Novel therapies for the prevention of atherosclerotic vascular disease

1. Novel therapies for the prevention of atherosclerotic vascular disease Prof. John Kastelein Academic Medical Centre Amsterdam, The Netherlands

2. Novel Approaches to Modify Lipids and Lipoproteins • Low DensityLipoprotein • High DensityLipoprotein • TriglycerideRichLipoproteins • Inflammation • Lipoprotein a

3. Statin Prescription in the UK 800,000 60,000 700,000 50,000 600,000 40,000 500,000 Prescribed Items (000s) Net IngredientCost (000s) 400,000 30,000 300,000 20,000 Statins – Cost ( £ 000s) 200,000 Statins – Prescribed 10,000 100,000 0 0 08/09 07/08 06/07 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06

4. Percentage of the UK-population with TC > 5 mmol/l 100 90 80 70 60 50 40 30 20 10 0 16–24 25–34 35–44 45–54 55–64 65–74 75+ 16–24 25–34 35–44 45–54 55–64 65–74 75+ Men Women 1994 1998 2003 2006 Year 1994 % of the Population 1998 2003 2006

5. All-CauseMortality in the UK in those < 75 Years - 450 397 400 350 115 296 300 Data Mortality - DSR per 100,000 - All Causes 250 Other 107 Cancer 141 Other Circulatory 200 CHD 150 114 52 100 32 50 89 42 0 P Ave 06-08 P Ave 95-97 1995-1997 2006-2008 53% reduction

6. New Approaches to LDL Reduction What is in development? • Cholesterol Absorption Inhibitors • Squalene Synthase (SSI) inhibitors • Thyroxin Receptor Agonists • Apo B mRNA antisense drugs • Microsomal Triglyceride Transfer Protein (MTP) inhibitors • PCSK9 Inhibitors

7. New Approaches to LDL Reduction • Ezetimibe is and will be the only cholesterol absorption inhibitor in clinical use • Squalene synthase inhibitor development was discontinued because of liver toxicity • The thyroxine receptor agonist Eprotirome study in FH (Akka) was halted for toxicity in animals

8. Heterozygous Familial Hypercholesterolemia- Study Design 225 patients screened; 124 patients enrolled Active treatment Safety follow-up(for patients not entering OLE study) 2:1 active:placebo R Placebo Treatment period Screening Safety follow-up ≤4 weeks 26 weeks 24 weeks • Patients were randomized 2:1 to receive weekly subcutaneous injections of mipomersen 200 mg or placebo for 26 weeks Cromwell W, et all, [poster]. American Heart Association Scientific Sessions; Nov 14-18; Orlando, FL; 2009

9. Mipomersen Significantly Reduced LDL-C PET • 5.2% • –28.0% Reduction in LDL-C over 28 weeks (full analysis set)

10. Distribution of LDL-C % Change From Baseline % change in LDL-C from baseline at PET PET, primary efficacy time point, 2 weeks after final dose. Data on file.

11. MTPIs – Efficacy comes from its dual mechanism of action Intestinal cell MTP MTP inhibition will limit secretion of cholesterol and triglycerides from the intestine and liver X Chylomicron Diet Source triglyceride cholesterol Decreasesecretion to bloodstream Apo B-48 Liver cell MTP X Liver source triglyceride cholesterol VLDL Apo B-100 11

12. AEGR 733HoFH Phase II Study Design • Patients: • Men/women aged 18-40 • HoFH confirmed by genetic analysis • - Mean Baseline LDL = 614 mg/dl 6 Patients AEGR 733 0.03 mg/kg AEGR 733 0.1 mg/kg AEGR 733 0.3 mg/kg AEGR 733 1.0 mg/kg Washout 4 weeks 4 weeks 4 weeks 4 weeks 4 weeks • Open label, ascending dose trial • Very low fat diet • Visits: Screen, baseline, every 1, 2, and 4 weeks after each new dose, end of washout period Cuchel, M. et al. NEJM 2007; 356:148-56.

13. Change in Lipids Using Lomitapide with no Background Therapy 20 10 0 -10 0.03 mg/kg -20 0.1 mg/kg -30 0.3 mg/kg -40 1.0 mg/kg -50 -60 -70 LDL-C TGs HDL-C nonHDL-C +12 0 +4 +10 -4 -5 -7 -9 -10 -25 -31 -25 % Change from Baseline -34 -51 -60 -65 Cuchel, M. et al. NEJM 2007; 356:148-56. 13

14. HoFH Phase 3: 6-Month Lipid Efficacy

15. LDL Receptor Function and Life Cycle 15 15

16. The Role of PCSK9 in the Regulation of LDL Receptor Expression 16

17. Impact of an Anti-PCSK9 mAb on LDL Receptor Expression 17

18. Study Design heFH study REGN727 Follow-up Period (8 weeks) Run-in/Screening Period (1–7 weeks) TreatmentPeriod (12 weeks) N=15 Primary Endpoint %  calculated LDL-C from baseline to week 12 REGN727 150 mg Q4W w/alt PBO Secondary Endpoints % in other lipoproteins and apolipoproteins and % patients reaching prespecified LDL-C levels N=15 N=16 REGN727 150 mg Q2W Placebo Q2W REGN727 200 mg Q4W w/alt PBO REGN727 300 mg Q4W w/alt PBO N=15 WK -1 LDL-C ≥ 100 mg/dL (2.6 mmol/L) on stable statin dose  ezetimibe for ≥6 wks N=16 Stein EA et al. Lancet on-line May 26, 2012

