Fernando-Cruz Foundation Symposium, Hospital Clinico San Carlos, Madrid PDF Free Download

Fernando-Cruz Foundation Symposium, Hospital Clinico San Carlos, Madrid 2015 Management of Hypercholesterolemia beyond Statins : ODYSSEY and OSLER Trials M. John Chapman BSc (Hons), Ph.D., D.Sc., FESC Director Emeritus, INSERM, Research Professor, University of Pierre and Marie Curie Past-President, European Atherosclerosis Society Pitié-Salpetriere University Hospital, Paris, France

PCSK9 Inhibitors: From Target Discovery to Phase III to the Clinic PCSK9 (NARC-1) discovered PCSK9 GOF mutations associated with ADH* PCSK9 LOF Mutations found with 28% LDL-C and 88% CHD risk Humans null for PCSK9 have LDL-C ~15 mg/dl Plasma PCSK9 binds to LDL-R First Patients with FH / non-fh treated with PCSK9i mab 1 st FDA / EMEA PCSK9i filing 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Adenoviral expression in mice PCSK9 KO mouse LDL-C First subject treated with PCSK9 mab LDL-C in mice and non-human primates treated with anti-pcsk9 mab First publication POC in patients * ADH: Autosomal Dominant Hypercholesterolemia; Seidah NG. Proc Natl Acad Sci US 2003;100(3):928-33, Abifadel M. Nat Genet 2003;34(2):154-6, Maxwell KN. Proc Natl Acad Sci US 2004;101(18):7100-5, Rashid S. Proc Natl Acad Sci US 2005;102(15):5374-79, Lagace TA et al. JCI 2006;116:2995-3005 Cohen JC. N Engl J Med 2006;354(12):1264-72, Zhao Z. Am J Hum Genet 2006;79(3):514-23, Hooper AJ. Atherosderosis 2007;193(2):445-8, Chan JC. Proc Natl Acad Sci US 2009;106(24):9820-5: Stein et at N Engl J Med 2012;366:1108-18; Stein modified from Swergold, Regeneron.

CHOLESTEROL Cell membrane component Steroid hormone precursor Vitamin D precursor Bile acid precursor LXR agonist (oxysterols)

CHOLESTEROL HOMEOSTASIS NY-160626.038/020131YlsjoLS1 WHOLE BODY Peripheral Tissue Cholesterol Pool Dietary Cholesterol NPC1L1 Biliary Cholesterol Intestine NPC1L1 Cholesterol Pool Synthesis CM Liver Cholesterol Pool Synthesis VLDL nascent HDL LDL HDL Synthesis Skin Cholesterol Pool Synthesis Endocrine Glands Cholesterol Pool Excretion Skin Sterols 85 mg/j Steroïd Hormones 50 mg/j Synthesis Biliary Cholesterol 600 mg/j Bile Acids 400 mg/j

Thin cap, rupture-prone atherosclerotic plaque Thin cap Inflammation - macrophages - T lymphocytes - mast cells Cholesterol crystals Lipid-rich core Courtesy: Erling Falk

LDL is causal in the pathophysiology of atherosclerotic vascular disease INTERHEART Familial hypercholesterolemia RCTs with statins and cholesterol absorption inhibition Mendelian randomisation studies PCSK9 genetics Origin of Plaque components Modulation of Plaque composition and size by Statins

Control of plasma LDL- cholesterol levels: Key role of the cellular LDL receptor http://www.iemrams.spb.ru/english/molgen/fh-en/domain-e.htm. [Accessed 6 August 2015] DOMAINS Ligand binding (292 (292 aa) aa) NH 2 2 3 4 5 6 I II III IV V VI VII EXONS A B Epidermal growth factor precursor homology (400 aa) C O-linked sugars (58 aa) Membranespanning (22 aa) Cytoplasmic (50 aa) COOH

Plasma LDL degradation by the LDL Receptor pathway ER Golgi LDL LDLR Endosome (H + ) Coated vesicle Coated pit Lysosome (H + ) Recycling vesicle

Which factors principally control levels of LDL receptor activity in the liver?

