Safety and efficacy of AKCEA-APO(a)-LRx to lower

lipoprotein(a) levels in patients with established cardiovascular disease:

A phase 2 dose-ranging trial

University of California San Diego (ST, JLW); Akcea Therapeutics (E K-P, JG, LO’D), University of Cologne (IG-B); Montreal Heart Institute, (J-CT); Excel Medical Clinical Trials, (SJB); Charité-Universitätsmedizin Berlin and University Medicine Greifswald (E S-T); Oregon Health & Science University (MDS); Academic Medical Center (ESS); University of Kansas Medical Center, (P.M.M.); Herlev and Gentofte Hospital, Copenhagen

University Hospital and University of Copenhagen (BGN); Ionis Pharmaceuticals, Inc. (NJV, ST)

Sotirios Tsimikas, Ewa Karwatowska-Prokopczuk, Ioanna Gouni-Berthold, Jean-Claude Tardif, Seth J. Baum, Elizabeth Steinhagen-Thiessen, Michael D. Shapiro, Erik S. Stroes, Patrick M. Moriarty, Børge G. Nordestgaard, Jonathan Guerriero, Nicholas J. Viney, Louis O'Dea, Joseph L. Witztum on behalf of the

AKCEA-APO(a)-LRx Study Investigators

Disclosures This study was funded by Ionis Pharmaceuticals and Akcea Therapeutics

1. S. Tsimikas is an employee of Ionis Pharmaceuticals, has patents with UCSD, equity in Oxitope and served on advisory boards for Boston Heart Diagnostics.

2. E. Karwatowska-Prokopczuk is an employee of Akcea Therapeutics.

3. I. Gouni-Berthold has served as a consultant or on advisory boards for Amgen, Sanofi, Eli Lilly, Regeneron, Akcea, and Aegereon.

4. J. Tardif received research grants from Amarin, AstraZeneca, DalCor, Esperion, Ionis, Pfizer and Servier; honoraria from Amarin, DalCor, Pfizer, Sanofi and Servier; and minor equity interest in DalCor

5. S. Baum has served as a consultant or on advisory boards for Sanofi, Amgen, Cleveland Heart Labs, CLG Group, Guidepoint Global, Regeneron, Novo Nordisk, and Akcea.

6. E. Steinhagen-Thiessen served as Consultant for Sanofi, Amgen and AKCEA and I have research grants from Sanofi, Pfizer, Berlin Chemie, Chesii and Fresenius.

7. M. Shapiro has received research grants from the NIH and served as consultant or on advisory boards for Novartis, Esperion, Amarin.

8. E. Stroes has received research grants from the European Union – Horizon 2020 and Regeneron and served as a consultant or on advisory boards for Merck, Ionis, Chiesi, Akcea, uniQure, Athera, Amgen, Regeneron, and Sanofi-Aventis.

9. P. Moriarty as received research grants from Regeneron, Sanofi, Amgen, Ionis, Pfizer, Novartis and honoraria from Regeneron, Sanofi, Amgen, Amarin, served as a consultant or on advisory boards for Ambry Genetics, Duke, Esperion, Kaneka, RegenXBio, Kastle Therapeutics, Gemphire Therapeutics, Agerion, Stage II Innovations, Novartis..

10. B. Nordestgaard has served as a consultant or on advisory boards for AstraZeneca, Sanofi, Regeneron, Ionis, Akcea, Amgen, Kowa, Denka Seiken.

11. J. Guerriero is an employee of Akcea Therapeutics12. N. Viney is an employee of Ionis Pharmaceuticals. 13. L. O’Dea is an employee of Akcea Therapeutics.14. J. Witztum is a consultant for Ionis Pharmaceuticals, has

patents with UCSD and equity in Oxitope

Background• Lipoprotein(a) [Lp(a)] is an independent, genetic and likely causal

risk factor for CVD and aortic stenosis

• Lp(a) >50 mg/dL is associated with an increased risk of recurrent events in patients on statin therapy*

• Lp(a) mediates CVD risk through 3 main mechanisms:• Atherogenicity of its LDL-like moiety

• Anti-fibrinolytic effects of its apo(a) moiety

• Pro-inflammatory effects of its content of oxidized phospholipids (OxPL)

• There are no approved pharmacological therapies to specifically lower Lp(a) and statins are ineffective.

• Antisense oligonucleotides decrease apo(a) protein production in hepatocytes, the primary source of circulating Lp(a)

Tsimikas S. J Am Coll Cardiol2017;69:692–711

* Willeit et al Lancet 2018;392:1311-1320

AKCEA-APO(a)-LRx (ISIS 681257)• AKCEA-APO(a)-LRx is an antisense oligonucleotide (ASO)

that contains a GalNac ligand which binds to asialoglycoprotein receptors on hepatocytes leading to enhanced intracellular uptake

• It has a 30-fold higher potency than non-GalNac ASOs, thus allowing lower doses and dose intervals for similar therapeutic efficacy*

• A prior phase 1 trial with AKCEA-APO(a)-LRx in healthy volunteers with elevated Lp(a) showed a dose dependent, mean 68–92% reduction in plasma Lp(a)*

* Viney et al Lancet 2016; 388:2239-53.

