Akin Akinc, PhD Alnylam Pharmaceuticals

2014 ASH Annual Meeting

Special Scientific Symposium on RNA Therapeutics in Hematology

RNAi Therapeutics for Hemophilia and

Complement-Related Diseases

RNA Interference (RNAi) A New Class of Innovative Medicines

2

RNAi Therapeutics

Harness natural pathway

» Catalytic mechanism

» Mediated by small interfering

RNA or “siRNA”

Therapeutic gene silencing

» Any gene in genome

» Distinct mechanism of action vs.

other drug classes

» Unique opportunities for

innovative medicines

Clinically validated platform

GalNAc-siRNA Conjugates as RNAi Therapeutics

3

ASGPR

(pH>5)

GalNAc-siRNA

conjugate

Clathrin-coated pit

Clathrin-coated

vesicle

Endosome

Recycling

ASGPR

mRNA

Nucleus

protein

RISC

Asialoglycoprotein Receptor (ASGPR)

Highly expressed in hepatocytes

High rate of uptake

Recycling time ~15 minutes

Conserved across species

GalNAc-siRNA Conjugates (revusiran, ALN-AT3,

ALN-CC5, ALN-PCSsc, other programs) siRNA conjugated to N-acetylgalactosamine (GalNAc)

ligand

Efficient delivery to hepatocytes following subcutaneous administration

“Enhanced stabilization chemistry” (ESC) used with

ALN-AT3, ALN-CC5, ALN-PCSsc, and other programs

» Significantly improved potency and durability compared

with revusiran

GalNAc3

Discovery Development Phase 1 Phase 2 Phase 3

TTR-Mediated Amyloidosis

Hemophilia and Rare Bleeding Disorders

Complement-Mediated Diseases

Hypercholesterolemia

Hepatic Porphyrias

Alpha-1 Antitrypsin Deficiency

Hepatitis B Virus Infection

Beta-Thalassemia/Iron-Overload Disorders

Mixed Hyperlipidemia/Hypertriglyceridemia

Hypertriglyceridemia

Hypertension/Preeclampsia

Primary Hyperoxaluria Type 1

Additional Genetic Medicine/Other Programs

4

Alnylam Development Pipeline

ALN-TTRsc

Patisiran (ALN-TTR02)

ALN-AT3

Standard Template Chemistry (STC)-GalNAc Conjugate (SC)

LNP (IV) Enhanced Stabilization Chemistry (ESC)-GalNAc Conjugate (SC)

Delivery Technology:

ALN-CC5

ALN-PCSsc

ALN-AS1

ALN-AAT

ALN-HBV

ALN-TMP

ALN-ANG

ALN-AC3

ALN-AGT

ALN-GO1

Hemophilia and Complement-Mediated Diseases

5

Why RNAi Therapeutics? RNAi human translation achieved in multiple clinical

programs

GalNAc-siRNA conjugates have solved delivery challenge to liver

Hemophilia and complement-mediated diseases are technical and strategic fit » Significant unmet medical need

» Hepatocyte-expressed, secreted plasma protein targets

» Utilize existing delivery platform

» Well-validated, genetically defined pathways/diseases

» Phase 1 proof-of-concept possible

» Clear and rapid development

Hemophilia and Rare Bleeding Disorders Program Unmet Need and Product Opportunity

6

RNAi to treat hemophilia and rare bleeding

disorders (RBD) Hemophilias are recessive X-linked

monogenic bleeding disorders

» Hemophilia A: loss of function in Factor VIII

– >40,000 Patients in EU/US

» Hemophilia B: loss of function in Factor IX

– ~9,500 Patients in EU/US

Segments of high unmet need remain

» E.g., “Inhibitor” patients1,2 – 2,000 Patients in major markets; up to 6,000 WW

