Alberico L. Catapano

Professor

President EAS

University of Milano Italy

Management of Dyslipidaemias:

PCSK9 Inhibition

Conflict of interest

Grants, consulting fees and/or honoraria and delivering lectures from:

Aegerion, BMS, Genzyme, Kowa, Merck , Novartis, Pfizer, Recordati, Roche, and Sanofi-Aventis

Relationship between LDL-C and CVD

Adapted from Rosenson RS. Exp Opin Emerg Drugs. 2004;9:269-279.LaRosa JC et al. N Engl J Med. 2005;352:1425-1435.

LDL-C achieved, mg/dL (mmol/L)

WOSCOPS – Pl

AFCAPS - Pl

ASCOT - PlAFCAPS - Rx WOSCOPS - Rx

ASCOT - Rx

4S - Rx

LIPID - Rx

4S - Pl

CARE - Rx

LIPID - Pl

CARE - Pl

HPS - Rx

0

5

10

15

20

25

30

40(1.0)

60(1.6)

80(2.1)

100(2.6)

120 (3.1)

140(3.6)

160 (4.1)

180(4.7)

Even

t rate

(%

)

6

Secondary Prevention

Primary Prevention

Rx - Statin therapyPl – PlaceboPra – pravastatinAtv - atorvastatin

200(5.2)

PROVE-IT - Pra

PROVE-IT – Atv

TNT – Atv10

TNT – Atv80

IDEAL-Sim

IDEAL-Atv

HPS-Pl

AFCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study; ASCOT = Anglo-Scandinavian Cardiac Outcomes Trial;CARE = Cholesterol and Recurrent Events; HPS = Heart Protection Study; LIPID = Long-term Intervention With Pravastatinin Ischemic Disease; PROVE-IT = Pravastatin or Atorvastatin Evaluation and Infection Therapy; 4S = Scandinavian Simvastatin Survival Study; TNT = Treating to New Targets; WOSCOPS = West of Scotland Coronary Prevention Study.

Event (% per annum)

Statin/more Control/less

RR (CI) per1 mmol/L reduction in LDL-C Trendtest

704 (4.6%)

1189 (4.2%)

517 (4.5%)

1065 (4.5%)

303 (5.7%)

3837 (4.5%)

206 (2.9%)

339 (2.4%)

801 (2.5%)

1490 (2.9%)

4205 (2.9%)

7136 (2.8%)

1528 (3.6%)

910 (4.1%)

1866 (3.3%)

2007 (3.2%)

4508 (3.0%)

10973 (3.2%)

4416 (5.3%)

398 (7.8%)

633 (5.8%)

1203 (5.0%)

1317 (4.8%)

795 (5.2%)

217 (3.2%)

412 (2.9%)

1022 (3.2%)

1821 (3.6%)

5338 (3.7%)

8934 (3.6%)

1729 (4.2%)

1012 (4.6%)

2225 (4.0%)

2454 (4.0%)

5736 (3.9%)

13350 (4.0%)

0.72 (0.66-0.78)

0.64 (0.47-0.86)

0.61 (0.46-0.81)

0.81 (0.67-0.97)

0.77 (0.64-0.94)

0.71 (0.52-0.98)

0.87 (0.60-1.28)

0.77 (0.62-0.97)

0.76 (0.67-0.86)

0.77 (0.71-0.84)

0.80 (0.77-0.84)

0.79 (0.77-0.81)

0.78 (0.61-0.99)

0.77 (0.67-0.89)

0.77 (0.70-0.85)

0.76 (0.70-0.82)

0.80 (0.76-0.83)

0.78 (0.76-0.80)

(p=0.2)X2=2.04

1

(p=0.4)

