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Systemic Therapy: Pharmacological Approach or Cell/Gene Therapy

Systemic Therapy: Pharmacological Systemic Therapy: Pharmacological Approach or Cell/Gene TherapyApproach or Cell/Gene Therapy

Alan C. Yeung, MDStanford University School of Medicine

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20 Billions dollars question:20 Billions dollars question:20 Billions dollars question:

How do we find it (them) ?When should we look for them ?How do we treat them ?

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Stable (obstructive)Stable (obstructive) Vulnerable (nonVulnerable (non--obstructive)obstructive)

• Progressively flow-limiting• Often causes chest pain• Detected by angiography• Main target of interventional

therapies (angioplasty, stents)

• Minimal effect on blood flow • First symptom is often sudden death • No established detection method• Preventative drug therapies;

directed therapies still unproven

What is the Vulnerable plaque?

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TCFA

• Thin cap– Fibrous cap < 65 µm– Collagen depletion (due to loss of smooth

muscle)– Inflammatory cells (macrophage, lymphocyte)

• Lipid rich plaque– Hemorrhagic, necrotic core (size > 1.0 mm2

and/ or > 10% of the plaque area) – Angiogenic blood vessels into intima from the

adventitia

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Risks of Plaque RuptureRisks of Plaque Rupture

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What are the possible targets for treatment ?What are the possible targets for treatment ?What are the possible targets for treatment ?

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(1) Thin Cap

High lipidcontent

Fibro-fattyplaque

Stained histology section OCT

Histology courtesy of E. Mont and R. Virmani, Armed Forces Institute of Pathology, Washington, DC

Thin cap

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Thin Cap

LP:Lipid poolFC:Fibrous cap*: Guidewire artifact

LP

LPFC (70 µm)

Thrombus

*

Dr. Suzuki and Dr. Katoh Toyohashi Heart Center, JapanDr. Suzuki and Dr. Katoh Toyohashi Heart Center, Japan

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(2) Lipid Rich Plaque

Dr. U. Gerckens and Dr. R. Müller, Herzzenturm Siegburg, Germany

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Lipid rich plaque

Kawasaki Medical School Hospital

Akasaka M.D. Kume M.D.

HE Masson EVG

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(3) Macrophage Detection(3) Macrophage Detection

CD68

(macrophage)

CD68

(macrophage)

OCTOCT

Tearney GJ, et al, Circulation. 2003 Jan 7;107(1):113-9

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Macrophage DetectionMacrophage Detection

LightLab Imaging

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What are the possible systemic therapy?What are the possible systemic therapy?What are the possible systemic therapy?

•• Thin Cap: MMP inhibitorsThin Cap: MMP inhibitors

•• AtheromaAtheroma: Lipid therapy: Lipid therapy

•• Inflammation: CRP reductionInflammation: CRP reduction

•• Genetic: LDGenetic: LD

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Cholesterol LoweringCholesterol Lowering

ASTEROIDS STUDYASTEROIDS STUDY

•• Can we regress Can we regress atherosclerosis ?atherosclerosis ?

•• Corollary: Will Corollary: Will vulnerable plaque vulnerable plaque will also become will also become more stable ?more stable ?

•• LDL of 60mg/dlLDL of 60mg/dl

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24

25

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Hs CHs C--Reactive ProteinReactive Protein

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28

29

30

31

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Can we manipulate e.g. CRP ?Can we manipulate e.g. CRP ?Can we manipulate e.g. CRP ?

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Linkage DisequilibriumLinkage Disequilibrium

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Antrin® Photodynamic TherapyAntrinAntrin®® Photodynamic TherapyPhotodynamic Therapy

Optical Optical SelectivitySelectivity

Focal or RegionalFocal or Regional((multivesselmultivessel))

treatmenttreatment

AntrinAntrin ((MotexafinMotexafin Lutetium)Lutetium) Diffusing FiberDiffusing FiberDiode LaserDiode Laser

Tip of Tip of TransitTransit

Fiber Fiber markersmarkersMid LAD Mid LAD StenosisStenosis

IV or Local IV or Local DeliveryDelivery

N

N

NN O

O

OH

OH

LuO O OMe

O O OMe

OAcAcO

N

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Antrin Phototherapy (PT) depletes vascular macrophages in NZW rabbit injury model, local Antrin

Antrin Phototherapy (PT) depletes vascular Antrin Phototherapy (PT) depletes vascular macrophages in NZW rabbit injury model, macrophages in NZW rabbit injury model, local local AntrinAntrin

Hayase et al, Cardiovascular Research 2001, 49, 449-455.