– >15-25 Bleeds/year; >5 in-hospital days/year

– ~$300,000/year avg. cost; up to $1M/year

RBD patients3 » Includes deficiencies in Factors II, V, VII, X, and XI

» ~1,000 patients WW with severe bleeding phenotype

1 WFH 2012 Global Survey; 2 Antunes et al., Haemophilia. 20:65-72 (2014); 3Peyvandi et al., J Thromb Haemost; 10, 615-621 (2012)

AT

FIX

FVIII

Antithrombin and ALN-AT3 Program

7

Antithrombin (AT) is genetically defined

target AT is key natural anticoagulant

» Inactivates factors Xa and thrombin

» Attenuates thrombin generation

Human AT deficiency associated

with increased thrombin generation

Expressed in liver; circulates in plasma

Co-inheritance of thrombophilic traits in hemophilia Associated with milder bleeding, reduced factor

requirements, fewer complications

Includes heterozygous

» Antithrombin deficiency

» Factor VLeiden

» Protein C deficiency

» Protein S deficiency

Kurnik et al., Haematologica; 92:982-5 (2007); Ettingshausen et al., Thromb Haemost; 85:218-20 (2001);

Negrier et al., Blood; 81:690-5 (1993); Shetty et al., Br J Haematol; 138:541-4 (2007)

FVIIIa

FVIIa FVII

FIXa

FVa FV

FX

FXa

Fibrinogen Fibrin

Thrombin Prothrombin

Blood clot

Intrinsic system Extrinsic system

Hemophilia A

Hemophilia B

FIX

FVIII

AT

ALN-AT3 in clinical development ESC-GalNAc-siRNA for SC dosing

Positive top-line SAD Phase 1 results

Orphan drug status in US and EU (HA/HB)

Phase 1 MAD study in patients ongoing

Antithrombin Depletion Increases Thrombin

Generation in Hemophilia Plasma

8

Antithrombin depletion increases peak height and delays inhibition of thrombin

HB Donor Plasma HA Donor Plasma

0

20

40

60

80

100

120

140

0 10 20 30 40 50 60

Time (min)

Th

rom

bin

(n

M)

FVIII=100%, AT=100%

FVIII<1%, AT=100%

FVIII<1%, AT=60%

FVIII<1%, AT=40%

FVIII<1%, AT=20%

FVIII<1%, AT=10%

FVIII<1%, AT=0%

0 10 20 30 40 50 60

FIX=100%, AT=100%

FIX<1%, AT=100%

FIX<1%, AT=60%

FIX<1%, AT=40%

FIX<1%, AT=20%

FIX<1%, AT=10%

FIX<1%, AT=0%

Time (min)

Th

rom

bin

(n

M)

0

50

100

150

200

WT

HA + PBS

HA + 1 mg/kg

HA + 30 mg/kg

ALN-AT3 Improves Hemostasis Microvessel Laser Injury Model (HA Mice)

Deposition of Platelets

Akinc, ISTH, July 2013; In collaboration with Dr. Lacra Ivanciu and Dr. Rodney Camire

Group Animals (N) Injuries (N) Stable Thrombus (N) Percent AT mRNA in liver

WT 5 25 25 100%

HA + PBS 5 25 0 100%

HA + 1 mg/kg ALN-AT3 5 25 25 50%

HA + 30 mg/kg ALN-AT3 6 30 30 5%

0 30 60 90 120 160 180

0

100

200

300

400

500

Pla

tele

ts A

rea

(m

icro

ns

2)

Time (sec)

9

0

100

200

300

Time (sec)

Fib

rin

Are

a (

mic

ron

s2)

0 30 60 90 120 160 180

WT

HA + PBS

HA + 1 mg/kg

HA + 30 mg/kg

HA + 100U/kg Advate

Deposition of Fibrin

HA + 100U/kg Advate

ALN-AT3 Improves Hemostasis Saphenous Vein Bleeding Model (HA Mice)

Saphenous vein bleeding model adapted from Whinna1

Saphenous vein exposed and transected to initiate bleeding

Thirty seconds after cessation of blood loss, clot dislodged to re-initiate bleeding

