HEART FAILURE AND PRESERVED EJECTION FRACTION: CLINICAL STUDY DESIGN AND TREATMENT

Transcription

1 THE SOUTHPAW STUDY HEART FAILURE AND PRESERVED EJECTION FRACTION: CLINICAL STUDY DESIGN AND TREATMENT Mardi Gomberg-Maitland, MD, MSc Professor of Medicine, Inova Heart and Vascular Institute, VA USA

2 2 SAFE HARBOR STATEMENT Remarks today concerning United Therapeutics may include forward-looking statements which represent United Therapeutics expectations or beliefs regarding future events. We caution that such statements involve risks and uncertainties that may cause actual results to differ materially from those in the forward-looking statements. Consequently, all such forward-looking statements are qualified by the cautionary language and risk factors set forth in United Therapeutics periodic and other reports filed with the SEC. There can be no assurance that the actual results, events or developments referenced in such forward-looking statements will occur or be realized. United Therapeutics assumes no obligation to update these forward-looking statements to reflect actual results, changes in assumptions or changes in factors affecting such forward-looking statements. This presentation and any related discussions or statements are intended to educate investors about our company. Sometimes that process includes reporting on the progress and results of clinical trials or other developments with respect to our products. This presentation and any related discussions or statements are not intended to promote our products, to suggest that our products are safe and effective for any use other than what is consistent with their FDA-approved labeling, or to provide all available information regarding the products, their risks, or related clinical trial results. Anyone seeking information regarding the use of one of our products should consult the full prescribing information for the product available on our website at

3 3 WHAT IS WHO GROUP 2 PH? WHO Classification of Pulmonary Hypertension (PH) PULMONARY HYPERTENSION (PH) GROUP 1 Pulmonary Arterial Hypertension (PAH) GROUP 2 PH Due to Left Heart Disease GROUP 3 PH Due to Lung Disease GROUP 4 PH Due to Chronic Thromboembolism GROUP 5 PH Due to Unclear Multifactorial Mechanisms Systolic dysfunction Diastolic dysfunction Valvular disease Complex Congenital Heart Disease/Myopathy

4 4 THE UNDERLYING PROBLEM 1 EJECTION FRACTION % (EF) = Amount of blood pumped out of the ventricle Total amount of blood in ventricle One method to phenotype/ classify patients ½ have reduced EF, HFrEF ½ of the cohort have a preserved EF, HFpEF The heart can fail to eject blood normally and can fail because it does not relax normally (refills with blood) or both Success in heart failure therapeutics has been in HFrEF not HFpEF

5 5 SCOPE OF THE PROBLEM HEART FAILURE 2-5 ~5.7 MIL 50% ~2.85 MIL HFpEF % MIL PH HFpEF % K Combined PRE-AND-POST CAPILLARY PH HFpEF - SOUTHPAW 10-13

6 6 PH HFpEF PATIENTS HAVE WORSE PROGNOSIS VS PAH PH HFpEF 1 YEAR SURVIVAL PROGNOSIS FOR 0,1,2-3 RISK SCORES % PAH REGISTRY 1 YEAR SURVIVAL PROGNOSIS % % if no risk scores REGISTRY 1 / CHICAGO 1 yr survival / incident cases = 85% Percentage Survival RISK SCORES 0 (N=163) 1 (N=120) 2-3 (N=57) % for 1 risk score 60% for 2-3 risk scores REGISTRY 2 / USA 1 yr survival model cohort = 91% 1 yr survival incident cohort = 84.6%

7 7 PH-LHD PREDICTORS OF MORTALITY 14 Variable HR (95% CI) P value Systolic Blood Pressure 113 mmhg 2.6 (1.7,4.0) <.001 PA SAT 48 % 2.3 (1.3,4.3).006 Enlarged LA size 2.1 (1.1,3.8).023 HGB < (1.3,3.6).002 RV Hypertrophy 2.1 (1.1,4.0).021 This analysis was performed using 340 WHO Group 2 Pulmonary Hypertension patients with any follow-up from baseline diagnosis The c-index for the final model is.709 and c-index for the risk score is.708

8 8 HFpEF IS NOT AS SIMPLE AS WE THOUGHT

9 9 WHAT IS THE EF IN HFpEF? 40%, 45%, 50%? 18 To determine that LVEF is Preserved (whatever that means!) CHARM TOPCAT, IPreserve, PARAGON ASE normal CAVEATS Assessment of LVEF is a ±7 measurement HFrEF Low Ejection Fraction Preserved Ejection Fraction 10% 20% 30% 40% 50% 60% 70% 80% All Cutoffs are arbitrary»» There is no therapy for Heart Failure with LVEF > 40%!