X2=0.801

(p=0.3)X2=1.08

1

Control/less better

Statin/more better

0.45 0.75 1 1.3

More vs less statin

<2 mmol/L

≥2 to <2.5 mmol/L

≥2.5 to <3.0 mmol/L

≥3 to <3.5 mmol/L

≥3.5 mmol/L

Total

Statin vs contol

<2 mmol/L

≥2 to <2.5 mmol/L

≥2.5 to <3.0 mmol/L

≥3 to <3.5 mmol/L

≥3.5 mmol/L

Total

All trials combined

<2 mmol/L

≥2 to <2.5 mmol/L

≥2.5 to <3.0 mmol/L

≥3 to <3.5 mmol/L

≥3.5 mmol/L

Total

99% or

95% CI

CTT: More Intensive LDL Lowering

can Decrease CV Events by 40-50 %

Lancet 2010; 376: 1670

Consistent relationship between

LDL-C reduction and CHD relative risk

Robinson JG et al. J Am Coll Cardiol. 2005;46:1855–1862.

15 20 25 30 35 40

–20

0

20

40

60

80

100

LDL-C reduction, %

No

nfa

tal M

I an

d C

HD

de

ath

rel

ativ

e ri

sk r

edu

ctio

n, %

4S CARDSPOSCH ASCOT-LLANHLBI PROSPERLRC ALERTUpjohn HPSLos Angeles AF/TexCAPSMRC LIPIDOslo CARELondon WOSCOPS

LDL during statins and CV risk

JACC 2014;64:485

Variable response to intensive statin

therapy: 40 % do not get to LDL below

70 :A metaanalysis of 38153 patients

JACC 2014;64:485

1,8 mmol/L

(70 mg/dL)

Despite Statin Therapy,Many High-Risk Patients HaveMarked LDL Elevations

Den

sit

y

0,6

0,5

0,4

0,3

0

0,2

0,1

0

1 2 3 4 5 76

LDL-C (mmol/L)

Non high-risk

High-risk

LDL-C 2,6 mmol/L

(100 mg/dL)

46,8%

Gitt AK et al. Eur J Prev Cardiol 2012; 19: 221–30

NEW APPROACHES FOR THE (NEAR) FUTURE?

The PCSK9 (Proprotein Convertase

Subtilisin/Kexin type 9) Story

From discovery to clinical applications

Strategies for inhibition of PCSK9

PCSK9 : Rapid Progress from Discovery to Clinic

2003

PCSK9 (NARC-1) discovered

Seidah et al. PNAS 2003; 100: 928-33

PCSK9 GOF mutations (missense mutations)

cause Autosomal Dominant Hypercholesterolemia

Abifadel et al. Nat Genet 2003; 34: 154-6

Rashid S et al. PNAS 2005; 102: 5374-9

LDLR Protein Levels are Increased in Livers of

Mice with No PCSK9

LDLR

PCSK9

Ldlr -/- WT Pcsk9-/-

P and C denote the proprotein and cleaved forms of PCSK9

PCSK9 : Rapid Progress from Discovery to Clinic

PCSK9 KO mice LDL-C

Rashid et al. PNAS 2005; 102: 5374-9

PCSK9 LOF mutations (nonsense mutations)

associated with low LDL-C and large reduction

in the incidence of CHD

Cohen et al. Nat Genet 2005; 37:161-5

& N Engl J Med 2006; 354:1264-72

2005

Catalytic domainPCSK9

Y142X C679X

LDL-C<5%

%

n = 3,557

Dallas Heart Study

LOF (Nonsense) Mutations in PCSK9

Prodomain C-terminal

Cohen et al. 2005. Nat. Genet. 37:161-165. LDL Cholesterol

ARIC: 28% Reduction in LDL - 88% Reduction in

CHD in AA with PCSK9 (Y142X or C679X)

4

8

12

Coro

nary

Heart

Dis

ea

se

(%

)

Y142X or

C679X - +

** P = 0.008

PCSK9

mutations

n = 3,364

Cohen et al. 2006. N. Engl. J. Med. 354:1264-1272.