Control Treated

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Vulnerable PlaqueVulnerable PlaqueVulnerable Plaque

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Photodynamic TherapyPhotodynamic TherapyPhotodynamic Therapy

Absorption Fluorescence

Phosphorescence

1Sens

1Sens

3Sens

Type I

Type II

Biological Radicals

1O2

3O2

Biological Substrates

* 1Sens+

Oxidative Damageto Proteins & Lipids

hυ

*

*

Intersystem Crossing

Cell death occurs only if both light and drug present

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Antrin® (Motexafin Lutetium) AntrinAntrin®® (Motexafin Lutetium) (Motexafin Lutetium)

• Selective accumulation in atherosclerotic plaques

• Rapid clearance from plasma and normal tissues

• Light activation produces singlet O2 (very short path length) causing cell death

• Selective accumulation in atherosclerotic plaques

• Rapid clearance from plasma and normal tissues

• Light activation produces singlet O2 (very short path length) causing cell death

• Activation at 732 nm penetrates blood and tissue better than other photosensitizers in development

• Fluorescence detected at 750 nm with 460-480 nm excitation

• Activation at 732 nm penetrates blood and tissue better than other photosensitizers in development

• Fluorescence detected at 750 nm with 460-480 nm excitation

Treatment Wavelength

Optical Attenuations : Normalized to individual 825 nm datapoint

0

1

2

3

4

5

6

600 650 700 750 800 850 900Wavelength (nm)

Nor

mal

ized

abs

orba

nce

for H

bH

bO2.

-100

0

100

200

300

400

500HemoglobinOxy-hemaglobinMLu ext. coeff

Norm

alized molar ext. coeff. for M

Lu

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Intracellular Localization of AntrinIntracellular Localization of AntrinIntracellular Localization of Antrin

Human Macrophages

HCASMC

Mitochondria (green)

Antrin (red) Overlay

Woodburn et al., ACC 2002

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Lysosomal Instability after PhototherapyLysosomalLysosomal Instability after PhototherapyInstability after Phototherapy

Pre-treatment Post-PDT @ LD50

THP-1 Macrophages

THP-1 Macrophages + Acridine Orange

Woodburn et al., ACC 2002

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Control 20 ug/mlAntrin

2 J/cm2

LightAntrin + Light

Woodburn et al., ACC 2002

Antrin Phototherapy Induces Apoptosis in Human Macrophages

AntrinAntrin Phototherapy Induces Apoptosis in Phototherapy Induces Apoptosis in Human MacrophagesHuman Macrophages

Cytochrome C immunoreactivity assay in human THP-1 cells

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Antrin Biolocalization in Atheromatous PlaqueAntrin Antrin BiolocalizationBiolocalization in in AtheromatousAtheromatous PlaquePlaque

NZW Rabbit aorta, 10 mg/kg iv administration, analysis at 24h

Rockson SG et al., Circulation 2000; 102:591-6

8508007507006500

100

200

300

400PlaqueAortic Wall

Wavelength (nm)

Plaque

Aortic Wall

Fluorescent image

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Texaphyrin Uptake in Rabbit AtheromasTexaphyrinTexaphyrin Uptake in Rabbit Uptake in Rabbit AtheromasAtheromas

--

B/W image Fluorescence

-

RAM-11 (macrophage) Oil Red O (neutral lipids)

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0

20

40

Control

MLu onlyLight o

nlyMLu+10JMLu+30JMLu+100JMLu+300J

% o

f tot

al in

timal

are

a

* p<0.05 compared with control

* *

0

5

10

15

Control

MLu onlyLight o

nlyMLu+10JMLu+30JMLu+100JMLu+300J

% o

f tot

al in

timal

are

a

* p<0.05 compared with control

* *

Macrophage Burden as % of total Macrophage Burden as % of total intimaintima and mediaand media

IntraballoonIntraballoon IlluminationIllumination Bare Fiber IlluminationBare Fiber Illumination

YP Sun, ACC 2003 Poster Presentation

Macrophage depletion in Fat-Fed New Zealand White (NZW) Rabbit; iv AntrinMacrophage depletion in FatMacrophage depletion in Fat--Fed New Fed New Zealand White (NZW) Rabbit; iv Zealand White (NZW) Rabbit; iv AntrinAntrin

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Watanabe Hereditary Hyperlipidemic Rabbit (WHHL) Fat-Fed Model of Atherosclerosis

Watanabe Hereditary Watanabe Hereditary HyperlipidemicHyperlipidemic Rabbit Rabbit (WHHL) Fat(WHHL) Fat--Fed Model of AtherosclerosisFed Model of Atherosclerosis