Control of hepatic LDL-Receptor activity - Intracellular levels of cholesterol (reflecting uptake of cholesterol contained in LDL, VLDL and chylomicron remnants, and HDL), endogenous cholesterol synthesis, cholesterol conversion to bile acids, and excretion of bile acids and biliary cholesterol) via the SREBP pathway - PCSK9 - the IDOL pathway

What is PCSK9? How was PCSK9 identified as a key gene in cholesterol homeostasis?

What is PCSK9? Chromosome: 1p32.3 Gene: 12 exons cdna 3617 bp Protein: 692 amino acids Expressed in liver, kidney, intestine Undergoes autocatalytic cleavage in the ER to active conformation Appears to play the role of an intracellular protein chaperone http://www.genecards.org/cgi-bin/carddisp.pl?gene=pcsk9/. [Accessed 19 July 2011] Abifadel M, et al. Nature Genet 2003;34:154 6. Horton JD, et al. Trends Biochem Sci 2007;32:71 7. Abifadel M, et al. Hum Mutat 2009;30:520 9. Chen SN, et al JACC 2005;45:1611 9.

A PCSK9 GAIN-of-Function mutation causes Autosomal Dominant Hypercholesterolaemia Affected family members with: Total cholesterol in 90 th percentile Tendon xanthomas CHD Early MI Stroke Abifadel M, et al. Nat Genet 2003;34:154 6.

Absence of PCSK9 Leads to Marked Increase in LDL-R PCSK9 knockout mice : hepatic LDL-R levels Immunoblot Immunofluorescence against LDL-R PCSK9 decreases number of LDL-R : LDL-C Rashid S et al. PNAS 2005;102:5374 5379

Role of PCSK9 in regulation of the surface expression of LDL receptors LDL particles LDL-R PCSK9 routes LDL-R for lysosomal degradation LDL-R recycling blocked PCSK9 secretion Chan JC, et al. Proc Natl Acad Sci USA 2009;106:9820 5..

Regulation of PCSK9 is dynamic Upregulates PCSK9 Cholesterol depletion 2,3 SREBP2 1,3,4 Statins 3,4 Plasma PCSK9 level Downregulates PCSK9 Dietary and cellular cholesterol 4 Bile acids 3,4 1. Horton JD, et al. J Lipid Res. 2009;50:S172 7. 2. Lopez D. Biochem Biophys Acta 2008;1781:184 91. 3. Abifadel M, et al. Hum Mutat. 2009;30: supplementary information. 4. Abifadel M, et al. In: Toth PP. The Year in Lipid Disorders. Vol. 2. Oxford, UK: Atlas Medical Publishing Ltd. 2010:3 23. 5. Miao et al, ATVB. 2015;35:1589-1596.

Is there a major flaw In the MOA of statins?

Mechanism of statin-mediated upregulation of the LDLR gene via SREBP2 LDL-C Statin Lysosomal degradation LDLR SREBP2 Hepatocyte

Mechanism of statin-mediated upregulation of the LDLR and PCSK9 genes via SREBP2 LDL-C Statin Lysosomal degradation LDLR SREBP2 PCSK9 Hepatocyte Adapted from Konrad RJ et al. Lipids Health Dis 2011;10:38.

PCSK9 How do genetic mutations/variants in PCSK9 relate to LDL-C levels and CV risk? Can PCSK9 be targeted to reduce LDL-C and CVD?

Genetic variants of PCSK9 exert distinct roles in regulating LDL-C levels Lysosomal degradation of LDLR Plasma Recycling of LDLR Nucleus Already in JC presentation but I will get better picture quality for both Gain-of-function mutation Loss-of-function mutation Golgi apparatus Gain-of-function PCSK9 PCSK9 secretion Loss-of-function PCSK9 Plasma PCSK9 Gain of Function = Less LDLRs PCSK9 Loss of Function = More LDLRs

Elevated LDL-C levels in patients with GAIN-of-Function PCSK9 mutations Control 105 D35Y L108R 249 266 RARE S127R 287 F216L R218S 227 216 D374Y 350 Poirier S, Mayer G. Drug Des Devel Ther 2013;7:1135 48.