10 10 MANY PROCESSES LEAD TO HFpEF 9 Relaxation of the heart abnormalities High pressure in the lungs with right pump failure The membrane that lines the inside of the heart and blood vessels that control relaxation and contraction doesn t work Longitudinal pumping problems Skeletal muscle abnormalities Non-heart causes of volume overload Autonomic dysfunction Inability for heart rate to respond appropriately Inflammation Stiff arteries Ventricles and atria not working in coordinated fashion HFpEF

11 11 HFpEF PHENOTYPES 19 1 RHF/PH HFpEF 2 CAD-HFpEF 3 What everyone sees in clinic typical HFpEF (HTN, NIDDM obesity, CKD) 4 HCM like HFpEF 5 Rare causes of HFpEF 6 A-fib predominant HFpEF 7 Valvular HFpEF (multiple 2+ lesions) 8 9 Unclear HFpEF- what is a mix High output HFpEF of phenotypes and super sick (MG clinic patient)

12 12 HYPOTHESIS MAYBE WE CAN USE PROSTACYCLINS IN PH ASSOCIATED WITH RV DYSFUNCTION IN HFpEF

13 13 OVERLAP OF GENETICS ISOLATED/MIXED PH-LHD AND PAH 20 CLINICAL ANALYSIS Cpc-PH Similar to PH:» Younger age» Severe pulmonary vascular disease Cpc-PH Similar to Ipc-PH:» Medical comorbidities» Severity and chronicity of LV disease GENETIC ANALYSIS 141 SNPs with lung expression»actin» Binding Extracellular Matrix Basement Membrane MHC II Proteins Cpc-PH SNPs Ipc-PH SNPs PAH SNPs Ipc-PH = isolated post-capillary pulmonary hypertension; Cpc-PH = combined post-capillary and pre-capillary pulmonary hypertension; SNPs = single-nucleotide polymorphisms; PAH = pulmonary arterial hypertension; MHC = major histocompatibility complex; LV = left ventricular.

14 14 VR INSTRUCTIONS VIRTUAL REALITY EXPERIENCE

15 15 TREATING PH IN HFpEF 24,25 HFpEF patients are different than HFrEF patients; increasing as more people are elderly HFpEF patients experience greater BP reduction, less increase in CO and a greater likelihood of stroke volume drop with vasodilators RV dysfunction in HFpEF is a possible target R X PAH therapies may have a different effect in patients with HFpEF Therapies will need to be targeted more based on hemodynamics or other endpoints not previously used

16 16 WHAT DO WE KNOW SO FAR? THERE IS SOME EVIDENCE TO SUPPORT THE TREATMENT OF THE PULMONARY VASCULAR DISEASE COMPONENT OF PH HFpEF SHOULD WE TARGET THE RV AS WELL?

17 17 1 YR. DBPC TRIAL SILDENAFIL HFpEF 24 Pulmonary Arteriolar Resistance (wood units) 8 PLACEBO Pulmonary Arteriolar Resistance (wood units) 8 SILDENAFIL Improvement in mpap, PVR and vasomotility Improvement in RV fxn (TAPSE) and dimension, lower mrap 6 4 * 6 4 Improvement in LV relaxation and distensibility (structural changes and/or ventricular interdependence) 2 2 * * Improved lung alveolar gas conductance 0 Baseline 6 months 12 months Baseline 6 months 12 months 0 LEGEND Individual and mean (±SD) values. *P<0.01 vs baseline; P<0.01 vs corresponding placebo value.

18 18 DILATE-1 STUDY: PHASE IIB HEMODYNAMIC STUDY 26 A C Mean change from baseline in cardiac index (L/min/m²) Mean change from baseline in SVR (dyn-sec-c - 5) Time (hours) Time (hours) B D Mean change from baseline in PAWP (mm Hg) Mean change from baseline in map (mm Hg) Time (hours) Time (hours) LEGEND Did not change mpap (p=0.6) in 6 hrs BUT most patients did not reach target dose CI, PVR, SVR improved Increased SV did not increase PCWP Riociguat is vasodilatory and may improve diastolic function Placebo (n=11) Riociguat 2mg (n=10)

19 19 WHY SOUTHPAW: RATIONALE » Prostacyclins act as vasodilators to widen the blood vessels of the pulmonary and systemic arterial vascular beds. These drugs also inhibit platelet aggregation, and smooth muscle cell proliferation 2 3» No treatments approved to treat WHO Group 2 PH (PH HFpEF)» Although PH HFpEF is typically thought of as a disease of the left heart, there are also significant abnormalities in the right heart (RV remodeling, both adaptive and maladaptive) in PH HFpEF» Similar to how oral treprostinil treats PAH, it is thought that these components of PH HFpEF might be amenable to treatments with prostanoids

20 20 SOUTHPAW STUDY» Prostacyclins may be beneficial in PH associated with RV dysfunction in HFpEF» Target the PH HFpEF-RV phenotype

