inhibition of apolipoprotein c-iii with galnac …...placebo/week (n=4) 15 mg/week (n=6) 30 mg/week...

AbstractBackground: Apolipoprotein C-III (apoC-III) is synthesized principally by the liver, plays a pivotal role in regulating plasma triglyceride (TG) levels, and is causally associated with cardiovascular disease (CVD). ApoC-III inhibits the hydrolysis of TG-rich lipoproteins and delays clearance of lipoprotein remnants by the liver by inhibiting receptor-mediated uptake. AKCEA-APOCIII-LRx is a second-generation antisense oligonucleotide that selectively inhibits apoC-III protein synthesis. It contains an N-acetylgalactosamine (GalNAc) moiety targeted to hepatocytes to enhance potency.Methods: The safety, tolerability, and efficacy of AKCEA-APOCIII-LRx was assessed in a double-blind, placebo-controlled, dose-escalation Phase 1/2a study in healthy volunteers (age 18–65) with TGs ≥200 mg/dL. In ascending single-dose cohorts, 10, 30, 60, 90, and 120 mg given subcutaneously (sc) were evaluated sequentially. In ascending multiple-dose cohorts, 2 groups were given 15 and 30 mg weekly sc for 6 weeks and 1 group was given 60 mg every 4 weeks sc for 3 months. Results: There were significant dose-dependent mean reductions in fasting serum apoC-III and TG levels. In the ascending single-dose cohorts, apoC-III reductions of –4%, –32%, –65%, –78%, and –91%, and TG reductions of –12%, –11%, –43%, –68%, and –77% were observed with single doses of 10, 30, 60, 90 and 120 mg of AKCEA-APOCIII-LRx, respectively, 14 days after dosing. In the ascending multiple-dose cohorts, mean apoC-III reductions of –65%, –84%, and –83% and mean TG reductions of –61%, –71%, and –65% were observed in the 15 and 30 mg (weekly) and 60 mg (every 4 weeks) dosing cohorts, respectively, 1 week after the last dose. Significant reductions of up to ~–30% in apolipoprotein B (apoB) and increases of up to ~100% in high-density lipoprotein cholesterol (HDL-C) were also observed. ApoC-III protein levels remained reduced by up to 50% for ~90 days after the last dose. AKCEA-APOCIII-LRx was well tolerated with no injection-site or flu-like reactions, as well as no renal adverse events (AEs) or platelet reductions.Conclusions: Treatment with AKCEA-APOCIII-LRx results in an improved atherogenic lipid profile and durable pharmacology indicating a potential for monthly or less frequent dosing. Based on the encouraging tolerability and potential efficacy demonstrated in this study, a Phase 2 trial in subjects with high TGs and CVD has been initiated (January 2018).

IntroductionApoC-III ● ApoC-III is a 79-amino–acid glycoprotein, synthesized principally in the liver – Multiple apoC-III proteins on TG-rich lipoproteins and HDL particles● Plays a key role in determining serum TG levels – Potent inhibitor of lipoprotein lipase – Inhibits hepatic uptake of TG-rich lipoproteins

ApoC-III as a Target for CVD Risk Reduction1,2

● High plasma TG levels are known to be associated with an increased risk of CVD● Loss-of-function mutations in APOC3 have been shown to be associated with: – Marked reductions in plasma levels of TGs (mean reduction of 44%) and apoC-III – A favorable lipid profile, reduced CVD and increased longevity ● Old World Amish3; Ashkenazi Jews4; Exome Sequencing Project1; Copenhagen City cohorts2

● APOC3 is a promising therapeutic target for reducing residual cardiovascular risk

Figure 1. Antisense Technology Reduces Disease Causing Protein Levels by Targeting mRNA

AKCEA-APOCIII-LRx● Triantennary GalNac (GalNAc3) represents a new class of LIgand-Conjugated Antisense (LICA)

modifications for selectively targeting hepatocytes

Figure 2. Selective Delivery to Hepatocytes5

AKCEA-APOCIII-LRx has Improved Potency vs. non-LICA in Humans● A comparison of dose–response data of AKCEA-APOCIII-LRx and non-LICA following 6 SC doses

once-weekly for 6 weeks, or 4 weeks with 3 doses in the first week, in human subjects showed that AKCEA-APOCIII-LRx has at least 15x improved potency vs. non-LICA in reducing fasting serum apoC-III and TGs