Low LDL-C levels in patients with LOSS-of-Function PCSK9 mutations Control 105 R46L 86 R97 G106R 58 89 FREQUENT Y142X 53 C679X 68 Poirier S, Mayer G. Drug Des Devel Ther 2013;7:1135 48.

Frequency (%) Loss-of-Function PCSK9 mutations are associated with low LDL-C and low prevalence of CHD events Coronary Heart Disease (%) 30 20 No nonsense mutation (n = 3278) 50 th Percentile Mean 138 mg/dl 88% reduction in risk of CHD events during 15-year follow-up 12 10 0 0 50 100 150 200 250 300 8 9.7% 30 20 PCSK9 142x or PCSK9 679X (n=85) Mean 100 mg/dl (-28%) 4 10 0 1.2% 0 0 50 100 150 200 250 300 Plasma LDL-C in black subjects (mg/dl) No Yes PCSK9 142x or PCSK9 679X Adapted from Cohen JC et al. N Engl J Med 2006;354:1264 72.

Individuals who completely lack PCSK9 and have very low LDL-C levels are healthy Therefore, inhibition of PCSK9 may be a safe pharmacologic approach to dyslipidaemia management

Approaches to reducing PCSK9 interaction with the LDLR Bind plasma PCSK9 Monoclonal antibodies Evolocumab, now EMEA approved (Amgen) Alirocumab, now FDA approved (Regeneron/Sanofi) Bococizumab (Pfizer) Adnectins (Adnexis/BMS) Reduce PCSK9 synthesis sirna (Alnylam) Lambert G, et al. J Lipid Res. 2012. 53: 2515 24. http://www.lilly.com/sitecollectiondocuments/pipeline/clinical%20development%20pipeline/index.html. [Accessed 6 August 2015]

Impact of an anti-pcsk9 monoclonal antibody on LDL-R expression Anti-PCSK9 mab PCSK9 Increased LDLR surface concentration LDLR LDLR recycling Chan JC, et al. Proc Natl Acad Sci USA 2009;106:9820 5.

Free/total PCSK9 Conc. (ng/ml) Total alirocumab (ng/ml) X 0.01 LDL-C mean % change Alirocumab: Dynamic Relationship Between mab Levels, PCSK9 and LDL-C 200 0 180 160 140-10 -20 120 100 80-30 -40 60 40 20 Total alirocumab Free PCSK9 LDL-C -50-60 0 0 500 1000 1500 2000 2500 2 W Time (hours) -70 Stein EA et al. New Engl J Med 2012;366:1108 18.

The CV Risk Pyramid : Greatest clinical needs Familial Hypercholesterolemia (HeFH and HoFH) LDL-C levels often far from goal, even with potent statins and combination therapies Life-long exposure to high LDL-C; considered high risk even w/o additional risk factors High CV Risk Patients Patients not at LDL-C goal with currently available LLT (even high doses of potent statins) and persistent high risk Statin Intolerant Patients LDL-C levels often far from goal, due to intolerance Patients unable to tolerate at least 2 statins, including one at the lowest dose

Auto-immune disorders Chronic kidney disease (SHARP) Acute Coronary Syndromes Very high and high risk Dyslipidaemic patient populations Stable; Unstable CAD Ischaemic Stroke Metabolic syndrome Type 2 diabetes FH Non-FH hyperchol Chapman, MJ. Unpublished.

