aln-vsp02 phase 1 trial update - alnylam pharmaceuticals · liver targeting in vivo silencing of...
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ALN-VSP02 Phase 1 Trial UpdateDemonstrating RNAi in Man
Jared A. Gollob, M.D.
January 4, 2011
Dana-Farber Cancer Institute
Agenda
LNPs and ALN-VSP02: Background
Phase 1 Trial Safety Data
Pharmacodynamic Data
» 5’ RACE
» DCE-MRI
Summary
2
Lipid Nanoparticles for Systemic Delivery
3
Liver TargetingIn Vivo Silencing of ApoB in Non-Human Primates
4
Nature, 441, 111-114, Mar 2006
0
20
40
60
80
100
1mg/kg 2.5 mg/kg 1 mg/kg 2.5 mg/kg
2 day 11 day
% C
on
tro
l
Efficacy in primates with Systemic RNAi after single IV injection Rapid, potent, dose-dependent and durable effects
RNAi specific and leads to measurable therapeutic benefit
RNAi mechanism proven in vivo
8.911.7
*
9.2
**23.2
**
31.7
60.5
**72.4
Protein
mRNA** P < .005* P <.05
**
79.0
% C
on
tro
l
Day 11 Post-Dose (2.5 mg/kg)
Cholesterol LDL HDL
20
40
60
80
100109.8
34.1
*
14.2
**
>65%
Inhibition>85%
Inhibition
** P < .005* P <.05
0
Tumor TargetingMurine Liver Cancer Model
Orthotopic tumor model with intrahepatic Hep3B seeding in SCID miceSingle IV bolus injection of ALN-VSP or control siRNA
Mitotic arrest (monoasters) clearly detected in VSP-treated animals
KSP and VEGF target mRNAs cleaved in tumors confirming RNAi mechanism
5
Control siRNA
ALN-VSP
Keystone: RNAi, Feb 2009
hKSP mRNA
hKSP mRNA 3’ cleavage productRNA adapter
hKSP mRNA 3’ cleavage product
GR5N
cDNARev2Rev3
hVEGF mRNA
hVEGF mRNA 3’ cleavage product
hVEGF mRNA 3’ cleavage product
GR5N
cDNARev3Rev4
400
300200
100
4 2 1 mg/kg
VSP 02
400
300200
100
4 2 1 mg/kg
VSP 02
RNA adapter
PCR product 380 nt PCR product 210 nt
Does Animal Pharmacology Translate to Man?VSP02: First Opportunity to Show RNAi POC/POM in Man with LNP
VSP02 TTR01
Target kd in humans •VEGF: DCE-MRI and/or
angiogenesis biomarker
changes
•TTR lowering in blood
Clinical effect of target
kd
•Tumor response on CT
scans
•Improvement in neuropathy
score
•Improvement in cardiac
imaging
Improved clinical
outcomes with target
kd
•Improved PFS •Improved PFS
NDA •Improved PFS
•Improved survival
•Improved PFS
•Improved QOL
5’-RACE •Tumor biopsies • N/A
Target mRNA kd •Tumor biopsies • N/A
Specificity of target kd •Tumor biopsies • N/A
6
POC
POM
Liver Cancer ProgramALN-VSP02
RNAi to treat primary and secondary liver cancersPrevalent solid tumor and common site of
metastatic disease» ~700,000/yr: Incidence of HCC worldwide
» ~500,000/yr: Patients with liver metastasis
ALN-VSP is first dual-targeted RNAi drug» Targeting 2 pathways with 2 different siRNAs
increases potential therapeutic impact– Proliferation: Kinesin Spindle Protein (KSP)
– Angiogenesis: VEGF
» Lipid nanoparticle (LNP) formulation– From Tekmira Pharmaceuticals
Preferential biodistribution of LNPs to liver,
spleen, tumors » May be able to avoid dose-limiting on-target
toxicities associated with systemic delivery of small
molecules and antibodies:– KSP: myelosuppression, gastro-intestinal toxicity
– VEGF: Hypertension, bleeding, thrombosis,
proteinuria, bowel perforation
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ALN-VSP02
VEGF
KSP
ALN-VSP02 Phase I Study Design
Dose levels and dosing schedule0.1, 0.2, 0.4, 0.7, 1.0, 1.25, 1.5, 1.7 mg/kg
3 + 3 cohort design, planned expansion phase of up to 20 pts at MTD
15-min IV infusion q2 wks; premed with steroids, H1 and H2 blockers, acetaminophen
