RNA therapeutics for cardiovascular diseases

Sotirios Tsimikas, MD

Director of Vascular Medicine

Professor of Medicine

University of California San Diego

39th Panhellenic Congress of Cardiology

Oct 19, 2018

1

2

Disclosures

Named as co-inventor and receives royalties from patents

owned by the University of California San Diego on oxidation-

specific antibodies

Co-Founder of Oxitope, Inc

Dual appointment at UCSD and Ionis Pharmaceuticals

2

Unmet need – Beyond LDL-CFOURIER Trial Demonstrated 2% Absolute reduction n CVD events and no Effect of CVD Mortality

Sabatine et al. NEJM 2017 3

Lipoprotein Targets in Preventing and Treating Cardiovascular Disease

TG

ApoC-III

Lp(a)

Apo(a)

Genetically Validated Lipoprotein Targets

TG-LDL

ANGPTL3

LDL-C

apoB

4

FDA Approvals for RNA Therapeutics6 drug approvals to date

▪ 1998 - Vitravene (fomivirsen, Ionis) – CMV retinitis

▪ 2004 - Mucagen (pegaptanib, OSI Pharma)—VEGF

▪ 2013 - Kynamro® (mipomersen, Ionis)- HoFH

▪ 2016- Spinraza (nusinersen, Ionis) - SMA

▪ 2018- Tegsedi (inotersen-Ionis/Akcea) – TTR amyloidosis

▪ 2018- Patisiran (Onpattro- Alnylum)- TTR amyloidosis

▪ ?2018- Waylivra (volanesorsen, Ionis/Akcea)

5

U.S. Companies Developing RNA-targeted Therapies*

* As of April 2017

Antisense Technology Companies

Ionis Pharmaceuticals

Bio-Path Holdings

Enzo Biochem

Idera Pharmaceuticals

Rexahn

Sarepta Therapeutics

Wave Therapeutics

RNAi Technology Companies

Alnylam

Arrowhead Research Corp.

Dicerna Pharmaceuticals

Galenta Biopharma (previously RXi Pharmaceuticals)

Marina Biotech (f.k.a mdRNA)

Merck (Sirna)

Opko (f.k.a cuRNA)

PhaseRx

Rxi Pharmaceuticals

Quark Pharma

Sirnaomics

Solstice Biologics

SomaGenics

Additional RNA-targeting Technology

Companies

Company Platform Technology

Arcturus

Therapeutics LNP oligomers

Avidity

NanoMedicines Antibody-siRNA complexes (ARCs™)

Bioneer

SAMiRNA (Self-Assembled-Micelle-inhibitory-

RNA)

Halo-Bio, RNAi

TherapeuticsMultivalent RNAi

miragen miRNA

miRNA (subsidiary

of Asuragen)miRNA

Moderna

synthetic mRNA to upregulate protein

expression

Voyager

Therapeutics AAV-directed RNAi therapeutics

Ziopharm DNA therapeutics

◼ 24 non-U.S. companies developing

RNA-targeted therapies*

6

RNA Therapeutics to “Silence” GenesFundamentally Novel Therapy Compared to Small Molecules and Antibodies

Gene mRNA

Transcription

Translation

DISEASE

Traditional Small Molecule Drugs

Inhibitors or Agonists of proteins

Biologics

Inhibitors or Mimics of proteins

DISEASE

Disease-Causing

Protein

DISEASEX XTranslation

Disease-Causing

Protein

Antisense

OligonucleotideInhibition of RNA function

(no production of disease

causing protein) 7

AntisenseSingle-Strand

Multiple Mechanisms

DNAPhosphorothioate (PS)

2’-MOE, 2’-OMe, cEt, LNA

siRNADouble-strandRISC Mechanism

RNAPhosphodiester

2’-OMe, 2’-F

Aliphatic substituents

AptamerStructured

DNA or RNA Mixed modifications

Pegylation(REG1 anticoagulation system)

Distinct Chemical Classes of RNA-Based

Technologies & Therapeutics

Aptamer

Target

Protein

Sense

Strand

Antisense

Strand

Antisense

Strand

8

Isis Pharmaceuticals Confidential

RNaseH1 and siRNA Antisense Mechanisms

◼ siRNA Mechanism ◼ RNase H1 Mechanism

Antisense Strand

mRNA-Antisense Duplex

RNase H1

DNA

mRNA

Nucleus

Cytoplasm

Cell Membrane

Cell Membrane

CytoplasmNucleus

Antisense Strand

RNase H like nuclease

DNA

mRNA

RISCSense Strand

siRNA Duplex

9

9

Antisense

Oligonucleotide RNA Target

The Antisense Drug-Receptor Interaction

~15-20 base pairs required for specificity and bindingNatural DNA and RNA do not make good drugs due to insufficient stability and distribution in animalsThis can be addressed with appropriate chemical modification