Overview of ODYSSEY Clinical Trial Program 14 global phase 3 trials including >23,500 patients across >2,000 study centers HeFH population HC in high CV risk population Additional populations Add-on to max-tolerated statin (± other LMT) ODYSSEY FH I (NCT01623115; EFC12492) LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=471; 18 months ODYSSEY FH II (NCT01709500; CL1112) LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=250; 18 months Add-on to max-tolerated statin (± other LMT) ODYSSEY COMBO I (NCT01644175; EFC11568) LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=306; 12 months *ODYSSEY COMBO II (NCT01644188; EFC11569) LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=660; 24 months ODYSSEY MONO (NCT01644474; EFC11716) Patients on no background LMTs LDL-C 100 mg/dl N=100; 6 months ODYSSEY ALTERNATIVE (NCT01709513; CL1119) Patients with defined statin intolerance LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=250; 6 months ODYSSEY HIGH FH (NCT01617655; EFC12732) LDL-C 160 mg/dl N=105; 18 months ODYSSEY OLE (NCT01954394; LTS 13463) Open-label study for FH from EFC 12492, CL 1112, EFC 12732 or LTS 11717 N 1000; 30 months ODYSSEY LONG TERM (NCT01507831; LTS11717) LDL-C 70 mg/dl N=2,100; 18 months ODYSSEY CHOICE I (NCT01926782; CL1308) LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=700; 12 months ODYSSEY OUTCOMES (NCT01663402; EFC11570) LDL-C 70 mg/dl N=18,000; 64 months ODYSSEY CHOICE II (NCT02023879; EFC13786) Patients not treated with a statin LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=200; 6 months ODYSSEY OPTIONS I (NCT01730040; CL1110) Patients not at goal on moderate dose atorvastatin LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=350; 6 months ODYSSEY OPTIONS II (NCT01730053; CL1118) Patients not at goal on moderate dose rosuvastatin LDL-C 70 mg/dl OR LDL-C 100 mg/dl N=300; 6 months FH=familial hypercholesterolemia; HC=hypercholesterolemia; LMT=lipid-modifying therapy; OLE=open-label extension. *For the ODYSSEY COMBO II other LMT not allowed at entry. ClinicalTrials.gov. ODYSSEY Trials. http://clinicaltrials.gov. Accessed February 12, 2014.

Evolocumab Clinical Trial Program Program to Reduce LDL-C and Cardiovascular Outcomes Following Inhibition of PCSK9 In Different Populations (Latin): To advance To make progress 33

Evolocumab s PROFICIO clinical trial program addresses key areas of unmet need in the management of dyslipidaemia Combination therapy Monotherapy Phase 2 (n=631) Phase 2 (n=411) >35,000 patients (n=2067) (n=615) Statin intolerant Phase 2 (n=160) (n=307) (n=511)* HeFH HoFH/ Severe FH Phase 2 (n=168) Phase 2/3 (n=58) (n=331) Phase 2/3 (n=300) Completed trials Long-term safety and efficacy Open-label extension Atherosclerosis Secondary Prevention Neurocognition Phase 2 (n=1104) (n=905) (n=3671)* (n=970) (n=27,564) (n=1971)* HeFH, heterozygous hypercholesterolaemia; HoFH, homozygous hypercholesterolaemia. Clintrials.gov. * Amgen data on file.

SPIRE Bococizumab Clinical Development Programme Unmet Needs in the Management of CVD in High Risk Patients SPIRE (Studies of PCSK9 Inhibition and the Reduction of Vascular Events) N=~30,000 SPIRE Lipid Lowering Studies SPIRE CV Outcome Studies SPIRE HR (n=300) On statin High risk of CV event LDL-C 70 or 100 mg/dl SPIRE LDL (n=1,932) On statin High risk of CV event LDL-C 70 mg/dl SPIRE-1 (n=17,000) High Risk Primary and Secondary Prevention LDL-C 70 to <100 mg/dl on statins (or statin intolerant) SPIRE-2 (n=9,000) High Risk Primary and Secondary Prevention LDL-C 100 mg/dl on statins (or statin intolerant) SPIRE FH (n=300) HeFH (genetic diagnosis or Simon Broome Criteria), LDL >70 mg/dl SPIRE LL (n=690) On statin High / very high risk of CV event LDL-C 100 mg/dl NCT#: https://clinicaltrials.gov SPIRE HR: NCT01968954 SPIRE LDL: NCT01968967 SPIRE HF: NCT01968980 SPIRE SI (n=150) Statin intolerant LDL-C 70 mg/dl Studies on PCSK9 Inhibition and the Reduction of Vascular Events SPIRE-LL: NCT02100514 SPIRE-SI: NCT02135029 SPIRE-1: NCT01975376 SPIRE-2: NCT01975389