Normalized Intima/Media Ratio

0

20

40

60

80

100

120

140

Contro

lMLu

only30

J/cmf

75J/c

mf12

5J/cm

f17

5J/cm

f

Perc

ent

Normalized Macrophage Burden

0

50

100

150

Contro

lMLu

only30

J/cmf

75J/c

mf12

5J/cm

f17

5J/cm

f

Perc

ent

Control vs all Antrin-PT, p: 0.001~0.009 Control vs all Antrin-PT, p<0.072

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0

20

40

60

80

100

120

1 2 3 4 5 6 7 8

cells/mm2 plaque

cells

/mm

2 pl

aque

aortic segment #

PT segment

P < 0.0001

or or or

n= 32 14 10 11 10 4 23 17

BARS = SEM

Reduces cell density post-Antrin PTReduces cell density postReduces cell density post--AntrinAntrin PTPT

NZW injury model, 7d after PDTNZW injury model, 7d after PDT

Diffuser Diffuser centercenter

Hamblin, et. al, Wellman Labs, MGH, Boston

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Preclinical FindingsPreclinical FindingsPreclinical Findings

Antrin localizes Antrin localizes intracellularlyintracellularly in mitochondria and in mitochondria and lysosomeslysosomes

AntrinAntrin is selective to plaques rich in macrophages and is selective to plaques rich in macrophages and neutral lipidsneutral lipids

AntrinAntrin Phototherapy:Phototherapy:Reduces macrophages in all rabbit models studied

Produces significant plaque accellularity within days post-PT

Downregulates cytokines involved in monocyte migrationAppears to maintain or increase smooth muscle areaSuggests some collagen remodeling of PT lesion

Does not traumatize normal vessel walls.

Potentially remodels and stabilizes unstable plaque

Allows both focal and regional treatment of Allows both focal and regional treatment of diseased vessels.diseased vessels.

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Antrin Clinical DevelopmentAntrin Clinical DevelopmentAntrin Clinical Development

Peripheral Arterial Disease (PAD)Peripheral Arterial Disease (PAD)Phase I: Dose ranging for safety. Completed.

Rockson et. al. Circulation 2000; 102:2322

Phase II: Multi-center, double-blind, randomized trial for prevention of restenosis and treatment of de novo lesion. Study Completed. No adverse safety signals.

Coronary Arterial Disease (CAD)Coronary Arterial Disease (CAD)Phase I: Drug and light dose escalation in subjects

with CAD undergoing PCI with stentplacement. Completed. Kereiakes, et. al. Circulation 2003; 103:1310

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Antrin PhototherapyAntrin PhototherapyAntrin PhototherapyPhase 1 Coronary Artery DiseaseAngiographic Results

Enrollment: 79 patients

Design: Drug and light dose escalation for safety

Safety: No serious adverse effects

Results: Optimum regimen identified

Publication: Kereiakes, et. al. Circulation 2003; 103:1310

“The present phase 1 coronary study supports the apparent safety and tolerability of this treatment and materially extends our understanding of this emerging therapy in several ways.

“The present phase 1 coronary study supports the apparent safety and tolerability of this treatment and materially extends our understanding of this emerging therapy in several ways.

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Phase I CADParticipating Investigators & CentersPhase I CADPhase I CADParticipating Investigators & CentersParticipating Investigators & Centers

Dean KereiakesThe Lindner Center, Cincinnati

Daniel SimonBrigham and Women’s Hospital, Boston

Arthur M. SzyniszewskiMichigan Heart & Vascular, Ann Arbor

Alan Yeung

Stanford Medical Center, Palo Alto

Paul KramerMid-America Heart Institute, Kansas City

Howard HerrmannHospital of the University ofPennsylvania

Wendy ShearMinneapolis VA Medical Center

Jeffry PopmaQCA Core Lab, Boston, MA

Peter FitzgeraldIVUS Core Lab, Stanford, CA

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Eligibility:Eligibility: Patients With Coronary Arterial DiseasePatients With Coronary Arterial Disease

Design:Design: IV ANTRIN Followed 18IV ANTRIN Followed 18--24 Hours Later by Phototherapy.24 Hours Later by Phototherapy.Drug escalation (0.05 Drug escalation (0.05 –– 4 mg/kg)4 mg/kg)Light escalation (100Light escalation (100--600 J/600 J/cmcmff))

Safety Objectives:Safety Objectives:

* Extent of * Extent of restenosisrestenosis in in AntrinAntrin PTPT--treated lesions (QCA, IVUS)treated lesions (QCA, IVUS)* Pharmacokinetics in this CAD pop.* Pharmacokinetics in this CAD pop.