10

10

Examples of Chemical Modifications Used in RNA Therapeutic Agents

2ʹ-O-methoxyethyl (MOE)

OB

O

O

B

O

O

B

O

O

O

B

O

O

OP

O

O

OP

O

B

O

OP

O

OP

O

OP

OMe

OO

Me

OO

Me

OO

Me

OO

MeX = S, O

-X

-X

-X

-X

-X

11

11

RNAse H1 ASO Design and Ionis Clinical Experience

Clinical Experience with 2nd Generation ASOs

• >6000 subjects treated by IV and/or SC administration

• >60 clinical studies

• Multiple therapeutic indications

• >100 patients dosed for >1 year

• Some patients dosed for > 4 years

• Doses up to 1200 mg/wk tolerated

MOEMOE

↑ affinity

↑ stability

↑ tolerability

↑ affinity

↑ stability

↑ tolerability

RNase H1

Substrate

DNA

Chimeric RNase H1 ASO Design

• Specific sequence not repeated throughout genome, reducing potential for off-target binding

12

RNase H1 Terminating Mechanism

12

12

Composition of Lp(a) and Relationship to Plasminogen

1

3

Tsimikas J Am Coll Cardiol 2017;69:692-711 13

Continental Differences in the Prevalence of Elevated Lp(a)Lp(a) level gradient (high to low): Africa, South Asia, Europe, North America, South America, East Asia

14

Baseline Lp(a) Quartile vs. MACE ODYSSEY OUTCOMES

*Adj. for age, sex, race, geographic region, time since index event, BMI, smoking history,

diabetes, baseline LDL-C, and treatment assignment. Quartile interaction P-value in

adjusted model: p=0.44 with treatment, p=0.67 with baseline LDL-C

Quartile 1(<6.7 mg/dL)

Quartile 2(6.7 to <21.2 mg/dL)

Quartile 3(21.2 to <59.6 mg/dL)

Quartile 4(≥ 59.6 mg/dL)

0.0

2.5

5.0

7.5

10.0

12.5

MA

CE

Incid

ence (

%)

9.7%9.3%

12.2%

10.2%

Unadjusted Adjusted*

HR (95% CI)

Q2 vs Q1:

Q3 vs Q1:

Q4 vs Q1:

1.06 (0.93-1.21) 1.05 (0.92-1.20)

1.12 (0.99-1.28) 1.08 (0.95-1.23)

1.37 (1.21-1.55) 1.28 (1.13-1.46)

Quartile p-value: <0.0001 0.0005

15

What are the mechanisms through which Lpa) mediates CVD and CAVS?

Tsimikas JACC 2017;69:692-71116

OxPL-apoB and CVD Outcomes

Byun et al JACC 2015;65:1286-95 17

Lp(a)-OxPL and Aortic Stenosis

18

Unifying Hypothesis of Lp(a)-OxPL-ATX axis in CAVS

Torzewski et all JACC BTS 201719

2016 ESC/EAS Guidelines for the Management of Dyslipidemias

Catapano et al Eur Heart J 2016;37:2999-3058

Also endorsed by the 2016

Canadian Lipid Guidelines

20

Lp(a) – The Sword of Damocles?Lp(a) – The Sword of Damocles?

21

IONIS-APO(a)-LRx Produced Dose-dependent Significant Reductions in Lp(a)

Up to 99% Reduction in Lp(a),

with Mean Reduction of 92%

Multiple Ascending Dose

▪ Well tolerated with no safety

concerns

Lp

(a)

(nm

ol/

L)

Mean

% C

ha

ng

e F

rom

Baseli

ne

(+

/-S

EM

)

Study Day

20 mgPlacebo 10 mg 40 mg

Viney et al. Lancet 2016

Mean Lp(a) reductions:

10 mg= ↓ 68%

20 mg= ↓ 80%

40 mg= ↓ 92%

22

Phase 2ISIS 681257-CS6 STUDY

(AKCEA APO(a)-LRx)

A Randomized, Double-Blind, Placebo-Controlled, Dose Ranging Phase 2

Study of ISIS 681257 Administered Subcutaneously to Patients with

Hyperlipoproteinemia(a) and Established Cardiovascular Disease (CVD)

Accepted as a Late Breaking Clinical Trial at AHA

Nov 12 2018

23

Potential Design of CVOT Targeting Lp(a)

Lp(a) Cardiovascular Outcomes Trial

Inclusion Criteria:

Lp(a) >70 mg/dL, guideline recommended

LDL-lowering therapy, prior hx CVD

Lp(a) lowering therapy vs. Placebo

Primary Endpoint: MACE+ (CV Death, MI, Revascularization)

