CRO service specialized in NASH-HCC -Proprietary STAMTM mouse model- SMC Laboratories, Inc. smccro-lab.com Ver. 2021.1 1 Overview 1 Company 2 Rationale: NASH 3 STAMTM: Proprietary model for NASH-HCC 4 Pharmacological study 5 CRO service -2- Facts at a glance ■ Founded in October 2006 ■ A privately-held non-clinical CRO based in Tokyo, Japan; specialized in research on fibrosis and inflammation ■ CRO services - Non-clinical pharmacology - One of the leading CRO in liver research with Proprietary NASH-HCC (STAMTM) Model - In vivo disease models for metabolic disorders, inflammation, fibrosis and tumor - Histological imaging services - Histological scoring: NAFLD activity score, fibrosis and inflammation scores etc. -3- 2 CRO expertise: Leading CRO in NASH/HCC Over 600 clients worldwide Over 110 peer-reviewed papers and presentations 15 successful CTA packages The number of clients Region 550 500 450 Europe 400 Japan 350 US・ 300 Canada JPN 250 200 North Asia America 150 Europe 100 Asia・ 50 Oceania 0 2011 2012 2013 2014 (% of the customers) 2015 2016 2017 2018 (year) -4- CRO capability: ■ Facility - Accreditation by MEXT* - Sponsor audit (QAU) - Animal welfare audit by global pharmaceuticals ■ SPF-grade animal room: - 2080 mice ■ CRO science team: - 10 full-time researchers - 5 visiting scientists (MD, PhD) - 3 external pathologists ■ Equipment: - CT system (In vivo) - Endoscopy (In vivo) - Confocal microscopy - Dry-chemistry analyzer - Real-time PCR - Multi-mode microplate reader - And more… *MEXT: Ministry of Education, Culture, Sports, Science and Technology -5- CRO portfolio: Nonclinical disease models Available Services 1. Pharmacology study → Efficacy of existing drugs/drug candidates 2. Delivery of mouse samples (organs, plasma/serum, fecal etc.) → Target discovery and validation → Biomarker discovery and validation Disease model lineup ■ STAMTM: Premium model for NASH-HCC (mice) ■ Other inflammation/fibrosis/cancer models (mice) CCl4 BLM ・Liver fibrosis: CCl4 model, BDL model ・Acute liver failure : CCl4 model, Concanavalin A model D-gal/LPS model, TAA model ・Pulmonary fibrosis: BLM-induced lung fibrosis model Sirius red CT (Lung) ・Skin fibrosis: BLM-induced skin fibrosis model UUO DSS ・Renal diseases: UUO-induced renal fibrosis model Adenine-induced nephropathy model ・Renal diseases: Adriamycin-induced nephropathy model ・IBD: DSS-induced colitis model PAS Endoscopy ・Liver cancer: DEN-CCl4 liver cancer model ・Alzheimer’s disease: icv-STZ model -6- Overview 1 Company 2 Rationale: NASH 3 STAMTM: Proprietary model for NASH-HCC 4 Pharmacological study 5 CRO service -7- Why focus on NASH? ■ High prevalence US: NAFLD 55-155 million NASH 15-50 million JP: NAFLD 10~ million* NASH 2~ million* ■ Sharp increase in pediatric patients ■ Progression to HCC (NASH) ■ No established treatment ■ Economic loss -1 billion USD per year (US) Causes of Death in Japanese Diabetics ■ Comorbidity of diabetes - 1 in 8 diabetes patients die of liver fibrosis/HCC. - Over 30% of diabetes patients show liver injury. ■ NASH increases the risk of CVD *Japan Study Group of NAFLD (JSG-NAFLD) 2008-2011 Hotta N., et al., Journal of the Japan Diabetes Society 50:47, 2007 -8- NASH: clinical process and diagnosis Steatosis NASH Fibrosis HCC 10-30% 10-29%** 4-27%** (NASH to fibrosis) (NASH to HCC) 6.3 – 33% (med. 20%) 3 – 5% Similar to HCV in general population* in general population* Screening/Initial evaluation US Diagnosis -fatty change NAFL -chronic change NAFLD Liver biopsy NASH +/- fibrosis ALT↑ Imaging (CT, MR..) +/- HCC HBsAg (-) HCV (-) NAFLD fibrosis score ANA (-)~low Alcohol (-)~low US: Ultra Sound, CT: Computed Tomography, MR: Magnetic Resonance *CVD: Cardiovascular*Chalasani N., disease et al., Gastroenterology 142:1592, 2012 (AGA guideline), **Cohen J., et al., Science 332:1519, 2011 -9- No approved drugs: AGA guideline 2012 Intervention Recommendations GRADE* S Q Lifestyle ● Up to 10% weight loss may be needed to improve necroinflammation 1 B Metformin ● Metformin is not recommended as a specific treatment in adults with NASH 1 A ● Pioglitazone can be used to treat steatohepatitis in patients with biopsy-proven NASH Tiazolidinediones 1 B ● Long term safety and efficacy is not established ● α-tocopherol (800 IU/day) improves liver histology in non-diabetic adults with biopsy-proven 1 B Vitamin E NASH → First-line pharmacotherapy for this patient population ● NOT in other patient populations, pending further evidence supporting this efficacy 1 C UDCA ● UDCA is not recommended for the treatment of NAFLD/NASH 1 B ● Omega-3 fatty acids may be considered as first-line therapy for hypertriglycemia in patients Omega-3 fatty acid 1 B with NAFLD, but it is premature to recommend them ● Statins can be used to treat dyslipidemia in patients with