XERAVATM (eravacycline): A Novel Fluorocycline Antibacterial

XERAVATM (eravacycline): A Novel Fluorocycline Antibacterial Matteo Bassetti, MD, PhD Infectious Diseases Division University of Udine and Santa Maria Misericordia University Hospital Udine, Italy

Disclosures Research grants - Astellas, Pfizer, MSD, Gilead Advisor/consultant - Angelini, Astellas, AstraZeneca, Bayer, Basilea, Gilead, Menarini, MSD, Pfizer, Novartis, Shionogi, Vifor, The Medicines company, Tetraphase, Achaogen, Paratek, Melinta, Cidara, Nabriva Speaker/chairman Angelini, Astellas, AstraZeneca, Bayer, Pfizer, MSD, Gilead, Vifor, Novartis, Bayer,Tetraphase,Menarini, Cidara

IDSA Calls for 10 new antibiotics by 2020 11. Omadacycline 10. Eravacycline 9. Meropenem/vaborbactam 8. Plazomicin 7. Ceftazidime/Avibactam 6. Ceftolozane/Tazobactam 5. Oritavancin 4. Tedizolid Phosphate 3. Dalbavancin 2. Fidaxomicin IDSA = Infectious Diseases Society of America. http://www.nytimes.com/2010/07/business/27germ.html?_r=0 http://www.idsociety.org/10x20/ 1. Ceftaroline Fosamil

Eravacycline: A Novel Fluorocycline Novel, fully-synthetic fluorocycline antibiotic Two structural modifications: fluorine at C7 and pyrrolidinoacetamido group at C9 - F O N N H H3C N CH3 H H OH OH OH O OH O NH2 O Retains activity against the most common tetracycline-specific acquired resistance mechanisms (i.e., efflux and ribosomal protection) Binds to the 30S ribosomal subunit, disrupting bacterial protein synthesis XERAVA (eravacycline) [SPC]. Ireland Limited: Tetraphase Pharmaceuticals; 2018 Xiao, et al. J Med Chem. 2012; 55(2): 597-605; Grossman, et al. AAC. 2012; 56(5): 2559-2564

Anti-Gram-negative activity of new antibiotics MDR P.aeruginosa MDR Acinetobacter ESBL CRE Cefiderocol Ceftolozane- Tazobactam Ceftazidime-avibactam KPC and NDM-1 NO KPCs and OXA-48 (not active against MBLs) NO NO Ceftaroline fosamilavibactam KPCs and OXA-48 (not active against MBLs) NO NO Aztreonam-avibactam MBLs such as NDM NO Meropenem/vaborbactam Imipenem/cilastatinrelebactam KPCs KPCs and OXA-48 (not active against MBLs) NO^ NO NO Plazomicin most KPCs (not active against many NDMs) NO NO Eravacycline KPCs NO ^Active against P. aeruginosa, but not MDR P. aeruginosa., ESBL: extended-spectrum β-lactamases; KPC: K. pneumoniae carbapenemase; OXA: oxacillinase; MBL: metallo-β-lactamase; MDR: multidrug resistant; NDM: New Delhi metallo-beta-lactamase; CRE: carbapenemase-producing Enterobacteriaceae. Products in yellow are not licensed by EMA (status: phase II or III, pre-registration) Bassetti M et al. Expert Review of Anti-infective Therapy 2017 Jan;15(1):55-65

Eravacycline Pharmacokinetics Overview Absorption Mean (%CV) Plasma Exposure of Eravacycline 1 mg/kg After Single and Multiple IV Dose in Healthy Adults Cmax and AUC increased approximately doseproportionally over single-dose IV administration of doses from 1 mg/kg to 3 mg/kg Cmax (ng/ml) AUC0-12 (ng*h/ml) DAY 1 2125 (15) 4305 (14) DAY 10 1825 (16) 6309 (15) Distribution Elimination Mean t is 20 hours Metabolized primarily by CYP3A4- and FMO-mediated oxidation ~34% excreted in urine and 47% in feces as unchanged eravacycline (20% in urine and 17% in feces) and metabolites Protein binding increases with increasing plasma concentrations 79% to 90% bound at plasma concentrations, ranging from 100 to 10,000 ng/ml Vss=321L AUC, area under the curve; Cmax, maximum concentration; CYP, cytochrome P450; t, half-life; Vss, volume of distribution at steady state. XERAVA (eravacycline) [SPC]. Ireland Limited: Tetraphase Pharmaceuticals; 2018

Plasma and Intrapulmonary Concentrations of Eravacycline Eravacycline 1.0 mg/kg IV q12h for a total of seven doses Sample Site AUC0-12 (ug-h/ml) Site:Unbound Plasma Ratio Plasma (total) 4.56 Plasma (unbound) 0.77 ELF 4.59 6.44 AM 39.53 51.63 Connors KP, et al. Antimicrob Agents Chemother 2014;58:2113-2118