88%

HTN - 55%

Diabetes - 18%

Smoking - 30%

PCSK9 LOF, LDL-C and Risk of CHD

Population PCSK9 Mutation

LDL-C Reduction

CHD Reduction

ARIC Study 1

(US)

Y142X

or C679X28% 88%

R46L 15% 47%

3 independent

Danish Studies 2R46L 14% 34%

1. Cohen et al. 2006. N Engl J Med; 354:1264-1272

2. Benn et al. 2010. J Am Coll Cardiol; 55: 2833-42

FH exposes patients to high cholesterol from birth, with CHD earlier in life

Cumulative exposure (cholesterol-yrs) by age: FH vs. unaffected (healthy) individuals

Threshold for CHD:Reached on average by:

Age 15 for HoFH Age 40 for HeFH Age >60 in healthy individuals

Evidence of CVD early in life MI and CHD death at an average

age of 42 and 45 years, respectively1

Carotid arterial wall atherosclerosis progression noted from age 12 onwards2

Horton et al. J Lipid Res. 2009;50:S172-S177.1. Williams RR et al, JAMA. 1986;255(2):219-224.2. Weigman J Lancet 2004; 363: 369-37.

PCSK9 / NARC-1

Subtilisin subfamily

Tissue expression: liver, small intestine, kidney

(other tissues?)

Crystal structure (Piper et al. Structure 2007)

Its acts primarily as a secreted factor

PCSK9 is secreted into plasma

PCSK9: structure

VLDLRApoER2 (LRP8)LRP1CD36

PCSK9: cellular biology

PCSK9: cellular biology

Presence of PCSK9 Less LDLR Higher plasma LDL-C

PCSK9: cellular biology

Impact of PCSK9 on the LDL receptor

Secreted PCSK9 binds to the first EGF-A

repeat of the LDL-R at the cell surface

Internalization of the PCSK9/LDLR complex

Directing the LDLR for degradation in

lysosome rather than being recycled

Decrease of LDLR on hepatic cell surface

Modulation of PCSK9 levels by

lipid-lowering drugs

Statins increase human serum levels of PCSK9

Ezetimibe in combination with statins induces

a complementary increase in PCSK9 levels

Impact of fibrates is controversial

Statin

SREBP-2

Hepatocytes LDL-R numbers

LDL-R

+

PCSK9

-

Paradoxical effect of statin treatment

Farnier M. Am J Cardiovasc Drugs 2011; 11: 145-52

Regulation of the hepatocyte LDL Receptor

Plasma

LDL

Endosome

Golgi

apparatus

PCSK9

proteinEndocytosis

LDL-R

Plasma LDL

uptake

LDL-R

expression PCSK9

expression SREBP

activation

Statins

Hepatocyte

cholesterol content

Cholesterol

internalization

PCSK9

secretion

LDL, LDL-R

and PCSK9

degradation

Lysosome

LDL

protein

at cell

surface

Farnier M. Am J Cardiovasc Drugs 2011; 11: 145-52

The PCSK9 Story

From discovery to clinical applications

Strategies for inhibition of PCSK9

PCSK9 inhibitors in development

Compound Company Phase of clinical

development

mAbs

Alirocumab (REGN727/

SAR236553)1

Sanofi/Regeneron Phase 3

Evolocumab (AMG 145)2 Amgen Phase 3

RN-316 (PF-04950615)3 Pfizer/Rinat Phase 2 (completed)

RG 76524 Roche/Genentech Phase 2 (on hold – looking

for partner)

LY30150145 Eli Lilly Phase 2

LGT2096 Novartis Phase 2 (discontinued)

28

(1) http://clinicaltrials.gov/ct2/results?term=REGN727%2F+SAR236553&Search=Search