Cycle = 2 doses (1 month), tumor measurements after every 2 cycles, treat until disease
progression» ALN-VSP02-002 extension study for pts remaining on study beyond 4 cycles
8
Cycle 1 Cycle 4Cycle 3Cycle 2
W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Screening
Rx Rx Rx Rx Rx Rx Rx Rx
Adverse events
DCE-MRI
Tumor biopsy
Plasma samples
for VEGF/PLGF
d3-5 d8-10
d3-6
CT scan for tumor
measurement
Agenda
LNPs and ALN-VSP02: Background
Phase 1 Trial Safety Data
Pharmacodynamic Data
» 5’ RACE
» DCE-MRI
Summary
9
ALN-VSP02 Phase I Study StatusAs Reported at Chemotherapy Foundation Symposium
N=28 Enrolled to date; Cohorts 1-6
Total of 127 ALN-VSP02 doses administered
» Range of doses per patient: 2-13
Dose escalation ongoing
» Current dose 1.25 mg/kg
» MTD not yet reached
Key demographics
» Median age 56 yrs (range 34-78)
» 13 males, 15 females
» Tumor types
– Colorectal cancer (N=16)
– Pancreatic neuroendocrine tumor (N=1)
– Papillary renal cell cancer (N=1)
– Squamous cell cancer of head and neck (N=1)
– Pancreatic cancer (N=1)
– Esophageal cancer (N=1)
– Endometrial cancer (N=2)
– Angiosarcoma (N=1)
– Ovarian cancer (N=2)
– Synovial sarcoma (N=1)
– Mullerian stromal tumor (N=1)
All patients treated with multiple prior anti-angiogenic and/or chemotherapy regimens
10
Chemotherapy Foundation Symposium, November 2010
ALN-VSP02 Phase I Safety Summary
ALN-VSP02 generally well tolerated to date
» 127 doses administered to 28 patients across 6 dose levels
» Up to 13 doses given to single patient
No dose-dependent trends in clinical or laboratory adverse events
No dose-dependent changes in LFTs
Human plasma PK showed dose-proportional Cmax and AUC with no evidence
of drug accumulation
» Animal PK studies accurately predicted for human
Two dose-limiting toxicities
» 0.7 mg/kg: Liver failure and death after 2 doses (possibly related to study drug) in patient with
near complete replacement of liver by tumor and prior partial hepatectomy and splenectomy
» 1.25 mg/kg: Grade 3 thrombocytopenia after dose 1 (related to study drug), resolved within 5
days
Three grade 2 infusion reactions (one each at 0.4, 0.7 and 1.25 mg/kg), all 3
tolerated further treatment with prolongation of infusion duration
MTD not yet reached, dose escalation continuing
11
Chemotherapy Foundation Symposium, November 2010
Agenda
LNPs and ALN-VSP02: Background
Phase 1 Trial Safety Data
Pharmacodynamic Data
» 5’ RACE
» DCE-MRI
Summary
12
ALN-VSP02 PharmacologyTumor Biopsies
17 Tumor biopsies obtained from 9 patients
» 3 at 0.4 mg/kg
» 2 each at 0.7, 1.0 and 1.25 mg/kg
» Liver tumor biopsies in 6 patients
» Extrahepatic tumor biopsies in 3 patients
CT-guided core needle biopsies obtained pre-
and post-dose 1
» Analyses ongoing:
– 5’ RACE
– qPCR
– Drug levels
13
Drug Levels for All Biopsies to Date
Pt #
Dose
mg/kg
Tumor Type
(site of metastasis)
siRNA Levels (ng/g)
VEGF KSP
007 0.4 Colorectal (liver) 25.7 12.5
016 0.4 SCC H&N (liver) N/A N/A
017 0.4 Ovarian
(liver)
28.9 17.2
018 0.7 Pancreatic (liver) N/A§ N/A§
019 0.7 Colorectal (liver) 142 73.3
022 1.0 Colorectal (adrenal) 9.8 3.8
025 1.0 Sarcoma (gluteal
muscle)
0.45 0.4
026 1.25 Colorectal
(liver)
0.32 <LLOQ
031 1.25 Ovarian
(peri-umbilical)
4.9 3.6
14
N/A: Assay not performed§Very little tissue available for analysis
LLOQ: lower limit of quantitation
ALN-VSP02 PharmacologyTumor Biopsies