MethodsAKCEA-APOCIII-LRx Phase 1/2a Study Design ● Ascending single- and multiple-dose dose study in subjects with TGs ≥200 mg/dL● Double-blind, placebo-controlled, dose-escalation study

Single-Dose Cohorts

Cohorts Placebo(n)

AKCEA-APOCIII-LRx

(n)

10 mga 2 6

30 mga 2 6

60 mga 2 6

90 mgb 2 6

120 mgb 2 6

aTG inclusion ≥90 mg/dL; bTG inclusion ≥200 mg/dL D, day; f/u, follow up; R, randomization

Multiple-Dose Cohorts

Cohorts Placebo(n)

AKCEA-APOCIII-LRx

(n)

15 mg/weeka 2 6

30 mg/weeka 2 6

60 mg/montha 4 6

aTG inclusion ≥200 mg/dL D, day; f/u, follow up; R, randomization

ResultsPhase I: AKCEA-APOCIII-LRx in Healthy VolunteersBaseline Characteristics of Ascending Multiple-Dose Groups

Placebo/week(n=4)

15 mg/week(n=6)

30 mg/week(n=7)

Placebo/month(n=4)

60 mg/month(n=6)

Gender (M:F) 2:2 4:2 7:0 2:2 3:3

Age (years) 53 53 42 57 50

BMI (kg/m2) 27.5 28.7 30.6 28.2 27.7

Lipids and Lipoproteins, mg/dL

ApoC-III 13 14 10 13 15

Triglycerides 225 223 189 191 301

Total Cholesterol 230 225 229 257 271

HDL-C 38 53 40 46 40

Non–HDL-C 192 173 189 211 231

LDL-C 146 128 150 173 177

BMI, body mass index; LDL-C, low-density lipoprotein cholesterol

AKCEA-APOCIII-LRx: Ascending Single-Dose Cohorts – EfficacyFigure 3. Significant, Dose-Dependent, Prolonged Mean % Reductions in Serum ApoC-III in Ascending Single-Dose Cohorts (N=40)

● Mean % reduction in apoC-III on Day 30: 10 mg, –18%; 30 mg, –31%; 60 mg, –58%; 90 mg, –72%; 120 mg, –87% (Figure 3)

Figure 4. Significant, Dose-Dependent, Prolonged Mean % Reductions in Serum TGs in Ascending Single-Dose Cohorts (N=40)

● Mean % reduction in TGs on Day 30: 10 mg, –12%; 30 mg, –4%; 60 mg, –38%; 90 mg, –60%; 120 mg, –72% (Figure 4)

Figure 5. Significant, Dose-Dependent, Sustained Mean % Reductions in Serum ApoC-III Following 6 Weekly Doses of AKCEA-APOCIII-LRx (N=17)

● Mean % reduction in apoC-III on Day 43: 15 mg, –65%; 30 mg, –84% (Figure 5)

Figure 6. Significant, Dose-Dependent, Sustained Mean % Reductions in Serum TG Following 6 Weekly Doses of AKCEA-APOCIII-LRx (N=17)

● Mean % reduction in TGs on Day 43: 15 mg, –61%; 30 mg, –71% (Figure 6)

Figure 7. Significant, Dose-Dependent, Sustained Mean % Reductions in Serum ApoB Following 6 Weekly Doses of AKCEA-APOCIII-LRx (N=17)

● Mean % reduction in apoB on Day 43: 15 mg, –15%; 30 mg, –26% (Figure 7)

Figure 8. Significant, Dose-Dependent, Sustained Mean % Increases in Serum HDL-C Following 6 Weekly Doses of AKCEA-APOCIII-LRx (N=17)

● Mean % increase in HDL-C on Day 43: 15 mg, 50%; 30 mg, 56% (Figure 8)

Figure 9. Significant, Dose-Dependent, Sustained Mean % Reductions in Serum ApoC-III Following 4 Monthly Doses of AKCEA-APOCIII-LRx (N=10)

● Mean % reduction in apoC-III: Day 43, –80%; Day 92, –83% (Figure 9)