OLE/8 week FU ODYSSEY FH I and FH II Study Design Double-Blind Treatment Period (78 Weeks) HeFH patients on max tolerated statin ± other lipidlowering therapy LDL-C 1.81 mmol/l [70 mg/dl] (history of CVD) or 2.59 mmol/l [100 mg/dl] (no history of CVD) R Alirocumab 75 mg Q2W SC with potential to 150 mg Q2W SC (single 1-mL injection using prefilled pen for self-administration) n=323 (FH I); n=167 (FH II) n=163 (FH I); n=82 (FH II) Placebo Q2W SC Per-protocol dose possible based on pre-specified LDL-C level Assessments W0 W8 W16 W36 W64 W4 W12 W24 W52 W78 Dose if LDL-C >70 mg/dl at W8 Primary efficacy endpoint Pre-specified analysis Efficacy: All Patients To W52 Safety: Baseline-W78 (all patients at least W52) Clinicaltrials.gov identifiers: ODYSSEY FH I: NCT01623115; ODYSSEY FH II: NCT01709500. Kastelein, ESC 2014

Lipid Medication and LDL-C at Baseline All patients on background of max-tolerated statin ± other lipid-lowering therapy Alirocumab (N=323) FH I Placebo (N=163) Alirocumab (N=167) FH II Placebo (N=82) Any statin, % (n) 100% 100% 100% 100% High-intensity statin, % (n) 80.8% (261) 82.8% (135) 86.2% (144) 87.8% (72) Ezetimibe, % (n) 55.7% (180) 59.5% (97) 67.1% (112) 64.6% (53) LDL-C, mean (SD), mmol/l [mg/dl] 3.7 (1.3) [144.7 (51.2)] 3.7 (1.2) [144.4 (46.8)] 3.5 (1.1) [134.6 (41.3)] 3.5 (1.1) [134.0 (41.6)] Patients should receive either rosuvastatin 20-40 mg, atorvastatin 40-80 mg daily, or simvastatin 80 mg daily unless not tolerated and/or appropriate other dose given according to the judgement of the investigator. High-intensity statin: atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily. Kastelein, ESC 2014

LS mean (SE) % change from baseline to Week 24 Alirocumab Significantly Reduced LDL-C from Baseline to Week 24 versus Placebo Primary Endpoint: % Change from Baseline to Week 24 in LDL-C FH I FH II Alirocumab Placebo N=322 N=163 N=166 N=81 43.4% had dose increase at W12 38.6% had dose increase at W12 LS mean difference (SE) vs. placebo: 57.9% (2.7) P<0.0001 51.4% (3.4) P<0.0001 Intent-to-treat (ITT) Analysis Kastelein, ESC 2014

Evolocumab Q2W or QM: consistent LDL-C reductions across different studies Evolocumab vs placebo: consistent reduction in LDL-C, Q2W and QM Evolocumab vs ezetimibe: consistent reduction in LDL-C, Q2W and QM Treatment difference for % change from baseline in LDL-C Monotx MENDEL-2 N=614 Combotx LAPLACE-2 N=1896 HeFH RUTHERFORD-2 N=329 Long Term DESCARTES N=901 Monotx MENDEL-2 N=614 Combotx LAPLACE-2 N=1896 SI GAUSS-2 N=307 Evolocumab 140 mg Q2W Evolocumab 420 mg QM Results are for the mean of weeks 10 and 12 except for DESCARTES, which are for week 52. MENDEL-2: Koren MJ, et al. J Am Coll Cardiol 2014;63:2531 40; LAPLACE-2: Robinson JG, et al. JAMA 2014;311:1870 82; RUTHERFORD-2: Raal FJ, et al. Lancet 2015;385:331 40; DESCARTES: Blom DJ, et al. N Engl J Med 2014;370:1809 19; GAUSS-2: Stroes E, et al. J Am Coll Cardiol 2014;63:2541 8.

Raal FJ et al. Lancet 2015; 385: 331 40 Figure 2

Efficacy of LDL-C lowering by Evolocumab in heterozygous FH patients : RUTHERFORD-2 Evolocumab 140 mg Q2W Evolocumab 420 mg QM Raal FJ, et al. Lancet 2014; doi.org/10.1016/s0140-6736(14)61399-4 and supplementary material.