Primary Outcome VariablesPrimary Outcome Variables* DoseDose--limiting toxicities associated with limiting toxicities associated with AntrinAntrin Injection Injection

and/or illuminationand/or illumination* Phototherapy* Phototherapy--related procedural adverse eventsrelated procedural adverse events* Death, Stroke, CK or CK* Death, Stroke, CK or CK--MB > 3 x ULNMB > 3 x ULN

CAD Phase I DesignCAD Phase I DesignCAD Phase I DesignDose-escalation safety trial in subjects with CAD under-going PCI with stent placementDose-escalation safety trial in subjects with CAD under-going PCI with stent placement

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CAD Phase I DesignCAD Phase I DesignCAD Phase I Design

Secondary Outcome VariablesSecondary Outcome Variables* Late lumen loss/index (QCA; IVUS) at 6 monthsLate lumen loss/index (QCA; IVUS) at 6 months

** Angiographic Angiographic restenosisrestenosis rate (>rate (> 50%)50%)** TLR, TVR, TVFTLR, TVR, TVF** PharmacokineticsPharmacokinetics

Inclusion Criteria:Inclusion Criteria:* Target lesion * Target lesion stenosisstenosis >50% needing PCI >50% needing PCI * Target lesion for PCI * Target lesion for PCI << 30 mm long 30 mm long ** Men or womenMen or women >> 18 yrs old18 yrs old** Give informed consentGive informed consent

Exclusion Criteria:Exclusion Criteria:* Target lesions with previously placed * Target lesions with previously placed stentstent* Target lesions involving left main or * Target lesions involving left main or ostialostial left left

anterior descending arteriesanterior descending arteries

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Angiographic Analysis PlanBWH Angiography Core Lab – J. PopmaAngiographic Analysis PlanAngiographic Analysis PlanBWH Angiography Core Lab BWH Angiography Core Lab –– J. PopmaJ. Popma

Normal 1 Normal 2Pr

oxi

mal

Edge

Proxi

mal

Edge

Dis

tal Edge

Dis

tal Edge

Stent

Balloon

Illumination

Entire Analysis

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64.0 (43-85)Median Age, yrs

70.9%Men, %

20.3%Diabetes, %

16.5%Prior PCI, %

51.9%Prior MI, %

31.6%NYHA Class I, %

68.4%NYHA Class II, %

CAD Phase I StudyDemographics (n=79)CAD Phase I StudyCAD Phase I StudyDemographics (n=79)Demographics (n=79)

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19.1Stent Length (mm; mean)

3.33Stent Diameter (mm; mean)

40 %28 %32 %

LADLCXRCA

Target Vessel, %

CAD Phase I StudyTarget Vessel CharacteristicsCAD Phase I StudyCAD Phase I StudyTarget Vessel CharacteristicsTarget Vessel Characteristics

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51%GP IIb/IIIa Use

3.8% (n=3)

Bailout procedure[left main disease; angioplasty dissection]

0%Fiber could not be delivered

0%Interrupted Illumination

96.2%Procedural Success**

100%Device Success*

*Successful delivery of the illuminating fiber when attempted

**No in-hospital MACE

CAD Phase I StudyProcedure and Device PerformanceCAD Phase I StudyCAD Phase I StudyProcedure and Device PerformanceProcedure and Device Performance

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10.3 %Total CK-MB Elevation (>3xULN)

0 %Stent Thrombosis

1.3 %Target vessel revascularization

1.3 %Total CK Elevation (>3xULN)

0 %Stroke

0 %Death

0 %Emergent CABG

CAD Phase I StudyPreliminary Acute Safety (30 days)CAD Phase I StudyCAD Phase I StudyPreliminary Acute Safety (30 days)Preliminary Acute Safety (30 days)

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Antrin CAD Phase I Study Infusion Related EventsAntrinAntrin CAD Phase I Study CAD Phase I Study Infusion Related EventsInfusion Related Events

DoseDose

(mg/kg)(mg/kg)

NN PeripheralPeripheral

ParesthesiaParesthesia**

Rash*Rash*

0.050.05 55 1 (20.0%)1 (20.0%) 0 (0)0 (0)

0.150.15 55 0 (0%)0 (0%) 0 (0)0 (0)

0.50.5 66 0 (0%)0 (0%) 0 (0)0 (0)

11 66 1 (16.7%)1 (16.7%) 1 (16.7)1 (16.7)

22 2121 10 (47.6%)10 (47.6%) 3 (14.3)3 (14.3)

33 2626 14 (53.8%)14 (53.8%) 5 (19.2)5 (19.2)

44 1010 6 (60.0%)6 (60.0%) 3 (30.0)3 (30.0)