Figure 10. Significant, Dose-Dependent, Sustained Mean % Reductions in Serum TG Following 4 Monthly Doses of AKCEA-APOCIII-LRx (N=10)

● Mean % reduction in TGs: Day 43, –61%; Day 92, –65% (Figure 10)

Figure 11. Significant, Dose-Dependent, Sustained Mean % Reductions in Serum ApoB Following 4 Monthly Doses of AKCEA-APOCIII-LRx (N=10)

● Mean % reduction in apoB: Day 43, –22%; Day 92, –30% (Figure 11)

Figure 12. Significant, Dose-Dependent, Sustained Mean % Increases in Serum HDL-C Following 4 Monthly Doses of AKCEA-APOCIII-LRx (N=10)

● Mean % reduction in HDL-C: Day 43, 64%; Day 92, 76% (Figure 12)

Improved Atherogenic Lipid Profile: Mean % Change From Baseline in Key Lipids 1 Week After Last Dose

15 mg/week Day 43

30 mg/week Day 43

60 mg/monthDay 43a

60 mg/month Day 92

ApoC-III –65%** –84%** –80%* –83%*

TGs –61%** –71%** –61%* –65%*

LDL-C –3% –17% –10% –22%

ApoB –15%* –26%** –22% –30%*

Non–HDL-C –22%* –30%** –27%* –31%*

HDL-C +50%** +56%* +64% +76%*

Lp(a) –0.1% –11% –7% –27%

aMonthly dosing Day 43, 2 weeks after second dose, shown for comparison to weekly dosing cohorts

*p≤0.05; **p≤0.01

Clinical Safety and Tolerability for AKCEA-APOCIII-LRx● No serious AEs● No AEs leading to treatment discontinuation● No hepatic or renal signals● No injection site or flu-like reactions ● No clinically significant findings in routine hematology or biochemistry● No platelet reductions

Summary● Significant, dose-dependent lowering of apoC-III total protein – Approximately 80% reduced from baseline with 6 weekly or 2 monthly doses of AKCEA-APOCIII-LRx ● Durable response – ApoC-III protein levels remained reduced by up to 50% for ~90 days after the last dose● Associated significant dose-dependent reductions in TGs – Up to 71% reduced from baseline● Associated significant dose-dependent reductions in apoB and increases in HDL-C – Up to 30% reductions in apoB and increases of up to 100% in HDL-C  ● No safety signals identified

Conclusions● Treatment with AKCEA-APOCIII-LRx results in an improved atherogenic lipid

profile and durable pharmacology indicating a potential for monthly or less frequent dosing

● These data reinforce the consistency and predictability of target reduction with lower doses using Ionis’ LICA technology

● Based on the encouraging tolerability and potential efficacy demonstrated in this study, a Phase 2 trial in subjects with high TGs and CVD has been initiated (January 2018)

References1. TG and HDL Working Group of the Exome Sequencing Project, National Heart, Lung, and Blood Institute. N Engl J Med 2014;371:22–31; 2. Jorgensen AB et al. N Engl J Med 2014;371:32–41; 3. Pollin TI et al. Science 2008;322:1702–1705; 4. Atzmon G et al. PLoS Biol 2006;4:e113; 5. Prakash TP et al. Nucleic Acids Res 2014;42:8796–8807.

Conflicts of Interest: DisclosuresVeronica J. Alexander, Shuting Xia, Steve Hughes, Richard S. Geary are all employed by Ionis Pharmaceuticals. Eunju Hurh is employed by Akcea Therapeutics. Andres Digenio is a former employee of Akcea Therapeutics. Joseph L. Witztum is employed by the University of California San Diego and is a consultant for Ionis Pharmaceuticals. Sotirios Tsimikas has a joint appointment with Ionis Pharmaceuticals and the University of California San Diego.

AcknowledgmentsThe authors thank Swati Thorat at Akcea Therapeutics and ApotheCom for poster production support. This study was funded by Ionis Pharmaceuticals and Akcea Therapeutics, Inc.