45 On treament residual LDL= 280 mg/dl

TAUSSIG Raal 46et al ISA 2015

Cuchel et al, EHJ 2014

OSLER Program Phase 2 trials MONO- THERAPY MENDEL-1 (n=406) HYPERCHOL ON A STATIN LAPLACE-TIMI 57 (n=629) STATIN- INTOL GAUSS-1 (n=157) HETEROZYG FAM HYPERCHOL RUTHERFORD-1 (n=167) OTHER YUKAWA-1 (n=307) trials MENDEL-2 (n=614) LAPLACE-2 (n=1896) GAUSS-2 (n=307) RUTHERFORD-2 (n=329) DESCARTES (n=901) THOMAS-1 (n=149) THOMAS-2 (n=164) 4465 patients (74%) elected to enroll into OSLER extension study program 1324 from Ph2 trials into OSLER-1 3141 from Ph3 trials into OSLER-2 Eligible if medically stable and on study drug Randomized 2:1 Irrespective of treatment assignment in parent study Evolocumab plus standard of care (n=2976) Standard of care alone (n=1489) Trial Sponsor: Amgen Median follow-up of 11.1 months (IQR 11.0-12.8) 7% discontinued evolocumab early 96% completed follow-up Sabatine et al. N Engl J Med 2015; March 15: online

LDL Cholesterol Standard of care alone 61% reduction (95%CI 59-63%), P<0.0001 Absolute reduction: 73 mg/dl (95%CI 71-76%) Evolocumab plus standard of care (Parent study) (OSLER) N=4465 N=1258 N=4259 N=4204 N=1243 N=3727 Sabatine et al. N Engl J Med 2015; March 15: online

Change from Baseline (%) Change from Baseline (%) Change from Baseline (%) Change from Baseline (%) Change from Baseline (%) Change from Baseline (%) Other Lipid Parameters 52% in Non-HDL-C 47% in ApoB 26% in Lp(a) 10 0-10 -20-30 -40-50 5.9 P<0.001-46.1 10 0-10 -20-30 -40-50 5.5 P<0.001-41.7 5 0-5 -10-15 -20-25 -30 0.0 P<0.001-25.5 13% in Triglycerides 7% in HDL-C 4% in ApoA1 10 5 0-5 -10-15 3.5 P<0.001-9.1 10 8 6 4 2 0 1.7 P<0.001 8.7 8 7 6 5 4 3 2 1 0 2.6 P<0.001 6.8 Week 12 data; values are means except for TG and Lp(a) which are medians Standard of care alone Evolocumab plus standard of care Sabatine et al. N Engl J Med 2015; March 15: online

Mean % Change from Baseline Evolocumab 140 mg Q2W or 420 mg Q4W: Effect of Baseline TG on TG response N 1228 429 137 TG <150 mg/dl TG 150-250 mg/dl TG >250 mg/dl Mean TG 99.2 mg/dl Mean TG 186.8 mg/dl Mean TG 328.7 mg/dl With permission from Dr E. Stein

Cumulative Incidence (%) Sabatine et al. N Engl J Med 2015; March 15: online Cardiovascular Outcomes 3 Composite Endpoint: Death, MI, UA hosp, coronary revasc, stroke, TIA, or CHF hosp 2 1 HR 0.47 95% CI 0.28-0.78 P=0.003 Standard of care alone (N=1489) 2.18% 0.95% 0 Evolocumab plus standard of care (N=2976) 0 30 60 90 120 150 180 210 240 270 300 330 365 Days since Randomization

Estimated probability of event Robinson et al. N Enl J Med 2015; March 15: online Post-hoc Adjudicated Cardiovascular TEAEs (Same as primary endpoint of ongoing ODYSSEY OUTCOMES trial ) Kaplan-Meier Estimates for Time to First Adjudicated Major CV Event Safety Analysis (at least 52 weeks for all patients continuing treatment, including 607 patients who completed W78 visit) 0.10 Placebo + max-tolerated statin ± other LLT Alirocumab + max-tolerated statin ± other LLT 0.08 0.06 0.04 Cox model analysis: HR=0.46 (95% CI: 0.26 to 0.82) Nominal p-value = <0.01 Mean treatment duration: 65 weeks 0.02 0.00 No. at Risk Placebo Alirocumab 0 788 1550 12 776 1534 24 731 1446 36 703 1393 48 682 1352 60 667 1335 72 321 642 84 127 252 96 0 0 Weeks Primary endpoint for the ODYSSEY OUTCOMES trial: CHD death, Non-fatal MI, Fatal and non-fatal ischemic stroke, Unstable angina requiring hospitalisation. LLT, lipid-lowering therapy