NAFLD/NASH, but should not be Statin 1 B used to specifically treat NASH, pending evidence from RCTs *GRADE: Grading of Recommendations , Assessment, Development and Evaluation S (Strength of recommendation): 1 = strong, 2 = weak Q (Quality of evidence): A = high, B = moderate, C = low Chalasani N., et al., Gastroenterology 142:1592, 2012 (AGA guideline) -10- Drug candidates in clinical trials Company Drug Target Route Period Endpoint Stage Intercept: OCA - 18 months 1)Histology P3 FXR REGENERATE study 2)Fibrosis and NASH GENFIT: Elafibranor PPARα /δ Oral 72 weeks 1)Histology P3 RESOLVE-IT study 2)Fibrosis Galmed Aramchol Synthetic fatty acid Oral 52 weeks 1)% change in liver triglyceride P3 bile conjugate 2)Fibrosis, NAS etc. Allergan: Cenicriviroc (CVC) CCR5/CCR2 antagonist Oral 1 year 1)Fibrosis P3 AURORA study Allergan: Cenicriviroc (CVC) CCR5/CCR2 antagonist Oral 1 year 1)NAS P2 CENTAUR study Novartis/Allergan: Tropifexor (LJN452) FXR Oral 48 weeks 1) Number of participants with Adverse Events P2 TANDEM study Cenicriviroc (CVC) CCR5/CCR2 antagonist Oral 2) Fibrosis Novo Nordisk: Liraglutide GLP-1 SC 48 weeks 1)Histology P2 LEAN study 2)NAS Conatus: Emricasan Caspase inhibitor Oral 72 weeks 1)Fibrosis P2 ENCORE-NF study 2)NAS Gilead GS-9674 FXR Oral 24 weeks plus 30 1)Overall safety profile P2 days Gilead GS-0976 ACC Oral 24 weeks plus 30 1)Overall safety profile P2 days Gilead Simtuzmab Loxl2 SC 96 weeks 1)Fibrosis P2 2)Safety BMS BMS-986036 FGF21 - 16 weeks 1)Change in percent hepatic fat fraction P2 2) Average concentration Galectin GR-MD-02 Galectin-3 IV 16 weeks 1)LiverMultiScan P2 Therapeutics 2)MR-elastography NGM NGM282 FGF19 - 12 weeks 1)Change in absolute liver fat content P2 2)Change in percentage liver fat content Cempra Solithromycin Ketolide antibiotic Oral 13 weeks 1)NAS P2 2)Changes in steatosis Boehringer Ingelheim BI 1467335 SSAO/VAP-1 Oral 12 weeks 1)Target enzyme activity relative to baseline in P2 percent 2)Relative to ALT, AST, AP, GGT ,cleaved CK18, total CK18 change from baseline -11- Source: clinicaltrial.gov Overview 1 Company 2 Rationale: NASH 3 STAMTM: Proprietary model for NASH-HCC 4 Pharmacological study 5 CRO service -12- Advantages of STAMTM: Proprietary NASH-HCC model ■ Distinct from existing NAFL/diabetes models, STAMTM model represents the patient population who develops HCC among NAFL/diabetic populations. - By comparing with existing NAFL/diabetes models which never show fibrosis/HCC, 1) novel factors underlying worse prognosis can be investigated and 2) risk factor-modifying medicine/personalized medicine can be investigated in diabetes/metabolic disease fields. ■ Clear onset of NAFL/NASH and 100% progression to fibrosis/HCC without exception. - Both baseline and endpoint can be arranged according to researcher’s needs such as clinical study design, mechanisms of tested molecules, etc. ■ Histological phenotype (including perisinusoidal fibrosis) similar to human NASH. - Clinically equivalent endpoints (reduction of NAS, no increase of fibrosis, decrease of fibrosis) can be evaluated. - Major factors (①Inflammation, ②ballooning, ③fibrosis) and their relation with prognosis (HCC) can be evaluated. ■ Virus-independent HCC pathway in steatohepatitis-background can be investigated. -13- STAMTM: In vivo predictive pharmacology model Steatosis NASH Fibrosis HCC 100% 100% 100% ① CHEMICAL ② DIET 1st hit Continuous 2nd hit - low dose streptozotocin - - high fat diet feeding - Preparing pregnant C57BL/6J mice 4w 5w 6w 7w 9w 12w 16w Birth Fatty liver evident 0w NASH evident Fibrosis* evident Nodule evident HCC evident All mice at 6 weeks of age meet Fatty change (+) “baseline” criteria as in the case ALT↑ of clinical trial in human NAFLD Activity score↑ -14- * Perisinusoidal fibrosis resemble to human NASH 12 Mechanisms of STAMTM mice 2 day 4wks 5wks 7wks 9wks 12wks 16wks 20wks Birth 0w 16 wks 〜HCC phase 12 wks 〜Nodule formation 9-12 wks: Fibrosis (to chronic fibrosis) phase 7-8 wks: Steatohepatitis phase 5-6 wks: Steatosis phase 2nd hit Continuous high fat diet feeding ■ HFD augments fat deposition in the primed liver with increased lipogenesis. ■ Fatty acid oxidation induces ROS generation, lipid peroxidation, mitochondria dysfunction. ■ Recruitment and activation of inflammatory cells (macrophages followed by fibroblasts). ■ Proliferation of hepatocytes and formation of tumor. 1st hit Inhibition of O-GlcNAc-β-N-acetylglucosaminidase of β-cell (STZ) ■ β cell-injury early after birth drives regenerative response with islet inflammation. ■ Accumulation of macrophages in the islet and adipose tissue. ■ Induction of mild diabetic condition. ■ Up-regulation of scavenger receptors and TNF-α in the liver (“priming”). -15- Examples of treatment period 4w 5w 7w 9w 12w 16w 20w Birth 0w Steatosis-targeting