Number of hemostatic events in 30 min observation period recorded

Protocol details2 Treated animals received single SC

dose of ALN-AT3 to yield ~70% AT knockdown at time of model initiation

Control animals received 25 IU/kg Advate via IV administration 15 min prior to model initiation

N = 8 N = 15 N = 6 N = 9

p < 0.0001

Akinc, WFH 2014; 1Buyue et al., Blood; 112:3234-3241 (2008); 2In collaboration with Dr. Brian Cooley 10

0

5

10

15

20

-- Saline ALN-AT3 Advate

25 IU/kg

WT HA

Nu

mb

er

of

He

mo

sta

tic

Ev

en

ts

~70%

AT

KD

ALN-AT3 Single-Dose Pharmacology in NHP AT Silencing Leads to Increased Thrombin Generation

11

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

-14 0 14 28 42 56

Re

lati

ve

Se

rum

AT

Le

ve

ls

(Pre

-do

se

=1

)

Days

30 mg/kg 10 mg/kg 3 mg/kg 1 mg/kg

ASH, Dec 2012

ED50 for ALN-AT3 is ~1 mg/kg

Nadir for AT level ~Day 14

Fo

ld C

ha

ng

e P

ea

k T

hro

mb

in

% Antithrombin Knockdown

0.0

1.0

2.0

3.0

4.0

0 20 40 60 80 100

Experimental data

Computer-simulated model results

ALN-AT3 Repeat-Dose Pharmacology in NHP Monthly, SC Dosing

12

Animals: Cynomolgus monkeys (N=3 per group)

Dose levels: 0.5, 1 mg/kg, and 2 mg/kg (SC, monthly dosing)

# Dosing suspended in 2 mg/kg group after 3 doses due to AT levels <20%

0.0

0.2

0.4

0.6

0.8

1.0

1.2

-20 0 20 40 60 80 100 120

Re

lative

Pla

sm

a A

T

(Pre

-do

se

=1

)

Days

0.5 mg/kg 1 mg/kg 2 mg/kg

ALN-AT3 Treatment Groups

#

ALN-AT3 Treatment Normalizes Thrombin

Generation in Hemophilic NHPs with Inhibitors

13

Induction of Hemophilia A

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

Saline 0.25 0.50

Re

lati

ve

FV

III L

ev

els

Pre Ab 4 hr Post Ab

ALN-AT3 (mg/kg) qw

<0.01 <0.01 <0.01

Normalization of Thrombin Generation†

Pre-dose Saline 0.25 0.50

Normal Induced HA

Pe

ak

Th

rom

bin

(n

M)

0

20

40

60

80

100

120

140

ALN-AT3 (mg/kg) qw

60%

AT reduction

80%

AT reduction

†similar results obtained by ETP (p<0.01 at 0.50 mg/kg)

** (p<0.01)

ISTH, July 2013

ALN-AT3 Survival Benefit in HA Mice Results from 26-Week GLP Chronic Toxicity Study

14

Groups

Animals: Hemophilia A (HA) mice (B6;129S4-F8tm1Kaz)

Dosing: Saline, 10 mg/kg, and 30 mg/kg (SC, weekly dosing)

Group sizes: (N=70; 35 per sex) powered to account for spontaneous loss due to background

sensitivity of HA mouse strain

Interim results (through Week 25):

No adverse clinical signs; no changes in body weight, hematology or clinical chemistry

Survival benefit noted in treated animals (p <0.0001; Log-rank, Mantel-Cox test)

Survival of HA Mice

Days

0 50 100 150 200

0

50

100

% S

urv

ival

Saline

10 mg/kg ALN-AT3

30 mg/kg ALN-AT3

ALN-AT3 Treatment Groups

ALN-AT3 Phase 1 Study Dose-escalation Study in Two Parts

Study Design Randomized, single-blinded,

placebo-controlled SAD study in

healthy volunteers

Primary Objective Safety and tolerability of single

doses with AT knockdown <40%

Secondary Objectives Assess clinical activity

» AT knockdown

Study Design Open-label, MAD study in

subjects with moderate to severe

hemophilia A or B (N=up to 18)

Primary Objective Safety and tolerability of multi-

dose in hemophilia subjects

Secondary Objectives Assess clinical activity

» AT knockdown

» Increase in thrombin generation

Part

A Part

B

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See Sorensen, Oral Abstract 0693;

322. Disorders of Coagulation or Fibrinolysis: Novel Hemostatic

Therapies and Assays; Mon Dec 08 6:45-7:00PM.