Coronary disease & death before age 20 Untreated coronary disease before age 55/60 Cumulative LDL-C (mmol) HOZ Untreated Treat at 10yrs Non FH Treat at 18yrs Homozygous FH Heterozygous FH 200 150 100 50 0 12.5yrs Start low dose statin Threshold for CHD Start high dose statin 35yrs Without FH 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 Age in years Years Age 48yrs 53yrs 55yr Female sex Smoking Hypertension Diabetes Triglycerides HDL-C Lipoprotein(a) Nordestgaard et al, EHJ 2013; EAS Consensus Panel

Sabatine et al. N Engl J Med 2015; March 15: online Safety Adverse events (%) Evolocumab + stnd of care (N=2976) Standard of care alone (N=1489) Any 69.2 64.8 Serious 7.5 7.5 Leading to discontinuation of evolocumab 2.4 n/a Injection-site reactions 4.3 n/a Muscle-related 6.4 6.0 Neurocognitive 0.9 0.3 Laboratory results (%) ALT or AST >3 ULN 1.0 1.2 Creatine kinase >5 ULN 0.6 1.2

Sabatine et al. N Engl J Med 2015; March 15: online Adverse Events by Achieved LDL-C Adverse Events (%) Evolocumab subjects stratified by minimum achieved LDL-C <25 mg/dl (n=773) 25 to <40 mg/dl (n=759) <40 mg/dl (n=1532) 40 mg/dl (n=1426) All EvoMab (n=2976) Stnd of Care Alone (n=1489) Any 70.0 68.1 69.1 70.1 69.2 64.8 Serious 7.6 6.9 7.2 7.8 7.5 7.5 Muscle-related 4.9 7.1 6.0 6.9 6.4 6.0 Neurocognitive 0.5 1.2 0.8 1.0 0.9 0.3 Lab results (%) ALT/AST >3 ULN 0.9 0.8 0.8 1.3 1.0 1.2 CK >5 ULN 0.4 0.9 0.7 0.5 0.6 1.2

Trials: Alirocumab, Evolocumab, Bococizumab Patient Pop n Evolocumab (PROFICIO program) Alirocumab (ODYSSEY program) Bococizumab (SPIRE program) Trial N Dur n (m) Predicted Pt Exposure (Y) Min B/L LDL-C (mg/dl) Trial N Dur n (m) Predicted Pt Exposure (Y) Min B/L LDL- C (mg/dl) Trial N Dur n (m) Predicted Pt Exposure (Y) Min B/L LDL- C (mg/dl) HeFH RUTHERFORD-2 327 3 51 100 FH I 471 18 471 70 FH II 250 18 250 70 FH 300 12 200 >70 HAUSER (paeds) 150 6 50 130 HIGH FH 105 18 105 160. TESLA 50 3 8 130 HoFH TAUSSIG (OL) 300 60 1000 100 COMBO I 316 12 209 70 HR 600 12 400 >70 Combo Therapy LAPLACE-2 1896 3 258 80 COMBO II 720 24 958 70 OPTIONS I 345 6 51 70 LDL 1932 12 1288 >70 OPTIONS II 300 6 150 70 Monotherapy MENDEL-2 614 3 71 100 MONO 103 6 24 70 AI 300 3 50 70 Statin Intolerance GAUSS-2 307 3 47 None GAUSS-3 511 36 984 None ALTERNATIVE 314 6 47 70 SI 150 6 23 70 Long term DESCARTES 901 12 600 75 LONG-TERM 2341 18 2341 70 OSLER-2 (OL) 3671 24 5904 None OLE (OL) 1200 28 2800 None LL 690 12 460 100 Atheroma GLAGOV 970 18 970 60 Totals Patients 10462 Predicted Pt Yrs ~ 9943 Patients 5465 Predicted Pt Yrs ~ 7302 Patients 3972 Predicted Pt Yrs ~ 2421 CVD Outcomes FOURIER 27,564 Event driven NA 70 OUTCOMES 18,000 Event driven NA 70 SPIRE-1 17,000 SPIRE-2 9,000 Event driven Event driven NA 70 & <100 NA 100 Neurocognitive events EBBINGHAUS 1971 in FOURIER End of FOURIER N/A 70 For Predicted Pt Exposure, where randomization is unknown, assumed 2:1 in favour of active comparator; Assumed 1:1:1 randomization; Patients from 4 studies: FH1, FH2, High FH and Long-term. EUHQ-NP-145-0715-109452 References to support data: see slide notes No head-to-head studies available. No direct study comparison intended. This overview is intended to be used for scientific illustrative purposes only.