ISIS 681257 contains 20 nucleic acids, 13 phosphorothioate (PS) linkages, 6

phosphodiester (PO) linkages and theGalNAc3 complex linked to the 5’ end

of the ASO with a THA linker. MOE = 2′-methoxyethyl

Principal Investigators and SitesPrincipal Investigator Investigator Site Name Patients

enrolled, n

Ioanna Gouni-Berthold Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University of Cologne 29

Jean-Claude Tardif Montreal Heart Institute, University of Montreal 29Seth Baum Excel Medical Clinical Trials, LLC 19Elizabeth Steinhagen-Thiessen Charite - University Hospital Berlin - Campus Virchow - Hospital 19Michael Shapiro Oregon Health & Science University 17Erik Stroes Academic Medical Center 16Patrick Moriarty University of Kansas Medical Center 15Bǿrge Nordestgaard Copenhagen University Hospital 15Daniel Gaudet ECOGENE-21 13

Marina Cuchel Perelman School of Medicine at The University Perelman School of Medicine at The University of Pennsylvania Translational Medicine & Human Genetics 12

David Maron/Abha Khandelwal Stanford University Medical Center 11Ib Christian Klausen Regionshospitalet Viborg, Hospitalsenhed Midt 10Robert Rosenson Cardiometabolics Unit, Icahn School of Medicine at Mount Sinai 10Anthony DeMaria UC-San Diego 9Samuel Butman Verde Falley Medical Center Cardiovascular Research 9

Principal investigators and SitesPrincipal investigator Investigator Site Name Patients enrolled, n

Howard Weintraub New York University School of Medicine 8Ruth McPherson University of Ottawa Heart Institute 8Michael Koren Jacksonville Center for Clinical Research 6Jean Bergeron Clinique des maladies lipidiques de Québec 6

Christie Ballantyne Center for Cardiovascular Disease PreventionBaylor College of Medicine and DeBakey Heart & Vascular Center 5

Anthony DeFranco Aurora St. Luke's Medical Center 5Karen Aspry Miriam Hospital 5Haitham Ahmed Cleveland Clinic 2Rolf Andersen LGHealth / Penn Medicine Research Institute 2Linda Hemphill Massachusetts General Hospital 1Prediman Krishan Shah Cedars Sinai Medical Center 1Michael Miller University of Maryland Medical Center 1Russell Strader UCH-MHS 1Merle Myerson Bassett Medical Center – Bassett Research Institute 1George Thanassoulis Research Institute of the McGill University Health Centre 1

Objective, Patient Population, Inclusion/Exclusion Criteria• This was a multicenter, international, randomized, blinded, placebo-controlled, dose-

ranging Phase 2b study• The patient population included:

• Subjects with pre-existing cardiovascular disease (CAD, MI, PAD, stroke/TIA) and baseline Lp(a) ≥60 mg/dL (~≥150 nmol/L) (normal levels: <30 mg/dL or <75 nmol/L)

• Key exclusion criteria included:• Revascularization or lipoprotein apheresis within 3 months of screening• Acute coronary syndrome, major cardiac surgery, or stroke/TIA within 6 months of screening• NYHA class IV• Uncontrolled hypertension (>160/100 mm/Hg) • Use of oral anticoagulants

Study Design and Endpoints - AKCEA-APO(a)-LRx Trial

QW = every week; Q2W = every 2 weeks; Q4W = every 4 weeks; R = randomization; SC = subcutaneous.

*Cohorts (SC administration):

20 mg or placebo Q4W40 mg or placebo Q4W60 mg or placebo Q4W20 mg or placebo Q2W20 mg or placebo QW

Treatment duration: 6-12 months

Five cohorts*,N per cohort=54, randomized 5:1

(45 active, 9 placebo)

≤4 weeksScreening 16 weeks follow up

R

The primary endpoint was the mean percent change in Lp(a) from baseline to week 25–27 depending on dose regimenSecondary endpoints included:• Mean percent change in OxPL-apoB, OxPL-apo(a), LDL-C,

apoB and the percentage of patients reaching Lp(a) <50 mg/dL (<125 nmol/L)

Statistical Analyses• The primary endpoint was analyzed using an ANCOVA model with treatment

group as factor and log-transformed baseline Lp(a) as covariate. • The full analysis and safety sets were all patients who were randomized and

received at least 1 dose of Study Drug and were used for the primary analysis of efficacy and safety, respectively. Because all patients received at least one dose of Study Drug, the full analysis set represents the intention-to-treat (ITT) population.

Laboratory measurements

OxPL-apoB, oxidized phospholipids on apolipoprotein B-100;OxPL-apo(a), oxidized phospholipids on apolipoprotein(a)

• Lp(a) molar concentrations (nmol/L) were measured with an isoform-independent assay at the Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington

• Lp(a) mass (mg/dL) was estimated by dividing molar concentration by 2.5 (nmol/L ÷ 2.5 = mg/dL)

• OxPL-apoB and OxPL-apo(a) levels were measured with established assays at the University of California San Diego

• All safety lab measurements were measured at Medpace Reference Laboratories

Baseline patient demographic characteristics

PCSK9 = proprotein convertase subtilisin/kexin type 9; QW = once a week; Q2W = every 2 weeks; Q4W = every 4 weeks; SD = standard deviation.