Complement Disease Program Unmet Need and Program Opportunity

Complement-Mediated Diseases Excessive complement activity drives disease

pathophysiology in many indications

» Paroxysmal nocturnal hemoglobinuria (PNH)

» Atypical hemolytic uremic syndrome (aHUS)

» Neuromyelitis optica (NMO)

» Myasthenia gravis

» Many others

SolirisTM (eculizumab) is blockbuster drug

» >$1.5B in reported 2013 sales

» >$2.0B in forecasted 2014 revenue

New therapeutic options needed Consistent level of efficacy

SC delivery for more tolerable treatment regimen

Reduce access barriers to treatment

16

17

Complement C5 and ALN-CC5 Program

Complement C5 is genetically validated target Key component of terminal pathway

» C5 cleavage releases C5a; initiates membrane

attack complex (MAC) formation

C5 deficiency associated with minimal

complications » Susceptibility to increased Neisserial infections

» Many C5 deficient mouse strains

Majority expressed in liver; circulates in

plasma

Complement C5 is clinically validated target Eculizumab is anti-C5 Mab

Approved in PNH and aHUS » In PNH, >80% inhibition of hemolytic activity

associated with clinical benefit1

Potential advantages of synthesis inhibition

vs. protein binding approach

ALN-CC5 CTA filed ESC-GalNAc-siRNA for SC dosing

Efficacy in pre-clinical animal models

CTA filed; initial data mid ’15

Initiation

C3 Convertase

C5 Convertase

Terminal Pathway

Factor B

Alternative Pathway Classical Pathway Lectin Pathway

C3 C1

C3 C4 and C2

C3b

C3bBb C4bC2a

C3a Opsonization

Inflammation C3bBbC3b C4bC2aC3b

C5 C5a

C5b

Membrane attack complex (MAC)

C5b-C9

ALN-CC5

1Hillmen et al., NEJM; 350:552-9 (2004)

See Borodovsky Poster Abstract 1606;

508. Bone Marrow Failure: Poster I; Sat Dec 06 5:30-7:30

Robust and Sustained C5 Knockdown in NHP

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Robust knockdown of serum C5 with SC dosing in NHP for >7 months

Q2W Regimen: Every other week dosing (5 mg/kg, qw x 8, q2w thereafter)

QM Regimen: Every month dosing (5 mg/kg, qd x 5, qw x 8, 10 mg/kg qm thereafter)

2xW Regimen: 5 mg/kg 2xw x 8

Up to 99.2% knockdown of serum C5

98.4 ±0.7% knockdown as group average

Low inter-animal variation

Q2W Regimen provides optimal C5 knockdown results in NHP

» Expect QM dosing regimen in humans based on translation of ESC-GalNAc-siRNA conjugates

Serum C5

Q2W and QM Regimens

2xW Regimen Days 0 20 40 60 80 100 120 140 160 180 200 220

-20

0

20

40

60

80

100

2xw q2w qm

Days

%C

5 K

no

ck

do

wn

(N

orm

ali

ze

d t

o P

re-b

lee

d)

Individuals (Q2W and QM)

60 80 100 120 140 160 180 200 220

60

70

80

90

100

NHP3

NHP2

NHP1

NHP4

NHP5

NHP6

%C

5 K

no

ck

do

wn

(N

orm

alize

d t

o P

re-b

lee

d)