Eravacycline: Global In vitro Activity Against Gram-negative Pathogens: 2013-16 Surveillance MEM* AMK* PTZ FEP N ERV TGC Acinetobacter baumannii 1600 0.5/1 2/4 32/>64 32/>64 >64/>128 >16/>64 Citrobacter spp. 1275 0.25/0.5 0.5/1 0.5/1 2/64 0.25/1 Enterobacter spp. 1416 0.5/1 0.5/1 0.06/0.12 4/64 0.25/4 Escherichia coli 996 0.12/0.25 0.25/0.5 0.03/0.03 2/4 2/16 0.12/>16 Klebsiella spp. 3698 0.25/0.5 0.5/2 0.03/0.06 2/64 0.25/4 Proteus mirabilis 984 4/8 0.06/0.12 2/4 0.5/1 0.25/1 Serratia marcescens 902 0.06/0.12 2/4 2/16 0.25/0.5 Organism AMK: amikacin, ERV: eravacycline, FEP: cefepime, TGC: tigecycline, MEM: Meropenem, PTZ; piperacillin/tazobactam, MIC 50/90 units are in mcg/ml * = was not tested during all years In vitro activity does not necessarily correlate with clinical efficacy Data on file. 2018. Tetraphase Pharmaceuticals. Watertown, MA

Eravacycline: Global In vitro Activity Against Gram-positive Pathogens: 2013-16 Surveillance Organism Enterococcus faecalis VRE faecalis Enterococcus faecium VRE faecium Staphylococcus aureus MRSA Streptococcus anginosis group N ERV TGC LIN VAN* AMP* 1177 0.06/0.06 0.12/0.25 35 0.06/0.12 0.12/0.25 >32 852 0.03/0.06 0.12/0.25 1/>32 >8 310 0.06/0.06 0.12/0.25 >32 >8 2024 0.06/0.12 0.12/0.25 1/1 NT 1012 0.06/0.12 0.25/0.25 1/1 NT 1956 0.015/0.06 NT NT NT NT AMP: ampicillin, ERV: eravacycline, TGC: tigecycline, LIN, Linezolid; VAN, vancomycin; MRSA: methicillin-resistant S. aureus, VRE: vancomycin-resistant enterococci; units are in mcg/ml, * = was not tested during all years In vitro activity does not necessarily correlate with clinical efficacy Data on file. 2018. Tetraphase Pharmaceuticals. Watertown, MA

Eravacycline: In vitro Activity Against Anaerobic Pathogens N ERV TGC CLI MTZ Bacteroides fragilis 333 0.25/2 0.5/8 2/>128 <1/1 Bacteroides caccae 28 0.5/2 1/8 8/128 Bacteroides thetaiotamicron 157 0.5/2 1/8 8/>128 <1/1 Clostridium difficile 193 0.03/0.06 <0.06/0.25 4/16 0.25/0.5 Clostridium perfringens 91 0.12/0.5 0.5/2 1/>8 < Prevotella spp. 208 0.12/0.5 0.5/2 1/>8 < Organism ERV: eravacycline, CLI: clindamycin, TGC: tigecycline, MTZ: metronidazole, units are in mcg/ml In vitro activity does not necessarily correlate with clinical efficacy Snydman D, et al. Antimicro Agents Chemother 2018;62(5):e02206-17, Goldstein EC, et al. Anaerobe 2018;4:122-4, Morrissey I, et al. Presented at ID Week 2015, San Diego, CA

In vitro activity of eravacycline and comparators in Enterobacteriaceae, including subgroups of strains with an ESBL and a carbapenemresistant phenotype, isolated from patients in the EU Organism Escherichia coli E. coli ESBL Klebsiella oxytoca K. oxytoca ESBL Klebsiella pneumoniae K. pneumoniae ESBL K. pneumoniae CRE Proteus mirabilis P. mirabilis ESBL P. mirabilis CRE Serratia marcescens S. marcescens ESBL S. marcescens CRE Proteus vulgaris P. vulgaris ESBL P. vulgaris CRE N 153 43 150 13 147 57 16 150 18 65 150 19 1 149 17 53 ERV (mg/l) 0.12/0.25 0.12/0.25 0.25/0.25 0.25/2 0.5/1 0.5/1 0.5/1 2/4 4/4 1/1 1/1 1/1 MIC range (mg/l) 0.06-2 0.06-0.5 0.12-2 0.12-2 0.12-2 0.12-2 0.25-1 0.25-4 0.5-4 0.5/4 0.5-8 0.5-4 4-4 0.12-2 0.25-1 0.25-2 (mg/l) 0.25/0.5 0.25/0.5 0.5/0.5 0.5/2 4/4 4/8 4/8 2/4 4/4 2/4 2/4 Bassetti M et al. ECCMID 2016; TIG MIC range (mg/l) 0.12-2 0.12-0.5 0.25-2 0.25-2 0.12-4 0.12-4 0.5-2 0.25-8 1-8 0.5-8 0.25-4 0.5-4 4-4 0.5-8 0.5-4 0.5-4 %S 99.4 100 98.0 84.6 82.3 68.4 75.0 10.0 5.6 7.7 49.3 36.8 0.0 39.6 23.5 15.1