Inhibition of Apolipoprotein C-III with GalNAc-Conjugated Antisense Drug Potently Lowers Fasting Serum Apolipoprotein C-III and Triglyceride Levels in Healthy Volunteers with Elevated TriglyceridesVeronica J. Alexander1, Andres Digenio2, Shuting Xia1, Eunju Hurh2, Steve Hughes1, Richard S. Geary1, Joseph L. Witztum1,3, Sotirios Tsimikas1,3 1Ionis Pharmaceuticals, Inc., Carlsbad, CA; 2Akcea Therapeutics, Cambridge, MA; 3Department of Medicine, University of California San Diego, La Jolla, CA

Post-Treatmentf/u Period

Screeningup to 28 days

1 SC Dose

3:1

D190 days

R

Post-Treatmentf/u Period

Post-Treatmentf/u Period

Screeningup to 28 days 6 SC Doses over 6 Weeks

3:1

D113 weeks

R

D8 D15 D22 D29 D36

Screeningup to 28 days 4 SC Doses over 3 Months

3:2

D113 weeks

R

D29 D57 D85

ApoC

-III (

mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Single-Dose Cohorts (N=40)

BL 32 15 30 60 90120

1508

-50

-75

***

***

***

***

**

****

*

*

**

**

******

***

**

** **

**

**

*****

**

-100

50

25

0

-25

Placebo 10 mg 30 mg 120 mg60 mg 90 mg

*

ApoC

-III (

mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Weekly Multiple-Dose Cohorts (N=17)

BL 2 15 22 29 36 43 50 64 90127

1558

-25

-50

-75

-100

50

25

0

Placebo 15 mg 30 mg

****

**

**

**

****

*

*******

****

******** **** ApoC

-III (

mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Monthly Multiple-Dose Cohorts (N=10)

BL 2 15 29 43 57 71 85 92 99113

141176

204

-50

-25

-75

-100

50

25

0

Placebo

** *

*

*** ** * * *

*

*

**

60 mg

TGs

(mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Weekly Multiple-Dose Cohorts (N=17)

BL 2 15 22 29 36 43 50 64 90127

1558

0

-50

-100

150

100

50

Placebo 15 mg 30 mg

***

**

*****

**

*

* ** ****

****

TGs

(mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Monthly Multiple-Dose Cohorts (N=10)

BL 2 15 29 43 57 71 85 92 99113

141176

204

-50

-25

-75

-100

50

25

0

Placebo

***

* *** * *

*

*

**

60 mg

ApoB

(mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Weekly Multiple-Dose Cohorts (N=17)

BL 2 15 22 29 36 43 50 64 90127

1558

-20

-30

-40

20

10

0

-10

Placebo 15 mg 30 mg

*

*

**

*

**** **

**** * *

**

ApoB

(mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Monthly Multiple-Dose Cohorts (N=10)

BL 2 15 29 43 57 71 85 92 99113

141176

204

-20

-10

-30

-40

20

10

0

Placebo

**

**

** *

60 mg

**

HDL

-C, P

reci

pita

tion

Met

hod

(mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Weekly Multiple-Dose Cohorts (N=17)

BL 2 15 22 29 36 43 50 64 90127

1558

20

0

-20

80

60

40

Placebo 15 mg 30 mg

*

*** *

**

****

HDL

-C, P

reci

pita

tion

Met

hod

(mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

Monthly Multiple-Dose Cohorts (N=10)

BL 2 15 29 43 57 71 85 92 99113

141176

204

50

0

-50

150

100

Placebo 60 mg

*p≤0.05**p≤0.001

***p≤0.0001

*** * *

**

*

****

**

Trig

lyce

rides

(mg/

dL)

Mea

n (+

/- S

EM) %

Cha

nge

from

Bas

elin

e

Visit (day)Dose

*p≤0.05**p≤0.001

***p≤0.0001

Single-Dose Cohorts (N=40)

BL 32 15 30 60 90120

1508

-25

-50

-75***

***

**

*

**

**

******

*

*

*

*

**

*

*

-100

75

50

25

0

Placebo 10 mg 30 mg 120 mg60 mg 90 mg

***

This poster was presented at ACC18 – American College of Cardiology’s 67th Annual Scientific Session & Expo, Orlando, Florida, USA, March 10–12, 2018

AKCEA-APOCIII-LRx: Ascending Multiple-Dose (Weekly and Monthly) Cohorts – Efficacy