* Rashes were not phototoxic reactions. Duration of paresthesias and rashes ranged from 0-46 days, and 0-51 days, respectively. All were mild to moderate in severity

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Antrin (MLu) Pop Pharmacokinetics Rapid Clearance from PlasmaAntrinAntrin ((MLuMLu) Pop Pharmacokinetics ) Pop Pharmacokinetics Rapid Clearance from PlasmaRapid Clearance from Plasma

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

0 5 10 15 20 25

Time (hr)

Plas

ma

Con

c. (µ

g/m

L)

95% cleared from plasma

Functional T1/2 = ~ 25 min(Based on 48h sampling)

Across all drug doses: 0.05-4 mg/kg

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Follow-Up AngiographyQuantitative ResultsFollowFollow--Up AngiographyUp AngiographyQuantitative ResultsQuantitative Results

2.93 / 2.94 mmPre / PostPre / Post-- ref. vessel diameter (mean)ref. vessel diameter (mean)

6.8 %PostPost--PCI % PCI % stenosisstenosis (median)(median)

66.0 %PrePre--PCI % PCI % stenosisstenosis (median)(median)

1.02StentStent Segment Late lumen loss (mm)Segment Late lumen loss (mm)

1.75StentStent Segment MLD (mm)Segment MLD (mm)

2/70 (2.9 %) (0.3, 9.9)

Edge segmentsEdge segments

24/71, 33.8 % (23.0, 46.0)

Stent SegmentStent Segment (Binary Restenosis) (Binary Restenosis)

Overall % Overall % (95% CI)(95% CI)

There were no clinically significant differences between the stent, balloon injury, illumination and analysis segments

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Mean (SE) late lumen loss by quantitative coronaryMean (SE) late lumen loss by quantitative coronaryangiography stratified by study stage, angiography stratified by study stage, MLuMLu dose, and dose, and light light fluencefluence..

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Qualitative Assessment by IVUS (N=39)Qualitative Assessment by IVUS (N=39)Qualitative Assessment by IVUS (N=39)

Incomplete appositionIncomplete apposition

Preserved incomplete apposition:Preserved incomplete apposition:

Resolved incomplete apposition:Resolved incomplete apposition:

Late incomplete apposition:Late incomplete apposition:

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11

00

Stent edge dissectionStent edge dissection

004466--month followmonth follow--upupBaselineBaseline

Intraluminal thrombusIntraluminal thrombus

0000

66--month followmonth follow--upupBaselineBaseline

Hongo, et. al., manuscript under preparation

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Quantitative Assessment by IVUS (N=39)Quantitative Assessment by IVUS Quantitative Assessment by IVUS (N=39)(N=39)

Percent Neointima Volume ObstructionPercent Neointima Volume Obstruction

Light Light (J/cm(J/cm--fiber)fiber)

MLu MLu (mg/kg)(mg/kg)

NN

(%)(%)

100100 100100 200200--6006000.050.05--1.01.0 2.02.0--4.04.0 2.02.0--3.03.0

(9)(9) (7)(7) (23)(23)

0

10

20

30

40

50

60

Hongo, et. al., manuscript under preparation

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Quantitative Assessment by IVUS (N=39)Quantitative Assessment by IVUS Quantitative Assessment by IVUS (N=39)(N=39)

Percent Change in Plaque VolumePercent Change in Plaque Volume

Light Light (J/cm(J/cm--fiber)fiber)

MLu MLu (mg/kg)(mg/kg)

100100 100100 200200--6006000.050.05--1.01.0 2.02.0--4.04.0 2.02.0--3.03.0

NN (9)(9) (7)(7) (23)(23)

(%)(%)

0

5

10

15

20

25

30

Hongo, et. al., manuscript under preparation

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Safety Summary - CADSafety Summary Safety Summary -- CADCAD

ANTRIN Phototherapy is feasible, wellANTRIN Phototherapy is feasible, well--tolerated and tolerated and safe in >250 trial patients to date.safe in >250 trial patients to date.

No drug/light dose-limiting toxicities

Self-limited paresthesias with > 2.0 mg/kgSuccessful and safe intravascular light delivery

Absence of late incomplete Absence of late incomplete stentstent apposition with PTapposition with PT

Very low incidence of geographical missVery low incidence of geographical miss

No evidence of deleterious edge effectsNo evidence of deleterious edge effects

No reported treatmentNo reported treatment--related aneurysmsrelated aneurysms

No observed No observed subacutesubacute stentstent thrombosis or thrombosis or proliferativeproliferativefibrosis within the reference segmentfibrosis within the reference segment