PCSK9 mab Outcomes Trials Study FOURIER ODYSSEY OUTCOMES SPIRE-1 SPIRE-2 Who? Patients aged 40-85 with history of clinically evident CVD at high risk for recurrent event Patients aged 40 hospitalized for ACS recently (<52 weeks) Background lipid lowering treatment and at high risk of a CV event N 27,500 18,000 17,000 9000 Primary endpt Time to CV death, MI, hospitalization for UA, stroke, or coronary revasc, whichever occurs first Time to CHD death, any nonfatal MI, fatal and non-fatal ischemic stroke, hospitalization for UA Confirmed major cardiovascular event [CV death, non- fatal MI, non-fatal stroke, and hospitalization for UA needing urgent revascularization] LDL-C 70 mg/dl (or non- HDL-C 100 mg/dl) 70 mg/dl 70 and <100 mg/dl (or non- HDL-C 100 mg/dl and <130 mg/dl) 100 mg/dl (or non HDL C 130 mg/dl) 59

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1 OSLER-1: Phase 2 programme Open-label Study of Long-term Evaluation Against LDL-C Patients with hyperlipidaemia and mixed dyslipidaemia Completed a qualifying evolocumab Phase 2 parent study Eligible if medically stable and on study drug Age 18 to 75 years n=1104 R A N D O M I Z E D 2:1, irrespective of treatment assignment in parent study Evolocumab 420 mg QM + standard of care (n=736) Standard of care alone (n=368) Koren et al. Circulation 2014;129:234 43. At Week 52, patients in the evolocumab + SOC group achieved an LDL-C reduction of 52% (SE, 1%)

1 OSLER subpopulations: patients with T2DM, IFG or MetS Disease categorization (parent-study baseline): T2DM (n=72): By patient history IFG (n=95): No T2DM, but presence of FPG 110 mg/dl and < 126 mg/dl MetS (n=291): No T2DM, and presence of 3 IDF criteria Presented by Henry RR, et al. American Association of Clinical Endocrinologists, Las Vegas, NV. May 2014.

1 OSLER: Conclusions In patients with T2DM, IFG or MetS: Evolocumab (420 mg monthly) treatment reduced LDL-C by up to 52% (P < 0.001) at week 52 Reductions were comparable to those observed in patients without these three conditions Evolocumab dosed monthly demonstrated encouraging safety and tolerability at 1 year of treatment Presented by Henry RR, et al. American Association of Clinical Endocrinologists, Las Vegas, NV. May 2014.

Median FPG (mg/dl) Median HbA1c (%) 1 Time course of plasma levels of FPG and HbA1C 135 125 115 105 95 85 135 125 115 105 95 85 135 125 115 105 95 85 135 125 115 105 95 85 7.5 7 6.5 6 5.5 5 7.5 7 6.5 6 5.5 5 7.5 7 6.5 6 5.5 5 7.5 7 6.5 6 5.5 5 Patients with T2DM Patients with IFG Patients with MetS Patients without MetS, IFG or T2DM Presented by Henry RR, et al. American Association of Clinical Endocrinologists, Las Vegas, NV. May 2014.

PCSK9 inhibition : The Future 1) Cardiovascular outcomes in Phase III trials 2) Impact on atherosclerotic vascular disease (AVD) 3) Impact of TGRL, remnant and Lp(a) lowering, and possibly HDL raising, on progression of AVD and CV events 3) Long term, real life, safety data from post-marketing surveillance 4) Evaluation of efficacy in other patient populations at high risk