Both Classical and Alternative Pathways Strongly

Inhibited

19

Up to 96.9% inhibition of alternative pathway (CAP) activity (mean 95.1±0.93%), and up to

96.2% inhibition of hemolysis (mean 88.0±6.1%)

» Q2W Regimen provides optimal inhibition of complement activity in NHP but monthly likely in humans

based on translation of ESC-GalNAc conjugates

In line with results observed in published reports on eculizumab

Days 0 20 40 60 80 100 120 140 160 180 200 220

0

20

40

60

80

100

CAP Hemolysis

Complement Activity (Q2W)

Days 0 20 40 60 80 100 120 140 160 180 200 220

0

20

40

60

80

100

Complement Activity (QM)

%A

cti

vit

y o

r h

em

oly

sis

re

du

cti

on

QM Regimen

%A

cti

vit

y o

r h

em

oly

sis

re

du

cti

on

CAP Hemolysis

Q2W Regimen

C5 Knockdown Reduces Proteinuria

Rat Membranous Nephropathy Model

20

D4 D-10

Anti-Fx1A

C5 siRNA

D-7 D-3 D1 D5 D0

Urine

D-2

Urine

CVF

~90% reduction in urinary albumin levels with C5 knockdown in rat model of Passive Heymann Nephritis (PHN) Nephritis induced by injection of sheep anti-rat kidney fraction antiserum (anti-Fx1A)

» Cobra venom factor (CVF) treated rats receive daily injections

Similar reduction in urinary albumin excretion to CVF complement depletion

Urinary Albumin

a Fx1a only CVF C5 siRNA 0

2

4

6

8

10

12

U r i

n a

r y A

L B

( m

g / 2

4 h

r s ) Day -2

Day 5/6

Hemolytic Activity

a Fx1a only CVF C5 siRNA 0

20

40

60

80

100

% H

e m

o l y

s i s

Pre-dose Day 6

Glomerular MAC Deposition is Prevented with C5

Silencing

No glomerular C5b-9 deposition with C5 siRNA or CVF treatment Equivalent glomerular sheep IgG deposition regardless of

treatment, as expected

αFx1a alone C5 siRNA CVF

C5b-9

Sheep

IgG

21

C5 Knockdown Results in Equivalent Activity to Anti-C5 Ab

Mouse CAIA Model

Circulating liver-derived C5 key driver of pathology in mouse CAIA Little or no role for locally produced C5

-4 -2 0 2 4 6 8 10

0

2

4

6

8

10

12

Day

Maximal CDA score = 12 Anti-C5 Ab – BB5.1

PBS (N=7)

Anti-C5 Ab (50 mg/kg, N=7)

siRNA-Ctr (10 mg/kg, N=6)

siRNA-C5 (5 mg/kg, N=7)

Clin

ica

l Dis

ea

se

Ac

tiv

ity

D0 D3 D5 D10 D-5

Col Ab LPS

siRNA C5

Anti-C5 Ab

Disease Activity

22

ALN-CC5 Phase 1 Study

23

ALN-CC5 CTA filed

Phase 1/2 study expected to start in early ’15; Initial data

expected in mid ’15

ALN-CC5 with SC dosing

Parts A/B: SAD/MAD in up to 60 normal healthy volunteers

» Randomized, double-blind, placebo-controlled study

» Assess safety, tolerability, PK/PD, and clinical activity

Part C: Multi-dose in up to 8 PNH patients

» Open-label study

» Assess safety, tolerability, PK/PD, clinical activity, and LDH reduction

Summary

24

RNAi therapeutics continue to progress in clinical trials

ALN-AT3 and ALN-CC5 are Alnylam’s first programs in hemophilia and complement-mediated disease, respectively » Robust AT and C5 target knockdown observed with

monthly SC dosing in NHPs

» Pharmacodynamic activity observed in multiple preclinical models

ALN-AT3 currently in Phase 1 in hemophilia patients, and ALN-CC5 will be in Phase 1/2 in early 2015

Thank You