19. Changes in LDL-C from Baseline to Week 12 by Treatment Group (mITT Population)REGN 727 *P<0.0001 for % change REGN727 vs. Placebo. 1LS mean (SE), using LOCF method. Stein EA et al. Lancet on-line May 26, 2012

20. Change in Calculated LDL-C at 2 Weekly Intervals From Baseline to Week 20REGN727 Mean (SE) % Change in LDL-C from Baseline Mean percentage change in calculated LDL-C from baseline to weeks 2, 4, 6, 8, 10, 12 , 16 and 20 in the modified intent-to-treat (mITT) population, by treatment group. Stein EA et al. Lancet on-line May 26, 2012

21. Attainment of Prespecified LDL-C Levelsat Week 12 (mITT Population) - REGN727 † † * ** % Patients Achieving Prespecified LDL-C Level *P=0.006; **P=0.007; †P<0.0001 Stein EA et al. Lancet on-line May 26, 2012 P-values obtained from the exact score test.

22. Novel Approaches to Modify Lipids and Lipoproteins • Low Density Lipoprotein • High Density Lipoprotein • Triglyceride Rich Lipoproteins • Inflammation • Lipoprotein a

23. New Approaches for Raising HDL What is in development? • Cholesterol Ester Transfer Protein (CETP) inhibitors • ER-Niacin / Laropiprant combination • ApoA1 based strategies • LCAT replacement strategies • ABCA1 agonists / miR-33 inhibition

24. Thedal-HEARTProgram tests a novel hypothesis: enhancing HDL efficacy through CETP modulation treats the underlying disease of atherosclerosis and will attenuate CV riskDouble blind, randomized, placebo-controlled studies The Dal-HEARTProgramdalcetrapibHDL Evaluation, Atherosclerosis& Reverse cholesterol Transport dal-OUTCOMES1 15,600 patients recently hospitalizedfor ACS To evaluate the effect of dalcetrapib on CVoutcomes RECRUITMENT COMPLETE dal-VESSEL2 450 patients withCHD or CHD riskequivalent To evaluate the effect of dalcetrapib onendothelial function and blood pressure, measured by FMD and ABPM RECRUITMENT COMPLETE dal-PLAQUE3 130 patients withCHD To evaluate the effect of dalcetrapib oninflammation, plaque size and burden, measured by PET/CT and MRI RECRUITMENT COMPLETE dal-PLAQUE 24 900 patients withCAD To evaluate the effect of dalcetrapib onatherosclerotic disease progression, assessed by IVUS and carotid B-mode ultrasound RECRUITING

26. Effects on LDL-C and HDL-C Anacetrapib Anacetrapib 100 120 Placebo Placebo 100 80 80 60 60 40 40 20 20 0 0 LDL-C HDL-C +138.1% (p<0.001) -39.8% (p<0.001) LDL-C (mg/dL) (SE) HDL-C (mg/dL) (SE) Base-line 6 12 18 24 30 46 62 76 6 12 18 24 30 46 62 76 Base-line Study week Study week

27. Adjudicated CV Events and Death **Post hoc analysis.

28. Adjudicated CV Events and Death Primary Bayesian Analysis: Event distribution indicates a 94% predictive probability of dismissing a 25% increase (Torcetrapib-Type) in CV events **Post hoc analysis.

29. Future 30,000 patients with occlusive arterial disease in North America, Europe and Asia Background LDL-lowering with atorvastatin Randomized to anacetrapib 100 mg vs. placebo Primary outcome: Coronary death, myocardial infarction or coronary revascularization www.revealtrial.org.

30. New Approachesfor LDL Reductionand HDL Raising • The real battle in the future will be between PCSK9 Mab’s and CETP inhibitors * oral versus sc* every day versus bi-weekly or once monthly* atherogenic lipoproteins with or without HDL increase* time to efficacy* cost

31. ApoA1 Based Therapies • ApoA1 Mimetics, such as APL-180 Novartis • Full-length ApoA1, such as ApoA1 Cerenis Therapeutics • Pre-Beta HDL, as generated by delipidation, HDL Therapeutics Inc. • Reconstituted HDL, CSL Ltd. • ApoA1 Milano, The Medicines Company • Trimeric ApoA1, Borean Pharma and now Roche • RVX-208, as developed by Resverlogix

32. New Approaches for Reduction of TG rich Lipoproteins What is in development? • Microsomal Triglyceride Transfer Protein (MTP) inhibitors • DiacylGlycerolAcylTransferase(DGAT) inhibitors • Marine Omega 3 Fatty Acids • ApoCIII mRNA antisense drugs • Lipoprotein lipase gene therapy

33. Conclusion In the next five years, we will prove or disprove that additional LDL lowering with other agents than statins is effective and we will show or not show that the HDL hypothesis is true.