health Outcomes

Simvastatin ³40 mg + ER niacin 2 g 3300 patients § Men and women Simvastatin ³40 mg § Aged ³45 years § Established vascular disease and atherogenic dyslipidemia (low HDL-C and high triglycerides) 4-year follow-up

Primary End Point Key Secondary End Points § Composite of CHD death, nonfatal MI, § Composite of CHD death, nonfatal MI, ischemic stroke, or hospitalization for or ischemic stroke high-risk ACS with objective evidence of ischemia

clinicaltrials.gov/ct/show/NCT00120289 AIM-HIGH—Results Primary Outcome

1o Endpoint: CHD Death, nonfatal MI, ischemic stroke, high-risk ACS, hospitalization for coronary or cerebrovascular revascularization

Boden WE. N Engl J Med. epub 15 Nov 2011; doi 10.1056/NEJMoa1107579. AIM-HIGH Early Termination • Lipids – Baseline: LDL-C 71 mg/dL w/ prior stain Rx (94% of subjects) – On Rx: HDL-C ↑ 25% ERN vs ↑ 10% “placebo” (<2/3 of projected) • Data, Safety and Monitoring Board chose early termination – Due to futility (likely lack of efficacy) - 1° Endpoint HR 1.05 – Early concern about possible increased stroke rate signal • Potential explanations for lack of observed efficacy: – “Placebo” arm received IR niacin, ↑ statin dose & ↑ ezetimibe (poor test of HDL hypothesis w/ just 15% net ↑ HDL-C) – Early study termination (VA HIT also negative at 3 y) – Sl lower than expected event rate (but still >5%/yr) – High prior statin use (94%, 40%>5y), prior niacin use (20%)

Press conference transcript; May 26, 2011. Available at: www.nhlbi.nih.gov/new/remark/aim-high-transcript.htm. Brinton EA. J Clin Lipi. 2011. Rosenson RS. Curr Athero Rep. 2012 (in press). HPS2—THRIVE: Treatment of HDL to Reduce the Incidence of Vascular Events

ER-Niacin + Laropiprant 25 000 patients Statin therapy to optimal § Men and women LDL-C level § Aged 50-80 years § History of MI, stroke, or PAD Placebo § ~7000 patients with diabetes § Coordinating centers in UK, China, and Scandinavia 4-year follow-up Primary End Point § MI, stroke, revascularization procedures

Landray et al. N Engl J Med. 2014. 371:203 Effect of ERN/LRPT on MAJOR VASCULAR EVENTS

Risk ratio 0.96 (95% CI 0.90 – 1.03)

15 Logrank P=0.29 15.0% 14.5%

Placebo 5 ERN/LRPT Patients suffering events (%)

0 0 1 2 3 4 Years of follow-up HPS2-THRIVE: SUMMARY

• No significant benefit of ER niacin/laropiprant on the primary outcome of major vascular events when added to effective statin-based LDL-lowering therapy • Significant excesses of serious adverse events (SAEs) due to known and unrecognised side-effects of niacin. Over 4 years, ER niacin/laropiprant caused SAEs in ~30 patients per 1000 • No clear evidence of differences in efficacy or safety in different types of patient (except for an excess of statin- related myopathy in Chinese patients) • Findings are consistent with previous niacin trials. The role of ER niacin for the treatment and prevention of cardiovascular disease needs to be reconsidered Cholesteryl ester transfer protein (CETP)

CETP promotes the transfer of cholesteryl esters from the HDL fraction to the atherogenic non-HDL fractions.

Barter et al. BBA. 1978;531:233. Ha & Barter. Comp Biochem Physiol, 1982, 71B:265 Effect of CETP inhibition

Inhibiting CETP decreases the concentration of atherogenic non-HDL fractions and an increases that of the potentially antiatherogenic HDL fraction

It is therefore possible that inhibiting CETP in humans will protect against atherosclerotic cardiovascular disease

Barter & Rye J Lipid Res. 2012; 53:1755-1766 CETP Inhibitors and Modulators

Evacetrapib

CETP

Barter et al. N Engl J Med. 2007;357:2109-2122. Qiu et al. Nat Struct Mol Biol. 2007;14:106-112. http://www.ama-assn.org/ama1/pub/upload/mm/365/dalcetrapib.doc. http://www.ama-assn.org/ama1/pub/upload/mm/365/anacetrapib.pdf. http://www.ama-assn.org/ama1/pub/upload/mm/365/torcetrapib.doc. Lipid Effects of CETP Inhibitors/Modulators % Change from Baseline