17 Tumor biopsies obtained from 9 patients
» 3 at 0.4 mg/kg
» 2 each at 0.7, 1.0 and 1.25 mg/kg
» Liver tumor biopsies in 6 patients
» Extrahepatic tumor biopsies in 3 patients
CT-guided core needle biopsies obtained pre-
and post-dose 1
» Analyses ongoing:
– 5’ RACE
– qPCR
– Drug levels
15
RNAi Produces Precise Cleavage of Target
mRNA
16
mRNA
mRNAdegradation
dsRNAdicer
Cleavage
Strand separation
Complementary pairing
Cleavage
(A)n
(A)n
Synthetic siRNA
Targeted Gene
Silencing
RISC
5’ RACE
5’ RACE AssayMethod for Demonstrating RNAi
17
Sequence Analysis
Factors Influencing Ability to Show RNAi By
5’ RACE in Tumor Biopsies
Expression level of target mRNA
Amount of tissue in biopsy that expresses target
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VEGF-A and KSP mRNA Levels in Normal Liver and Tumors
Very low expression of KSP mRNA in normal liver and tumors
Relatively abundant expression of VEGF-A mRNA in both
normal liver and tumor
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1
10
100
1000
10000
liver hcc crc
Mo
lecu
les
VEGF KSP
Tumor Core Biopsies
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Fibrosis
Tumor necrosis
Viable tumor
Viable tumor
Core biopsy
CT-guided Core Needle Biopsy
Tumor Core Biopsies
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Liver
Viable Tumor
Liver
Tissue Components of Biopsies Analyzed to Date
Tumor biopsies from liver very heterogeneous with regards to amounts of
tumor, normal liver, and dead tissue
Post-treatment biopsies from 3 patients at 0.4 mg/kg:» Little to no tumor, abundant normal liver
» Can be used for VEGF 5’ RACE, since robust VEGF expression in liver
» Not informative for KSP 5’ RACE, as very little expression in normal liver
Post-treatment biopsies from 2 patients at 0.7 mg/kg:» Little tumor, very little normal liver
» Not informative for either VEGF or KSP 5’ RACE
22
Pt#
Dose
mg/kg
Tumor Type
site of metastasis
Pre-Treatment Biopsy (%) Post-Treatment Biopsy (%)
Tumor Liver Necrosis Tumor Liver Necrosis
007 0.4 Colorectal (liver) 14 0 86 17 80 3
016 0.4 SCC H&N (liver) 10 0 90 0 100 0
017 0.4 Ovarian (liver) N/A N/A N/A 0 95 0
018 0.7 Pancreatic (liver) 40 0 0 8 5 52
019 0.7 Colorectal (liver) 0 100 0 20 5 60
N/A: Biopsy not performed
Dominant Band Seen in 5’ RACE for VEGF in Two Post-Dose Clinical Samples
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200
300
007 017
pre post
016
pre post post
0.4 mg/kg
150
400
100
Non-clin
crchcc liver
Predicted VEGF mRNA
cleavage product band
Human RNAi Proof of MechanismResults from Blinded Molecular Analysis of Human Biopsy Samples
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Patient 007-016
Pre-treatment
Patient 006-017
Post-treatment (2 days)
Patient 007-016
Post-treatment (2 days)
Post-treatment
Pre-treatment
27.9%
29.2%
1.4%
rea
ds/t
ota
l rea
ds m
ap
pin
g to
th
e tra
nscrip
t
% Specific cleavage
as proportion of all
sequence readsUntreated controls
Evidence
of RNAi
NO
YES
YES
Untreated control
(colorectal cancer-crc)
Untreated control
(hepatocellular cancer-hcc)
Untreated control
(normal liver)
0.64%
0.26%
0.1%
5’ --- Location along VEGF Transcript ---3’
NO
NO
NO
as.factor(start)
pe
r_
ob
s
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
0.000.050.100.150.200.25
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9007
pre
007po
s0
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pre
