James M. McKenney, PharmDPresident and CEO, National Clinical Research, Inc.

Professor Emeritus, Virginia Commonwealth University Richmond, VA

Clinical Trials for PCSK9

2014 NLA Scientific Sessions, Orlando, FL

Dr. McKenney is an employee of National Clinical Research which has received research funding from Sanofi, Regeneron, Amgen, Pfizer, BMS, Novartis, and Lilly which are developing PCSK9 therapies

Speaker Disclosure

The Interplay Between LDL-C, Hepatocyte Cholesterol Synthesis, LDL-R, and PCSK9

9am 12pm 3pm 6pm 9pm 12am 3am 6am 9am

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PCSK9

Lathosterol

Total Cholesterol

Persson et al. Arterioscler Thromb Vasc Biol 2010; 30: 2666-2672

Diurnal Variation of Cholesterol Synthesis and PCSK9

Food Intake

PCSK9 Inhibitors in Development

Investigational Product Company Stage of

Development

Monoclonal antibodies

Alirocumab (SAR236553, REGN727) Sanofi (Regeneron) Phase III

Evolocumab (AMG 145) Amgen Phase III

Bococizumab (PF-0490615, RN316) Pfizer (Rinat) Phase IlI

LY3015014 Lilly Phase II

Other PCSK9 biologics

ALN-PCS (siRNA) Alnylam, The Medicines Comp Phase I

Revised from Stein et al Annu Rev Med. 2014; 65: 417-431

Effect of ALN-PCS on LDL-C AfterA Single 0.400 mg/kg Dose

0 5 10 15 20 25 30

1.2

1.0

0.8

0.6

LDL-

C r

elat

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to b

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(mg/

dL)

Days

Findings: Mean PCSK9 reduction = 70% Mean LDL-C reduction = 40% Effect duration ~ 30 days

32 normal volunteers received doses ranging from 0.015-0.400 mg/kg (#24) or normal saline (#8) via IV infusion over one hour

144 mg/dL

Fitgerald et al Lancet 2014; 383: 60-68

iRNA discovered in 1998Nobel Prize in 2006First POC study with siRNA

Impact of mAb on LDL-C Homeostasis

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0 500 1000 1500 2000 2500

Free/Total PCSK9

 Con

c. (n

g/mL)

Total R

EGN727 (ng/mL)  X

 0.01

Time (hours)

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

Total REGN727/SAR236553

10 20 40 60 80 100

(days)

Unbound alirocumab concentration

ALIROCUMAB 150 mg SCDynamic Relationship Between mAb Levels, PCSK9 and LDL-C

Stein EA et al. NEJM 2012; 366: 1008-1118.

(days)

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0 500 1000 1500 2000 2500

Free/Total PCSK9

 Con

c. (n

g/mL)

Total R

EGN727 (ng/mL)  X

 0.01

Time (hours)

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

free PCSK9

(days)

10 20 40 60 80 100

Unbound alirocumab concentrationStein EA et al. NEJM 2012; 366: 1008-1118.

ALIROCUMAB 150 mg SCDynamic Relationship Between mAb Levels, PCSK9 and LDL-C

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LDL‐‐C m

ean % cha

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Free/Total PCSK9

 Con

c. (n

g/mL)

Total R

EGN727 (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‐c

(days)

10 20 30 40 60 80 100

Unbound alirocumab concentration

Stein EA et al. NEJM 2012; 366: 1008-1118.