CETP Agent Dose (Mg/day) HDL-C (%) LDL-C (%) TG (%)

Torcetrapib 60 61 -24 -9

Anacetrapib 100 138 -40 -7

Evacetrapib 500 129 -36 -11

Dalcetrapib 600 31 -2 -3

Adapted from Cannon C et al. JAMA. 2011;306:2153-2155. Nicholls SJ et al. JAMA. 2011;306:2099-2109. TA-8995

• Increases HDL cholesterol by 180%

• Reduces LDL cholesterol by 47%

• Reduces Lp(a) by 35%

• Increases the HDL-mediated efflux of cholesterol from macrophages by 47% Hovingh et al Lancet; 2015;386(9992):452. CETP inhibitors:

•Reduce LDL cholesterol by up to 47%,

•Reduce apoB by up to 34%,

•Increase HDL cholesterol by up to 180%,

•Increase apoA-I by up to 65%

•Reduce Lp(a) by up to 37%

•Increase HDL-mediated efflux of cholesterol from macrophages by up to 47%. But There are now three randomised clinical outcome trials in humans in which treatment with a CETP inhibitor has not reduced the risk of having a clinical cardiovascular event ILLUMINATE Trial

Torcetrapib plus atorvastatin 15,087 patients Treatment with atorvastatin for at at high CV risk least 30 days Atrovastatin alone Sites in North America, Europe and Asia Pacific Planned 4.5 year follow-up Primary End Point: Major CV events

Barter et al, NEJM 2007;357:2109-2122 Torcetrapib: BUT Increased Cardiovascular and Non-cardiovascular Morbidity and Mortality

100 98 Atorvastatin only 96 HR = 1.25 P = 0.0001 94 92 90 Torcetrapib plus atorvastatin 0 Patients Without Event (%) Event Without Patients 0 90 180 270 360 450 540 630 720 810 Days After Randomization

Is the toxicity of torcetrapib related to the mechanism or the molecule?

Barter PJ et al. N Engl J Med. 2007;357:2109-2122. Torcetrapib Caused Off-target Hyperaldosteronism

• Torcetrapib arm of ILLUMINATE trial showed significant:1 – ↑ Systolic Blood Pressure: § Mean ↑5.4 mmHg § >15 mmHg ↑ SBP: 19.5% torcetrapib arm (vs 9.4% placebo arm, p<0.001) – ↓ serum potassium – ↑ serum bicarbonate – ↑ serum sodium – ↑ serum aldosterone • Inverse relationship of CVD and on-Rx-HDL-C preserved • Conclusion: ↑ CVD in ILLUMINATE likely due to off-target actions of torcetrapib, not related to CETP inhibition1,2

1. Barter PJ et al. N Engl J Med. 2007;357:2109-2122. 2. Rosenson RS. Curr Athero Rep. 2008;10:227-229. Analysis of the Off-target Characteristics of Investigational CETP Inhibitors/Modulators

Characteristic Torcetrapib Anacetrapib Dalcetrapib Evacetrapib

Clinical evidence of increased BP Yes1 No2 No3 No7 Preclinical evidence of increased Yes3 No4 No3 No8 aldosterone production*

Preclinical evidence of aldosterone synthase (CYP11B2) mRNA Yes3 ? No3 ? induction*

Preclinical evidence of RAAS- Yes5 ? No5 ? associated gene induction*

L-type Ca2+ channel activation* Yes6 ? No6 ?

1. Barter et al. N Engl J Med. 2007;357:2109-2122. 2. Masson D. Curr Opin Invest Drugs. 2009;10:980-987. 3. Stein et al. Am J Cardiol. 2009;104:82-91. 4. Forrest et al. Br J Pharmacol. 2008;154:1465-1473. 5. Stroes et al. Br J Pharmacol. 2009;158:1763-1770. 6. Clerc et al. J Hypertens. 2010: in press. 7. Nicholls et al. JAMA 2011;306:2099-2109 8. Cao et al. J Lipid Research. 2011;52:2169-2176 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

Primary End Point CHD death, non-fatal MI, atherothrombotic stroke, unstable angina requiring hospitalization or resuscitated cardiac arrest

Schwartz et al. Am Heart J. 2009;158:896-901. dal-OUTCOMES Trial

Treatment with dalcetrapib did not cause harm but nor did it reduce cardiovascular events