Phase 3 IGNITE Program Investigating Gram-Negative Infections Treated with Eravacycline IGNITE-1-4 IGNITE-2-3 Complicated Complicated Intra-Abdominal Infections Urinary Tract Infections www.clinicaltrials.gov; www.tetraphase.com

ERV vs LEVO in cuti IV eravacycline failed to meet the FDA primary endpoint (responder rate at end of care[eoc]) using a 10% non-inferiority margin (-10% CI: -14.1%, -6.0%).

IGNITE1 and IGNITE4: Study Design IGNITE: Investigating Gram-Negative Infections Treated With Eravacycline POST-TREATMENT EVALUATIONS NONINFERIORITY TRIAL (NI margin: IGNITE1 10%, IGNITE4-12.5%) Eravacycline 1 mg/kg IV q12h IGNITE1: N=541 (1:1) IGNITE4: N=500 (1:1) Primary Endpoint Test of Cure Secondary Endpoint Long-term follow-up DAYS 25-31 DAYS 38-50 4- to 14-Day Dosing Period IGNITE1: Ertapenem 1 g IV q24h IGNITE4: Meropenem 1 g IV q8h DAYS 1-14 Secondary Endpoint End of therapy The design of both studies adhered to both the FDA and EMA development guidance Solomkin J, et al. JAMA Surg. 2017;152(3):224-232; Tsai et al., Presented at ECCMID 2018, Madrid, Spain

IGNITE1/4: Demographics ITT/MITT Population IGNITE1 ITT Population IGNITE4 MITT Population Gender, male, n% ERV (N = 270) 156 (57.8) ETP (N = 271) 163 (60.1) ERV (N = 250) 139 (55.6) MEM (N = 249) 129 (51.8) Race, White, n% 263 (97.4) 260 (95.9) 249 (99.6) 249 (100) 182 (67.4) 195 (72) 180 (72) 174 (69.9) 65 to 75 62 (23) 44 (16.2) 50 (20) 48 (19.3) 75 26 (9.6) 32 (11.8) 20 (8) 27 (10.8) 28.02 (5.66) 27.02 (5.01) 27.61 (5.53) 27.05 (4.88) < 10 (%) 235 (87.0) 221 (81.5) 220 (88) 210 (84.3) 11-15 (%) 28 (10.4) 40 (14.8) 27 (10.8) 31 (12.4) 16-20 (%) 4 (1.5) 5 (1.8) 3 (1.2) 7 (2.8) 21-25 (%) 0 1 (0.4) 0 1 (0.4) 1 (0.4) 0 0 0 Age, Mean, y (SD) <65 Body mass index, kg/m2, mean (SD) Baseline APACHE II category, n (%) >25 (%) ERV: Eravacycline, ETP: Ertapenem, MEM: Meropenem Solomkin J, et al. JAMA Surg. 2017;152(3):224-232; Tsai et al., Presented at ECCMID 2018, Madrid, Spain

IGNITE1/4 Baseline Pathogen Distribution micro-itt Population 2717 total baseline isolates 3.6 isolates/patient Newman, et al. Presented at IDWeek 2018, San Francisco, CA

IGNITE1/4: 1o Efficacy Endpoint (FDA) Clinical Response at TOC micro-itt Population 100 Difference -0.7 95% CI, -4.9,3.6 Difference -0.8 95% CI, -7.1,5.5 Difference -0.5 95% CI, -6.3,5.3 ERV 1 mg/kg q12h % Clinical Cure 80 88.7% 89.3% 86.8% 87.6% 90.8% 91.2% Eravacycline demonstrated noninferiority to ertapenem and meropenem in the FDA primary analyses 60 40 20 0 Comparator(s) 368/415 385/431 Pooled Data 1920 198/226 IGNITE1 (ETP) 177/195 187/205 Eravacycline achieved high clinical cure rates IGNITE4 (MEM) Clinical Cure (micro-itt Population) ERV: Eravacycline, ETP: Ertapenem, MEM: meropenem; micro-itt: microbiological Intent-to-treat, TOC: Test of Cure Solomkin J, et al. JAMA Surg. 2017;152(3):224-232; Tsai et al., Presented at ECCMID 2018, Madrid, Spain