4 yr median f/u

Randomize to:

24

Potential RCT of Mild-Mod Aortic Stenosis

Lp(a) AS Trial (n=600)

Lipoprotein(a) Directed Antisense Therapy to Reduce

Progression of Aortic Stenosis Trial

Inclusion Criteria:

Lp(a) >60 mg/dl, AVA 1.3-1.7 mm2, EF >50%

ASO to apo(a) (sc monthly) vs. Placebo

Primary Endpoint: 3 Year change in AVA or mean AV gradient by echocardiography

Secondary Endpoints: 1- Rate of AVR

2- Progression of AV calcification measured by

AoV calcium and Na18F uptake

25

Potential RCT of Aortic Stenosis

OxPL AS Trial (n=600)

OxPL Directed Therapy to Reduce

Progression of Aortic Stenosis Trial

Inclusion Criteria:

OxPL-apoB in upper tertile, AVA 1.3-1.7 mm2, EF >50%

OxPL-ATX directed Rx vs. Placebo

Primary Endpoint: 3 Year change in AVA or mean AV gradient by

echocardiography

Secondary endpoints: 1- Rate of AVR

2- Progression of AV calcification measured by

AoV calcium and Na18F uptake26

We did it Jenkins!

We found the Higgs

boson!

Now let’s search for a

medical cure for

aortic valve stenosis

The future?…

27

APOC3 as a Target for CHD Risk Reduction

40% Reduction in apoC-III

40% Reduction in TG

40% Reduction in CHD Risk

28

FCS (Familial Chylomicronemia Syndrome)A Rare Genetic Disease Due to Mutations in LPL

European and FDA Orphan Drug Designation

29

30

Familial Chylomicronemia Syndrome (FCS): A Severe and Rare Genetic Disorder

▪ Background:▪ Rare autosomal recessive disorder (orphan disease)

▪ Caused by null loss-of-function LPL, GPIHPB1, APOC2, APOA5, LMF1 gene mutations

▪ Clinical expression/risk:▪ TG most often > 1000 mg/dl (11,1 mmol/L)

▪ Signs and symptoms:

▪ Abdominal pain (recurrent, often severe)

▪ Plasma lactescence and viscosity

▪ Lipemia retinalis

▪ Hepatosplenomegaly

▪ Eruptive xanthomas

▪ Acute pancreatitis

▪ Pancreatic insufficiency

▪ Diabetes, other complications30

APPROACH TrialPrimary Endpoint

Patients had an average 77% reduction in triglycerides at 3 months on volanesorsen, as compared to an average of 18% increase on placebo, p<0.001, for an absolute difference in average percent change of -94%

-100

-80

-60

-40

-20

0

20

40 Volanesorsen

(n=33)

Placebo

(n=33)

94% Treatment Effect

(-121.7, -66.6)

p-value < 0.001

LSM (95% CI) %

Change from

Baseline in TG

(mg/dL)

Placebo (N=33)

Baseline TG* 2152 (1153)

Month 3 TG* 2367 (1315)

Volanesorsen (N=33)

Baseline TG* 2267 (1259)

Month 3 TG* 590 (497)

-77

+18

31

Relationship of TG levels and CVD in dal-OutcomesPotential Effect of IONIS-APOCIII-LRx (now in Phase I)

32

Adjusted for age, sex, smoking, diabetes, HDL-C, BMI

0.0

0.5

1.0

1.5

2.0

≤80 >80-103 >103-130 >130-175 >175

Ris

k o

f p

rim

ary

en

dp

oin

t ev

en

t(Q

1=r

efe

ren

t)

Quintiles of triglycerides (mg/dL)

PlaceboIONIS-APOCIII-LRx

Schwartz et al., J Am Coll Cardiol 2015;65:2267-75

Risk reduction

32

Acknowledgments

UCSD

Calvin YeangXiaohong Yang

Phuong MiuJoseph Witztum

Ionis

Nick VineyVickie Alexander

Mark GrahamRosanne CrookeMichelle Fugett

Joseph TamiLynnetta WattsSteve HughesRichard GearyStanley Crooke

Ionis/Akcea

Ewa ProkopczukBoyan Litchev

Karren WilliamsPhil Piscitelli

Jonathan GuerrieroLouis O’Dea

Collaborators

Santica MarcovinaPatrick Moriarty

F. M. Van der WalkJ. C. van CapelleveenRaimund Pechlaner

Erik StroesJohn Kastelein

Romain CapouladePatrick Mathieu

Phil PibarotPia Kamstrup

Borge NordestgaardPeter WilleitManuel Mayr

Stephan Kiechl

33