ALIROCUMAB 150 mg SCDynamic Relationship Between mAb Levels, PCSK9 and LDL-C

Impact of Statin Therapy on PCSK9 & LDL-R

Impact of Statin Therapy on PCSK9 Levels

PCSK9 Change

Atorvastatin 80 mg (1) +47%

Atorvastatin 40 mg (2) +34%

Rosuvastatin 20 mg (3) +28% (men)+35% (women)

Controls (4)

Statin therapyStain-ezetimibe therapyTitration of atorva 5 to 80 mg/dTitration of rosuva 5 to 40 mg/d

+45%+77%+30%+37%

1. Welder et al. J Lipid Res 2010; 51: 2714-27212. Careskey et al. J Lipid Res 2008; 49: 394-398

3. Awan et all. Clin Chem 2012; 58: 183-1894. Dubuc et al. J Lipid Res 2010; 51: 140-149

Statin

Impact of mAb + Statin on LDL-C Homeostasis

x

Mean % ∆ in LDL-C (Placebo Adjusted) from Baseline to Week 12 With PCSK9 mAb on a Stable Statin Dose

InterventionmAb added to stable atorvadose of 10-40 mg QD with LDL-C ≥ 100 mg/dL

n=183, Duration = 12 wks

% Change LDL-C

InterventionmAb added to stable statin and LDL-C > ~85 mg/dL

n=631, Duration = 12 wks

% Change LDL-C

Alirocumab 50 mg Q2W -35% Evolocumab 70 mg Q2W -42%

Alirocumab 100 mg Q2W -59% Evolocumab 105 mg Q2W -60%

Alirocumab 150 mg Q2W -67% Evolocumab 140 mg Q2W -66%

Alirocumab 200 mg Q4W -38%

Alirocumab 300 mg Q4W -43% Evolocumab 280 mg Q4W -42%

Evolocumab 350 mg Q4W -50%

Evolocumab 420 mg Q4W -50%

McKenney et al. JACC 2012;59 2344-2353 Giugliano et al. Lancet 2012; 380: 2007-17

3

Mean percentage change in calculated LDL-C from baseline to weeks 2, 4, 6, 8, 10, and 12 in the modified intent-to-treat (mITT) population, by treatment group. Week 12 estimation using LOCF method.

LDL‐C Mean % Cha

nge from

 Baseline

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0BASELINE WEEK 2 WEEK 4 WEEK 6 WEEK 8 WEEK 10 WEEK 12

Placebo SAR 50mg Q2W SAR 100mg Q2W

SAR 200mg Q4W SAR 300mg Q4W SAR 150mg Q2W

∆  ‐ 64.2%

∆  ‐ 47.7%

∆ - 5.1%

∆  ‐ 39.6%

∆  ‐ 72.4%

∆  ‐ 43.2%

% LDL-C ∆ with Alirocumab Administered Q2W in nonFH Hypercholesterolemic Patients

McKenney et al. J Am Coll Cardiol 2012;59 2344-2353

-40%

-50%

-60%

-70%

-80%

W 8 Wk 9 Wk 10 Wk 11 Wk12

-40%

-50%

-60%

-70%

-80%

-90%

∆ L

DL-

C

LDL-C Reduction with Evolocumab Dose Ranging Study From Week 8 to 12

Q4W

Q2W

Giugliano et al. Lancet 2012; 380: 2007-17

70 mg

105 mg

140 mg

280 mg420 mg350 mg

Mean % ∆ in LDL-C From Baseline to End of Study With PCSK9 mAbs on a Stable Statin Dose

Intervention8 wks, n=92

Baseline LDL-C = 122 mg/dL

% Change LDL-C

Intervention52 wks, n=901

Baseline LDL-C = 104 mg/dL

% Change LDL-C

Atorvastatin 80 mg QD -17% Diet Evolocumab 420 mg Q4W -52%

Atorvstatin 10 mg QD + Alirocumab 150 mg Q2W -66% Atorvastatin 10 mg QD +

Evolocumab 420 mg Q4W -55%

Atorvastatin 80 mg QD + Alirocumab 150 mg Q2W -73% Atorvastatin 80 mg QD +

Evolocumab 420 mg Q4W -47%

Atorvastatin 80 mg QD +Ezetimibe 10 mg QD +Evolocumab 420 mg Q4W

-47%

Roth et al. NEJM 2012;367: 1891-1900 Blom et al. NEJM 2014; 370: online Mar 29, 14

Evolocumab was added to a stable diet or atorvastatin regimen (4 to 12 wks) in patients with LDL-C ≥ 75 mg/dL.