(2) http://clinicaltrials.gov/ct2/results?term=AMG+145&Search=Search

(3) http://clinicaltrials.gov/ct2/results?term=PF-04950615&Search=Search

(4) www.roche.com/irp2q12e-annex.pdf p131

(5) http://clinicaltrials.gov/ct2/show/NCT01890967?term=LY3015014&rank=3&submit_fld_opt=

(6) http://clinicaltrials.gov/ct2/results?term=LGT209&Search=Search

PCSK9 inhibitors in development

Compound Company Phase of clinical

development

(si)RNA

ALN-PCS1 Alnylam Pharmaceuticals Phase I (IV formulation)

Pre-clinical (SC formulation)

Adnectin

BMS-9624762 BMS Phase I

Mimetic Peptides

EGF-A peptide3 Department of Cardiovascular and

Metabolic Disease Research,

Schering-Plough Research Institute

Pre-clinical

Prodomain and C-terminal domain

interaction disruption4

Department of Cell Biology and

Anatomy, School of Medicine,

University of South Carolina

Pre-clinical

29

(1) http://clinicaltrials.gov/ct2/results?term=ALN-PCS&Search=Search

(2) http://www.clinicaltrials.gov/ct2/show/NCT01587365

(3) Shan L, et al. Biochem Biophys Res Commun. 2008 .10;375(1):69-73.

(4) Du F, et al. J Biol Chem. 2011 286, 43054-43061.

Impact of PCSK9 inhibition on LDL receptor

expression

30

For illustration purposes only

Alirocumab : relationship between mAb levels, PCSK9 and LDL-C

-70

-60

-50

-40

-30

-20

-10

0

0

20

40

60

80

100

120

140

160

180

200

0 500 1000 1500 2000 2500

LDL-

-C m

ean

% c

han

ge

Fre

e/T

ota

l PC

SK9

Co

nc.

(n

g/m

L)To

tal R

EGN

72

7 (

ng/

mL)

X 0

.01

Time (hours)

Free PCSK9, Total REGN727/SAR236553 Concentration and Mean % Change LDL-C vs Time

Total REGN727/SAR236553 free PCSK9 LDL-c2 W 4 W

PCSK-9 antibody reduces LDL-C

Stein EA et al. N Engl J Med. 2012;366:1108–1118.

Stein et al; N Engl J Med 2012; 366: 1108-18

Subcutaneous dose of 150 mg with Atorvastatin

SC injections

Days 1 29 43

Multiple-dose Phase 1 Trial with

Alirocumab

33

SC injections

Days 1 29 43

34Stein et al; N Engl J Med 2012; 366: 1108-18

Multiple-dose Phase 1 Trial with Alirocumab

Subcutaneous dose of 150 mg with Atorvastatin

Patient population LDL-C (%) ApoB (%) Lp(a) (%) TG (%)

On stable atorvastatin therapy1 - 67,3 - 58,3 - 28,6 - 28,6

On atorvastatin 10 mg2 - 66,2 - 54,4 - 34,7 - 4,0

Heterozygous FH3 - 57,3 - 43,8 - 19,5 - 5,7

1. Mc Kenney et al. J Am Coll Cardiol 2012; 59: 2344-53

2. Roth et al. N Engl J Med 2012; 367: 1891-900

3. Stein et al. Lancet 2012; 380: 29-36

Data expressed as % change vs placebo (except ref. 2 : % change vs baseline)

Effect of Alirocumab mAb 150 mg Every 2

Weeks (data from phase 2 trials)

35

Efficacy of Alirocumab in patients with HC on

stable Atorvastatin therapy

% change in LDL-C by stratified Atorvastatin dose

McKenney et al. J Am Coll Cardiol 2012; 59: 2344-53

Change in Calculated LDL-C at Two Weekly

Intervals From Baseline to Week 20

Stein EA et al. Lancet. 2012;380:29–36.