100 Difference -0.5 95% CI, -4.2,3.2 89.6% 90.1% Difference -1.8 95% CI, -7.4,3.8 87% 88.8% Difference 0.8 95% CI, -4.1,5.8 ERV 1 mg/kg q12h 92.4% 91.6% Comparator(s) 50 0 466/520 466/517 Pooled Data 235/270 238/268 IGNITE1 (ETP) 2350 228/249 IGNITE4 (MEM) Clinical Cure (MITT Population) Eravacycline demonstrated non-inferiority to ertapenem and meropenem in the EMA primary analyses % Clinical Cure % Clinical Cure IGNITE1/4: 1o Efficacy Endpoint (EMA) Clinical Response at TOC MITT and CE Population 100 Difference -0.5 95% CI, -3.4,2.4 94.8% 95.3% Difference -1.7 95% CI, -6.3,2.8 Difference 0.8 95% CI, -2.9,4.5 92.9% 94.5% 96.9% 96.1% 50 0 440/464 447/469 Pooled Data 2239 225/238 218/225 2231 IGNITE1 (ETP) IGNITE4 (MEM) Clinical Cure (CE Population) Solomkin J, et al. JAMA Surg. 2017;152(3):224-232; Tsai et al., Presented at ECCMID 2018, Madrid, Spain

IGNITE1/4:Per Pathogen Clinical Response at TOC micro-itt Population % Clinical Cure ERV 1 mg/kg q12h 100 90 80 70 60 50 40 30 20 10 0 Comparator(s) ERV: Eravacycline TOC: Test of Cure Solomkin J, et al. JAMA Surg. 2017;152(3):224-232; Tsai et al., Presented at ECCMID 2018, Madrid, Spain

Clinical and Microbiological Outcomes at TOC in the microitt Population for Subjects with Gram-Negative Bacilli Pathogens Baseline Pathogen Pooled ERV Microbiological cure No. /Total no. (%) Pooled ERV Clinical cure No. /Total No. (%) Pooled Comparator Microbiological cure No./Total No. (%) Pool Comparator Clinical cure No. /Total No. (%) Enterobacteriaceae 277/314 (88.2) 271/314 (86.3) 296/325 (91.1) 289/325 (88.9) CEPH-R& 41/48 (85.4) 43/48 (89.6) 40/45 (88.9) 40/45 (88.9) ESBL confirmed 32/36 (88.9) 32/36 (88.9) 26/29 (89.7) 25/29 (86.2) MDR% 35/46 (84.7) 40/46 (87) 29/32 (90.6) 29/32 (90.6) Acinetobacter baumannii 13/13 (100) 13/13 (100) 7/7/ (100) 7/7 (100) 13/13 (100) 13/13 (100) 5/5/ (100) 5/5 (1000 5/5 (100) 5/5 (100) 1/1 (100) 1/1 (100) 12/12 (100) 12/12 (100) 5/5 (100) 5/5 (100) * CEPH-R& ESBL confirmed MDR% ERV = eravacycline; a = Includes Citrobacter freundii, Enterobacter cloacae, Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, and Morganella morganii. & = CEPH-R - 3rd/4th-generation cephalosporin-resistant % = MDR = Multidrugresistant.- resistant to at least one member of >=3 antibiotic classes Ditch K et al. Presented at ASM Microbe 2018, Atlanta, GA

IGNITE1/4: Selected Adverse Reactions in 1% of Patients Adverse Reactions Eravacycline N = 520 n (%) Comparators N = 517 n (%) Infusion site reactions 40 (7.7) 10 (1.9) Nausea 34 (6.5) 3 (0.6) Vomiting 19 (3.7) 13 (2.5) Diarrhea 12 (2.3) 8 (1.5) Hypotension 7 (1.3) 2 (0.4) Wound dehiscence 7 (1.3) Comparators: ertapenem and meropenem 1 (0.2) Infusion site reactions: catheter/vessel puncture site pain, infusion site extravasation, infusion/injection hypoaesthesia, infusion/injection site phlebitis, infusion site thrombosis, injection site/vessel puncture site erythema, phlebitis, phlebitis superficial, thrombophlebitis, and vessel puncture site swelling XERAVA (eravacycline) [SPC]. Ireland Limited: Tetraphase Pharmaceuticals; 2018

Eravacycline Pros Broad spectrum (Gram+ [MRSA], Gram- [including ESBLs, KPC, NDMs], anaerobes) Acinectobacter Favorable safety and tolerability profile expected Q12-Q24 interval Oral dosing Good lung penetration Con Contraindicated in pregnancy and in children Failed in cuti P3 trial Oral formulation: low bioavailability? Relative to tigecycline: 2-4 more potent; 2 higher AUC AUC, area under the plasma drug concentration-time curve; NDM, New Delhi metallo-β-lactamase