The explanation for the failure of dalcetrapib in this trial is not known but may have been because dalcetrapib did not reduce the concentration LDL-C

Schwartz et al. N Engl J Med. 2012; 367:2089-2099 . dal-OUTCOMES Trial

It may also have been because the HDL fraction was dysfunctional ACCELERATE trial Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition with Evacetrapib in Patients at a High-Risk for Vascular Outcomes

Evacetrapib 130 mg 12,500 patients Treatment with a statin for at least at high CV risk 30 days Placebo Sites in North America, Europe and Asia- Pacific countries Planned 3 year follow-up Primary End Point CV death, MI, stroke, coronary revasc or hospitalization for UA ACCELERATE Trial

This trial has been stopped early because of futility

Treatment with evacetrapib did not cause harm but nor did it reduce cardiovascular events

The explanation for the failure of evacetrapib in this trial is not known ACCELERATE Trial

It is possible that the trial stopped too soon CARE Trial with Pravastatin

Baseline LDL-C 139 mg/dL

LDL-C 28% lower in pravastatin group than in placebo

Sacks et al. N Engl J Med. 1996; 335:1001 . CARE Trial with Pravastatin

Sacks et al. N Engl J Med. 1996; 335:1001 . DEFINE trial Determining the EFficacy and Tolerability of CETP INhibition with AnacEtrapib

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

76 week follow-up

Primary End Point Lipid efficacy and the safety

Cannon et al. NEJM. 2010; 363:2406-2415. DEFINE trial

HDL-C (mg/dL) ApoA-I (mg/dL) 120 240 Anacetrapib 100 200 Anacetrapib 80 160

60 120 Placebo 40 80 Placebo 20 40

0 0 O 24 76 O 24 76 Study Week Study Week

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

120 100 Placebo Placebo 100 80 80 60 Anacetrapib 60 40 Anacetrapib 40 20 20

0 0 O 24 76 O 24 76

Study Week Study Week

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 New Approaches for Raising HDL

What is in development?

•ApoA1 based strategies • LCAT replacement strategies • ABCA1 agonists

49 ApoA1 Based Therapies

Ø ApoA1 Mimetics, such as APL-180 Novartis

Ø Full-length ApoA1, such as ApoA1 Cerenis Therapeutics

Ø Pre-Beta HDL, as generated by delipidation, HDL Therapeutics Inc.

Ø Reconstituted HDL, CSL Ltd.

Ø ApoA1 Milano, The Medicines Company

Ø Trimeric ApoA1, Borean Pharma and now Roche

Ø RVX-208, as developed by Resverlogix

50 51 Apo A1 Milano

• Mutation in Apo A1 characterised by the replacement of arginine by cysteine at position 173. • ApoA1 Milano was first identified by Dr. Cesare Sirtori in Milan, who also demonstrated that its presence significantly reduced cardiovascular disease, even though it caused a reduction in HDL levels and an increase in triglyceride levels

IVUS clinical trial using selective delipidated HDL

Step 1 Step 2 Step 3 Collected~1 litre Plasma enriched Re-infused preβ of plasma through process enriched plasma

• Used patients own HDL • Cholesterol removed from αHDL to yield preβ-HDL • Preβ enriched plasma is re-infused into patient

Walksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35. 54 IVUS Clinical Trial Using Selective Delipidated HDL

Treatment arm (N=14)

1:1 randomization (N=28) Control arm (N=14)

Day 0 1 2 3 4 5 6 7 8 Week

IVUS IVUS Treatment or control plasma infusion

Walksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35. 55 Results of the IVUS Clinical Trial Using Selective Delipidated HDL

4 2.8 2 ) 3 0

-2 -1.73

volume (mmvolume -4

-6 -6.24 atheroma -8

-10 Preβ-HDL infusion Control infusion Change in -12 -12.18 -14 Change in total Change in 10mm most atheroma volume diseased segment Waksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35. 56 57

Conclusion

• Low HDL-C predicts high CVD risk

• Existing HDL raising therapies have inconsistent effects

• CETP inhibitors greatly raise HDL-C levels, but their effect on HDL function and clinical outcomes remains in question

• Many new HDL-C raising treatments are in development (APO A1 agonists, delipidating agents, etc)

• Clinical trials have not yet proven that: • HDL is a causal factor vs biomarker of risk • Raising HDL-C reduces CVD risk