Me

an

(±S

E)

% c

ha

ng

e in

LD

L-C

fro

m b

ase

line

-30

-40

-60

0

-20

10

20

-10

-50

-70

-80

Baseline Week 2 Week 4 Week 6 Week 8 Week 10 Week 12 Week 16 Week 20

Placebo 150mg Q4W 200mg Q4W 300mg Q4W 150mg Q2W

LAPLACE-2: Percent Reduction LDL-C Mean of Weeks 10/12 (N=1899)

Adapted from: Robinson JG, et al. JAMA 2014 [In press].

Evolocumab Q2W & Q4W 59–66% reductions LDL-C vs baseline

Ezetimibe 17–24% reductions LDL-C vs baseline

Placebo Q2W

Placebo Q4W

Ezetimibe QD + Placebo Q2W

Ezetimibe QD + Placebo Q4W

Evolocumab 140 mg Q2W

Evolocumab 420 mg Q4W

Treatment armAtorvastatin

80 mg

Rosuvastatin

40 mg

Rosuvastatin

5 mg30

-70

-50-40

-60

-10

-100

-20-30

Atorvastatin

10 mg

Simvastatin

40 mg

-90-80

01020

Me

an

% C

ha

ng

e in

LD

L-C

fro

m B

ase

line

All p<0,001 for Weeks 10/12 vs Placebo + Ezetimibe

a Top 5 in evolocumab treatment group. b One subject died after the end of study. c Reported using high-level term groupings which included injection

site (IS) rash, IS inflammation, IS pruritus, IS reaction, and IS urticaria. d Binding antibody was present at baseline and at the end of study. No neutralizing antibodies were detected.

Robinson JG, et al. JAMA 2014 [In press].

LAPLACE-2 Safety

n (%)

Any Statin +

Placebo

(n=558)

Atorvastatin +

Ezetimibe

(n=221)

Any Statin +

Evolocumab

(n=1117)

Any TEAEs 219 (39) 89 (40) 406 (36)

Most common AEsa

Back pain

Arthralgia

Headache

Muscle spasms

Pain in extremity

14 (3)

9 (2)

15 (3)

6 (1)

7 (1)

7 (3)

4 (2)

5 (2)

6 (3)

3 (1)

20 (2)

19 (2)

19 (2)

17 (2)

17 (2)

Serious AEs 13 (2) 2 (1) 23 (2)

AEs leading to study drug discontinuation 12 (2) 4 (2) 21 (2)

Deaths 1 (0,2) 0 (0)b 0 (0)

CK >5 x ULN 2 (0,4) 0 (0) 1 (0,1)

ALT or AST > 3 x ULN 6 (1) 3 (1) 4 (0,4)

Potential injection site reactionsc 8 (1) 2 (1) 15 (1)

Neurocognitive AEs

Cognitive deterioration

Disorientation

0 (0)

0 (0)

1 (0,5)

1 (0,5)

0 (0)

0 (0)

Post-baseline binding antibodies NA NA 1 (0,1)d

LAPLACE trial showed that AMG 145 reduced LDL-C by up to 64% at

week 12 and up to 90% of patients achieving LDL-C <70 mg/dL*

LDL goal achievement

*NCEP-ATP III LDL-C goals

Amgen data on file.

25 50 75 100 125 150 175 200 225LDL-cholesterol (mg/dL)

High risk patients treated with statins

High risk patients

treated with statins

+ 140mg Q2W AMG 145GOAL

ODYSSEY MONO Phase 3 Trial

• Mean LDL-C and free PCSK9 levels in patients treated with

alirocumab according to uptitration status

LDL-C Free PCSK9

M. Farnier et al Poster EAS Madrid 2014

41

PK/PD of Alirocumab 150mg Q4W in

Combination with Fenofibrate

Dotted lines indicate no measurement taken for this period

42

J. Rey et al Poster #1183/131 ACC 2014

Ezetimibe 10

(N=51)

Alirocumab 75 Q2W/150 Q2W

(N=52)

Patients with any TEAE 40 (78,4%) 36 (69,2%)

