TCT, Washington –September 22nd , 2010

1. Jean-Philippe COLLET* Jean-Sébastien HULOT Ghalia ANZAHA Ana PENA Thomas CHASTREJohanne SILVAIN Guillaume CAYLA Anne BELLEMAIN-APPAIX Jean-Baptiste VIGNALOU,Farzin BEYGUI Olivier BARTHELEMY Sophie GALIER Vanessa GALOIS Gilles MONTALESCOT *Pitié-Salpêtrière Hospital_URMS_937 75013 Paris-Assistance Publique des Hôpitaux de Paris “CLopidogrel and respOnseVariability Investigation Study”A Randomized Study Comparing the effect of two Clopidogrel LD according to the presence of CYP2C19*2 TCT, Washington –September 22nd , 2010 JP COLLET DISCOSURES: Research Grants : BMS-Sanofi Aventis, Eli Lilly, Medtronic, Cordis ,Johnson&Johnson. Consulting Fees : AstraZeneca, BMS, DaiichiSankyo, Eli Lilly, Sanofi-Aventis. LectureFees: AstraZeneca, BMS, DaiichiSankyo, Eli Lilly, andSanofi-Aventis

2. STENT THROMBOSIS (n=4905) Odds Ratio, fixed model Bilateral CI, 95% for trials, 95% for MA 2C19*2 2C19*1 10/375 8/1014 8/73 4/186 13/247 11/525 10/680 7/1805 41/1375 30/3530 2C19*2 better 2C19*2 worse Mega et al. (0.26) Collet et al. (0.15) Giusti et al. (0.34) Sibbing et al. (0.24) Total OR 3.45 95% CI: 2.14-5.57, p<0.001, phet=0.78 events / size 0123451020 Odds Ratio J Am Coll Cardiol 2010; 56(2):134-143

3. Collaborative Meta-analysis: CYP2C19 and Stent Thrombosis in Patients on Clopidogrel Risk Ratio (95% CI) P value Carriers vs Noncarriers 2.81 (1.81-4.37) < .0001 Heterozygotes vs Wild Type 2.67 (1.69-4.22) < .0001 Homozygotes vs Wild Type 3.97 (1.75-9.02) < .001 0.5 1.0 15.0 Risk Lower With CYP2C19 Variant Risk Higher With CYP2C19 Variant N = 5772 Mega JL.American Heart Association; November 2009; Orlando, Florida.

4. FDA boxed warning • Clopidogrel has diminished effectiveness in individuals based on their CYP2C19 genotype, specifically in those who harbor two CYP2C19 reduced-function alleles • Clinical implications of this genetic-based hazard? • Only early after initiation or during longer-term therapy as well • In the presence of two or at least one CYP2C19 reduced-function allele http://products.sanofi-aventis.us/PLAVIX/PLAVIX.html. Accessed April 20, 2010.

5. Objectives • To determine whether high dose of clopidogrel can overcome genetic resistance by • comparing the pharmacokinetic (PK) and pharmacodynamic (PD) responses • to two LDs (LD) of clopidogrel (300mg vs. 900mg) • according to carriage of CYP2C19*2 genetic variant

6. Trial organisation ACTION Study Group (Academic Research Organization, Paris) 1-Coordinating Center: Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris 2-Sponsor: AP-HP (Assistance Publique-Hôpitaux de Paris) 3-Data center, Statistics: Unité Recherche Clinique, Pitié-Salpêtrière Hospital, Paris 4-Funding: Programme Hospitalier de Recherche Clinique (070117)

7. CLOVIS-2 Study design Young-post MI patients aged <45 years H0 H1 H2 H4 H6 H0 H1 H2 H4 H6 300 mg 300 mg PK PK PK PK PK PK PK PK PK PK Aspirine 75 mg/j ±Clopi 75 mg/ j PD PD PD PD 900 mg 900 mg Phase 1 Phase 2 Wash out 4 weeks

8. Statistics • Sample size: to demonstrate that 300-mg LD would produce a 40% lower RR-RPA in carriers of CYP2C19*2 vs. non carriers • Inclusion of 45 carriers was required to yield 90% power with an α-risk error of 0.05 and assuming a 20% SD for the difference between regimens • PD was primarily defined as RR-RPA (%) to adjust for pre-treatment status with clopidogrel MD. • The absence of carryover effect was checked and comparison between clopidogrel response across genotype groups and the two LDs tested was evaluated by the Kruskall-Wallis test.

9. Clovis-2 Flow Chart 566 patients <45 years enrolled (1996 up to 2009) 224 never treated with clopidogrel and 50 without genotype 292 patients <45 years eligible with clinical follow-up 182 declined to participate 51 carriers agreed to participate 43 Heterozygous carriers (wt/*2) were matched with 43 non carriers (wt/wt) 8 Homozygous carriers (*2/*2) were matched with 16 non carriers (wt/wt) 106 patients available for final analysis

10. Study Endpoints • Relative reduction in residual platelet aggregation (% RPA6hours)–(% RPAbaseline)/(% RPAbaseline)x100 (LTA 20µ Mol ADP) • Area under the plasma concentration (AUC0-6)–time curve of H4 active metabolite (in ng.h/mL) from baseline to six-hours post loading (electrospray liquid chromatography tandem mass spectrometry )

11. Patients characteristics

12. Patient characteristics

13. Baseline Residual Platelet Aggregation p<0.02 for all p<0.04 p=0.16 100 p=0.03 75 µmol/L-induced Residual Platelet Aggregation (%) 50 ADP 20 25 0 wt/wt wt/*2 *2/*2 CYP2C19*2 genotype

14. Relative Reduction in RPA 900mg-LD 300mg-LD <0.0005 for all* <0.003 for all* 0.03 0.04 0.20 <0.001 100 p<0.001 p=0.0045 mol/L-induced 75 m residual platelet aggregation (%) 50 Relative change of ADP 20 25 0 wt/wt wt/*2 *2/*2 wt/wt wt/*2 *2/*2

15. Active Metabolites Formation 900mg-LD 300mg-LD p<0.01 for all p<0.001 for all 0.038 0.10 0.153 0.059 50 p=0.012 p=0.02 40 30 0-6 H4 Active metabolite (ng.h/ml) AUC 20 10 0 wt/wt wt/*2 *2/*2 wt/wt wt/*2 *2/*2

16. High-On Treatment Platelet Reactivity 300mg-LD 900mg-LD 80 <0.0017 for all* <0.0005 for all* 0.024 <0.0004 0.1 <0.0001 p<0.0001 p<0.0001 60 ADL 20 µmol/L-inducedMPA 40 20 0 wt/wt wt/*2 wt/wt wt/*2 *2/*2 *2/*2

17. PK/PD correlations R2=0.20 for 300mg-LD and 0.23 for 900mg-LD (p<0.0001 for both curves). • significant between AUC0-6 and RR-RPA for both LDs (right-shift of the 900 mg-LD curve) • <10 ng.h/mLgreat variability of PD, not observed with the 900 mg-LD. • >20 ng.h/ml  meaningful inhibitory effect of clopidogrel loading

18. Conclusions • Co-dominant effect of the 2C19*2 loss-of function allele • High clopidogrel LD overcomes poor response in wt/*2 but not in *2/*2 carriers • *2/*2 carriers deserve alternate therapy • Define a clinical strategy to exploit this pharmacogenetic information to optimize outcomes with clopidogrel