21 21 SOUTHPAW STUDY DESIGN OVERVIEW NCT N=310 WHO GROUP 2 PH RANDOMIZE 1:1 24-WEEK treatment period 85 CLINICAL SITES

22 22 SOUTHPAW STUDY DESIGN OVERVIEW ORAL TREPROSTINIL NCT N=310 WHO GROUP 2 PH 24-WEEK treatment period RANDOMIZE 1:1 85 CLINICAL SITES PLACEBO

23 23 SOUTHPAW STUDY DESIGN OVERVIEW ORAL TREPROSTINIL NCT N=310 WHO GROUP 2 PH 24-WEEK treatment period RANDOMIZE 1:1 85 CLINICAL SITES KEY CLINICAL ASSESSMENTS PLACEBO

24 24 SOUTHPAW STUDY DESIGN OVERVIEW KEY CLINICAL ASSESSMENTS PRIMARY OBJECTIVE SECONDARY OBJECTIVES TERTIARY OBJECTIVES CHANGE IN 6MWD from baseline to week 24 Clinical worsening, NT-pro-BNP Safety, change in WHO Functional Class, patient-reported outcomes, biomarkers and genomics

25 25 SOUTHPAW STUDY DESIGN OVERVIEW ORAL TREPROSTINIL NCT WEEK treatment period N=310 WHO GROUP 2 PH RANDOMIZE 1:1 85 CLINICAL SITES KEY CLINICAL ASSESSMENTS PLACEBO INTERIM SAFETY REVIEWS BY DMC

26 26 SOUTHPAW STUDY DESIGN OVERVIEW INTERIM SAFETY REVIEWS BY DMC Interim safety reviews at N=10, 30, 60, 100, and 200 Allows increasing total daily dose of oral treprostinil

27 27 ADAPTIVE DESIGN: STUDY DRUG & DOSING CONSIDERATIONS & above 2 mg TID 4 mg TID 6 mg TID Individual up titration to a maximum in each cohort Ability to down titrate»» May not reach dose of 6 mg tid for maximum dose

28 28 SUMMARY AND PROGRESS TO DATE 1 2 Significant unmet medical need By enrolling patients with the correct phenotype (combined pre-and-post capillary PH HFpEF, RV dysfunction), and employing a cautious, adaptive design, Southpaw aims to safely treat these patients 3 4 After a slow start and some refining to the protocol, significant progress has been made in the past few months 27 RANDOMIZED» 14 in the past 2 months» 5 completed and enrolled into OLE» ~10% withdrawal rate (consistent with historical oral treprostinil data) THE FIRST DMC MEETING NOTED NO SAFETY CONCERNS

29 29 REFERENCES 1. Heidenreich PA. Circ Heart Failure 2013; Mozzafarian et al Savarese Cogswell and Thenappan Pothineni et al Owan et al Lam et al Leung et al Shah et al Gerges Rosenkranz et al Dixon 2015 (abstract). 13. Dixon, Trivedi and Shah Agarwal, Gomberg-Maitland. JHLT Humbert et al. AJRCCM 2006;173: Thenappan et al. Eur Resp J. 2007;30(6) Badesch et al. Chest 2010; 137: Solomon SD HFpEF-TT Oktay AA, Shah SJ. Curr Cardiol Rev Assad, Brittain. J Am Coll Cardiol Simonneau G, et al. J Am Coll Cardiol. 2013;62(25):D Bourke SJ. Postgrad Med J. 2006;82: Interstitial Lung Disease accessed December Guazzi M, et al. Circulation 2011;124: Schwartzenberg S, et al. J Am Coll Cardiol 2012; 59: Bonderman D. Circ 2013 Jul 30; 128(5): Moncada, S. et al. (1976) An enzyme isolated from arteries trans- forms prostaglandin endoperoxides to an unstable substance that inhibits platelet aggregation. Nature 263, Koh, E., et al. (1993) Effects of beraprost sodium, a stable analogue of prostacyclin, on hyperplasia, hypertrophy and glycosaminoglycan synthesis of rat aortic smooth muscle cells. Artery 20: Grosser, T., et al. (1995) Iloprost-induced inhibition of proliferation of coronary artery smooth muscle cells is abolished by homologous desensitization. Agents Actions Suppl. 45: Harada, M., et al. (1999) Prostacyclin synthase gene transfer inhibits neointimal formation in rat balloon-injured arteries without bleeding complications. Cardiovasc. Res. 43: Urashima T, Zhao M, Wagner R, et al. Molecular and physiological characterization of RV remodeling in a murine model of pulmonary stenosis. Am J Physiol Heart Circ Physiol. 2008;295:H Grossman NL, Fiack CA, Weinberg JM, Rybin DV, Farber HW. Pulmonary hypertension associated with heart failure with preserved ejection fraction: acute hemodynamic effects of inhaled iloprost. Pulm Circ. 2015;5:

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