Alirocumab and atorva 80 uptitration was given to randomized patients who were receiving a stable atorva 10 mg QD regimen and had a LDL-C ≥ 100 mg/dL

McKenney et al. J Am Coll Cardiol 2012;59 2344-2353

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Apo B nonHDL-C Lp(a)

-2% -2%

-34%*

-56%*

-63%*

-0%

-13%†

-26%*-29%*-27%*

-48%*

-56%*

Placebo50 mg Q2W100 mg Q2W150 mg Q2W

1LS mean (SE)2median (Q1-Q3)* p < 00001† p = 0.0022

Changes in Apo B, nonHDL-C, and Lp(a) from Baseline to Week 12 with Alirocumab

McKenney et al. J Am Coll Cardiol 2012;59 2344-2353

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1LS mean (SE)2median (Q1-Q3)* p < 0.05† p = 0.0006

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Trig2 HDL-C1 Apo A11

10%

-1%

7%* 4% 6%0% 1% 1%

-7% -6%

-19%†

0%

Placebo50 mg Q2W100 mg Q2W150 mg Q2W

Changes in Trig, HDL-C, and Apo A1 from Baseline to Week 12 with Alirocumab

The Statin Intolerant Patient

PCSK9 mAb in the Statin Intolerant Patient

Mean % ∆ in LDL-C (Placebo Adjusted) from Baseline to Week 12 With PCSK9 mAb

InterventionIntolerance to one statin

mAb or Exe alone or in combination

n=160, Duration = 12 wks

% Change LDL-C

InterventionIntolerance to 2 statins

mAb alone Q2W or Q4W vs Eze

n=160, Duration = 12 wks

% Change LDL-C

Evolocumab 280 mg Q4W -41% Ezetimibe 10 mg qd -18%

Evolocumab 350 mg Q4W -43% Evolocumab 140 mg Q2W -56%

Evolocumab 420 mg Q4W -51% Ezetimibe 10 mg qd -15%

Evolocumab 420 mg Q4W

Ezetimibe 10 mg qd-63% Evolocumab 420 mg Q4W -53%

Exetimibe 10 mg qd -15%

Stokes et al JACC 2014, in pressSullivan et al JAMA 2012; 308: 2497-2506

Impact of HeFH on LDL-C Homeostasis

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. All patients receiving stable statin therapy

Mea

n (S

E) %

Cha

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in L

DL-

C f

rom

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elin

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-70

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0

10

20BASELINE WEEK 2 WEEK 4 WEEK 6 WEEK 8 WEEK 10 WEEK 12 WEEK 16 WEEK 20

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

Visit

-68%

-43%

-32%

-29%

-11%

FH Patient Profile (n=77) >70% on max dose statin >70% on ezetimibe Baseline LDL-C = ~155 mg/dL

Rx Results On-Rx LDL-C = ~ 50 mg/dL LDL-C < 100 = 97% LDL-C < 70 = 81%

Stein et al Lancet 2012; 380: 29-36

% ∆ LDL-C from Baseline to Wk 12 with Alirocumab in HeFH Patients

Efficacy of LDL-C Reduction With PCSK9 mAb in FH and non-FH Patients Receiving Statin Therapy

McKenney et al. JACC 2012; 59: 2344-53Stein et al. Lancet 2012; 380: 29-36

Alirocumab 150 mg Q2W

non- FH -67.3%FH -57.3%

Evolocumab 420 mg Q4W

non-FH -50.3%FH -56.4%

Giugliano et al. Lancet 2012; 380: 2007-17 Raal et al. Circulation 2012; 126: 2408-2417

Impact of HoFH on LDL-C Homeostasis

% ∆ LDL-C

Evolocumab420 mg Q4W

% ∆ LDL-C

Evolocumab420 mg Q2W

All subjects (n=8) -16.5% -13.9%

Receptor defective (n=6) -22.9% -23.6%

Receptor negative (n=2) 2.6% 15.3%

Homozygous FH PatientsMean % in LDL-C from Baseline to Week 12 With Evolocumab

Stein et al. Circulation 2013; 128: 21123-2120

Patients

Mean age 34Receiving intensive statin + ezetimibe Rx

Mean Baseline LDL-C = 442 mg/dL (218-563)