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6p
os
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os
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8pre
018
po
st
01
9pre
019
po
st
sample
nc
post
pre
Patient 002-007 Pre-treatment
Patient 002-007 Post-treatment (7 days)
0.55%
0.66%
RNAi
Cleavage
NO
NO
p<0.0001*
p<0.0001
*T-test
5’ RACE Tumor Biopsy DataConclusions
In first 5 patients analyzed, 3 had abundant
normal liver/total mRNA that permitted VEGF 5’
RACE analysis
Predicted VEGF mRNA cleavage product seen
post-treatment in livers of 2/3 patients
» p<0.0001
» Biopsy from negative patient was obtained 7 days post
treatment
First demonstration of RNAi in man with LNP-
formulated siRNA
25
Agenda
LNPs and ALN-VSP02: Background
Phase 1 Trial Safety Data
Pharmacodynamic Data
» 5’ RACE
» DCE-MRI
Summary
26
ALN-VSP02 PharmacologyDCE-MRI
DCE-MRI (dynamic contrast-enhanced MRI) established as
radiologic test for assessing anti-VEGF effect of novel drugs in
clinical trials
Ktrans is key parameter
» Measure of blood flow and blood vessel permeability in tumors
» 40% or greater drop in Ktrans post-treatment considered a significant
drop in tumor blood flow
27
Example of Ktrans drop in patient treated
with oral anti-VEGFR drug AG-013736Liu G et al. JCO 2005;23:5464-5473
KtransBaseline (BL) Pre-Dose Day 4 Post-Dose 1 Day 7 Post-Dose 1
DCE-MRI Result at 0.7 mg/kgPatient 012: Pancreatic Neuroendocrine Tumor
28
T: liver tumor number
Ktrans2/IAUGC2: Δ DCE-MRI #1 (BL) to DCE-MRI #2 (Day 4)
Ktrans3/IAUGC3: Δ DCE-MRI #1 (BL) to DCE-MRI #3 (Day 7)
T1 T2 T3
Baseline MRI, coronal view Patient 003-012
-80
-60
-40
-20
0Ktrans2
IAUGC2
Ktrans3
IAUGC3
Ktr
an
s a
nd
IA
UG
C C
ha
ng
e
fro
m B
aselin
e (
%)
T1
T2
T3
T1
T2
T3
T1
T2
T3
T1
T2
T3
ASCO, June 2010
DCE-MRI ResultsSummary of Cohorts 1-4
29
» 21 evaluable liver tumors in
12 patients
» 19/21 tumors (90%)
showed decline in Ktrans
» 13 of 21 tumors (62%) had
↓Ktrans of ≥40%
» 8 of 12 patients (67%) had
average ↓Ktrans of ≥40%
# of evaluable
liver tumors:
0.1
mg/kg
0.2
mg/kg
0.4
mg/kg
0.7
mg/kgDose level:
Patient Number
Ave
rag
e K
tra
ns C
han
ge
Fro
m B
as
eli
ne (
%)
40% ↓
001 003 004 007 008 009 015 012 013 018 019 021-100
-80
-60
-40
-20
0
1 3 1 1 2 3 1 3 1 2 2 1
ASCO, June 2010
Agenda
LNPs and ALN-VSP02: Background
Phase 1 Trial Safety Data
Pharmacodynamic Data
» 5’ RACE
» DCE-MRI
Summary
30
Summary
Safety of LNP delivery to liver established in ALN-VSP02
Phase 1 liver cancer trial
Liver delivery and VEGF mRNA target engagement with
LNP-formulated siRNA demonstrated through 5’ RACE
assay on liver tumor biopsies
» Clear proof of RNAi activity in man
Preliminary DCE-MRI data from imaged liver tumors
further supportive of anti-VEGF pharmacology with ALN-
VSP02
Translatability of safety and pharmacology from NHP to
man greatly de-risks the LNP delivery platform
» Also highlights potential of liver-directed programs currently in
development including ALN-TTR and ALN-PCS
31
Acknowledgements
ALN-VSP02 Principal InvestigatorsSarah Cannon Cancer Center» Howard “Skip” Burris
Karmanos Cancer Institute» Pat LoRusso
Dana-Farber Cancer Institute» Geoffrey Shapiro
Beth Israel Deaconess Medical Center» Daniel Cho
Vall d’Hebron University Hospital (Barcelona)» Josep Tabernero
Hospital Clinico Universitario (Valencia)» Andres Cervantes
Hospital Universitario Virgen del Rocio (Seville)» Luis Paz-Ares
Alnylam PharmaceuticalsTekmira
32