Patients with any treatment emergent SAE 1 (2,0%) 1 (1,9%)

Patients with any TEAE leading to death 0 0

Patients with any TEAE leading to

permanent treatment discontinuation 4 (7,8%) 5 (9,6%)

n (%) = number and percentage of patients with at least one TEAE

Treatment-emergent AEs (TEAEs) are AEs that developed or worsened or became serious during the TEAE period

TEAE period: The TEAE observation period is defined as the time from the first dose of double-blind IMP to the last

dose of double-blind IMP injection + 70 days (10 weeks) as residual effect of alirocumab is expected until 10 weeks

after the stop of double-blind IMP injection.

ODYSSEY MONO Phase 3 Trial

Safety

M. Farnier et al Poster EAS Madrid 2014

Phase 3 Trials:

Alirocumab, Evolocumab, Bococizumab

ClinicalTrials.gov. available at: http://clinicaltrials.gov. Accessed May 20, 2014.

44

Trial Type

Alirocumab

Double-

Blinded

Trials

NDuration

(Mos)

Patient

Exposure

(Yrs)

Minimum

LDL-C

Levels

(mg/dL)

Evolocumab

Double-

Blinded Trials

NDuration

(Mos)

Patient

Exposure

(Yrs)

Minimum

LDL-C

Levels

(mg/dL)

BococizumabDouble-

Blinded Trials

NDuration

(Mos)

Patient

Exposure

(Yrs)

Minimum

LDL-C

Levels

(mg/dL)

HeFH

ODYSSEY

FH I471 18 496 ≥100

RUTHERFORD-2 300 3 46 ≥100 SPIRE-HF 300 12 200 ≥70ODYSSEY

FH II250 18 250,5 ≥100

ODYSSEY

HIGH FH105 18 106,5 ≥160

Combo

Therapy

ODYSSEY

COMBO I306 12 210 ≥ 70

LAPLACE-2 1700 3 231 ≥80

SPIRE-HR 600 18 600 ≥70

ODYSSEY

COMBO II660 24 960 ≥70

SPIRE-LDL 1600 18 1600 ≥70ODYSSEY

OPTIONS I350 6 50 ≥70

ODYSSEY

OPTIONS II300 6 50 ≥70

MonotherapyODYSSEY

MONO100 6 25.5 ≥100 MENDEL-2 600 3 92 ≥100

Statin

IntoleranceODYSSEY

ALTERNATIVE250 6 50 ≥70

GAUSS-2 300 3 46 NonePLANNED

GAUSS-3 500 3 NA NA

LTSODYSSEY

LONG-

TERM

2100 18 2340 ≥70

DESCARTES 905 12 602 ≥75

SPIRE-LL 939 12 626 >100OSLER

Open label 3515 12+ TBD TBD

Total Number of Patients 48924538 patient-years

In double-blind placebo controlled trials

Total Number of

Patients7820

1017 patient-yearsIn double-blind placebo

controlled trials

Total Number of

Patients3439

~3000 patient-years(assumes 2:1 randomization,

final number likely to be larger as anticipate

additional trials)

CVDOutcomes Trials

ODYSSEY OUTCOMES

18000Event Driven

N/A ≥70 FOURIER 22500Event Driven

N/A ≥70

SPIRE-1 12000Event Driven

N/A≥70 &<100

SPIRE-2 6300Event Driven

N/A >100

PCSK9 Monoclonal Antibody Therapy

Evidence to date

Very effective lowering of LDL-C, non HDL-C, ApoB

Positive effects on Lp(a), TG

Lipid effects in monotherapy and additive to other LDL lowering drugs

Unanswered issues

Longer term lipid efficacy (dosing interval)

No short-term safety issues (months)

Longer term safety profile

Immune effects over time

CVD outcome trial efficacy

Other issues

Relevance of other therapies at very low LDL-C levels

Cost

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