Phase III PCSK9 Development Plans

■ Familial hypercholesterolemia

■ Patients with high CVD risk and not at goal with statin Rx

■ Patients intolerant to statin therapy

■ Reduction of ASCVD events when added to a statin

Clintrials.gov (9/1/13)

Seeking indications for

Conclusions

■ Having an understanding of the interplay between cholesterol synthesis, LDL-R, PCSK9, and LDL-C helps us interpret the efficacy results with anti-PCSK9 therapies.

■ The mAbs currently in development are highly effective at lowering LDL-C, up to 70% on top of statin therapy.

■ These mAbs have a similar efficacy in patients with non-FH and HeFH dyslipidemias

■ Significant reductions are achieved in apo B, nonHDL-C, triglycerides, and Lp(a) levels

■ PCSK9 mAbs appear to be safe and well tolerated

Backup Slides

Evolocumab EfficacyMean ∆ in LDL-C from Baseline to Week 12 on Stable Statin

Intervention Baseline LDL-C (mg/dL)

% Change LDL-C

Attained LDL-C (mg/dL)

Placebo 124

Evolocumab 70 mg Q2W 120 -42%* 73

Evolocumab 105 mg Q2W 128 -60%* 54

Evolocumab 140 mg Q2W 120 -66%* 45

Evolocumab 280 mg Q4W 124 -42%* 69

Evolocumab 350 mg Q4W 124 -50%* 60

Evolocumab 420 mg Q4W 120 -50%* 58n = 631* p < 0.0001 for % change in LDL-C vs placebo Giugliano et al. Lancet 2012; 380: 2007-17

> 40 yo Hospitalization

with ACS in the past 4 months

Alirocumab SQ

Placebo SQ

Up to 64 months

Endpoint:First occurrence of:

CHD death, any non-fatal MI, fatal and non-fatal

ischemic stroke, UArequiring hospitalization

FOURIER

40 to 85 yo CV disease at high risk

for a recurrent event Fasting LDL-C ≥ 70 mg/dL

or non-HDL-C ≥ 100 mg/dL

Evolocumab SC Q2W or QM

Placebo SC Q2W or QM

60 months

Estimated completion:March 2018

Endpoint:Time to CV death, MI, hospitalization for UA,

stroke, or coronary revascularization

Estimated completion:February 2018

www.clinicaltrials.gov Nov 4, 2013

ODYSSEY Outcomes

Phase III PCSK9 Development Plans

Efficacy of AliocumabReduction in LDL-C With 150 mg SQ Q2W

HeFH Non-FHnonFH –no statin

-55.7%-64.7%

-57.0%

Stein et al. NEJM 2012; 366: 1108-1118

Multiple Dose Study, phase I

n=8n=8n=5

Dosing of Evolocumab

140 mg Q2W 420 mg Q4W

►Week 8 Week 9 Week 10 Week 11 Week 12

►0

· 10 —

· 90

►—100 —it— 280 mg n = 25 n = 6 n = 25 n = 16 n = 26

—M— 350 mg n = 27 n = 10 n = 26 n = 18 n = 27

—A— 420 mg n = 27 n = 17 n = 26 n = 19 n = 28

Week 8 Week 9 Week 10 Week 11 Week 12

10

· 90

—100

—•—• 70 mg n = 22 n=7 n = 23 n=16 n = 22

105 mg n = 25 n = 1 1 n = 28 n = 1 5 n = 28

140 mg n = 29 n = 16 n = 30 n = 20 n = 27

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-70%

-80%

W 8 Wk 9 Wk 10 Wk 11 Wk12

-40%

-50%

-60%

-70%

-80%

-90%

∆ LDL-C

LDL-C Reduction with Evolocumab Dose Ranging Study From Week 8 to 12