20 mg/Q4WN=48

40 mg/Q4WN=48

20 mg/Q2WN=48

60 mg/Q4WN=47

20 mg/QWN=48

PooledRx

N=239

Pooled placebo

N=47Age, years, mean (SD) 60 (9.6) 61.3 (10.6) 57.9 (11.5) 62.2 (9.7) 58.9 (8.0) 60.1 (10.0) 59.9 (10.5)Sex, male, n (%) 29 (60.4) 36 (75.0) 31 (64.6) 33 (70.2) 28 (58.3) 157 (65.7) 32 (68.1)Anti-Platelet Rx, n (%) 47 (97.9) 47 (97.9) 47 (97.9) 47 (100) 48 (100.0) 236 (98.7) 43 (91.5)Lipid-Lowering Rx, n (%)

StatinEzetimibePCSK9 inhibitor

42 (87.5)25 (52.1)8 (16.7)

44 (91.7)25 (52.1)11 (22.9)

43 (89.6)23 (47.9)9 (18.8)

44 (93.6)19 (40.4)10 (21.3)

44 (91.7)23 (47.9)13 (27.1)

217 (90.8)115 (48.1)51 (21.3)

39 (83.0)23 (48.9)10 (21.3)

Previous history, n (%)Coronary artery diseaseCarotid artery diseasePeripheral artery disease

44 (91.7)13 (27.1)9 (18.8)

45 (93.8)12 (25.0)10 (20.8)

45 (93.8)10 (20.8)4 (8.3)

46 (97.9)11 (23.4)1 (2.1)

44 (91.7)14 (29.2)5 (10.4)

224 (93.7)60 (25.1)29 (12.1)

45 (95.7)9 (19.1)4 (8.5)

MI, n (%) 25 (52.1) 25 (52.1) 31 (64.6) 20 (42.6) 27 (56.3) 128 (53.6) 27 (57.4)Stroke/TIA, n (%) 6 (12.5) 6 (12.5) 7 (14.6) 4 (8.6) 5 (10.4) 28 (11.7) 8 (17.0)Hypertension, n (%) 28 (58.3) 35 (72.9) 34 (70.8) 31 (66.0) 25 (52.1) 153 (64.0) 30 (63.8)Type 2 Diabetes, n (%) 7 (14.6) 8 (16.7) 5 (10.4) 4 (8.5) 6 (12.5) 30 (12.6) 10 (21.3)

AKCEA-APO(a)-LRx dose/regimen

Baseline laboratory variables20 mg/Q4W

N=4840 mg/Q4W

N=4820 mg/Q2W

N=4860 mg/Q4W

N=4720 mg/QW

N=48Pooled Rx

N=239Pooled Placebo

N=47

Lp(a), nmol/L, Mean/Median 279.7/246.6 236.6/220.0 250.6/238.2 233.9/204.5 248.2/233.7 249.9/224.3 258.2/231.6

Lp(a), mg/dL, estimatedMean/Median 111.9/98.6 94.7/88.0 100.3/95.3 93.6/81.8 99.3/93.5 100.0/89.7 103.3/92.6

OxPL-apoB, nmol/L, median (IQR)

24.6 (18.1, 33.1)

23.1 (16.2, 32.5)

23.9 (17.9, 29.2)

20.3 (16.6, 28.5)

23.7 (17.2, 30.7)

23.3 (17.4, 30.5)

21.2(17.2, 31.5)

OxPL-apo(a), nmol/L, median (IQR)

66.3 (57.8, 75.0)

65.9 (56.6, 71.9)

67.3 (60.8, 73.2)

61.9 (53.4, 72.7)

67.1 (60, 74.6)

65.8 (58.6, 73.8)

69.2 (59.6, 76.5)

LDL*, mg/dL, mean (SD) 89.3 (37.1) 77.4 (39.5) 74.4 (28.8) 67.6 (28.3) 76.1 (28.4) 77.0 (33.3) 79.4 (29.2)

ApoB, mg/dL, mean (SD) 80.7 (23.6) 71.9 (23.4) 69.3 (19.8) 68.5 (18.8) 70.6 (19.2) 72.2 (21.3) 73.8 (16.9)

HDL, mg/dL, mean (SD) 54.1 (15.5) 54.1 (19.3) 54.1 (19.3) 50.3 (11.6) 58.0 (19.3) 54.1 (19.3) 50.3 (19.3)

Triglycerides, mg/dL, median (IQR)

97 (44, 230.3)

97 (35, 283)

106(35, 204)

106 (53, 567)

89 (35, 266)

97(35, 567)

106 (35, 576)

hsCRP, mg/L, mean (SD) 2.9 (5.3) 2.3 (4.5) 1.6 (2.5) 2 (2.5) 2.2 (4.4) 2.2 (4.0) 2.4 (4.4)

AKCEA-APO(a)-LRx dose/regimen

* LDL-C is uncorrected for Lp(a)-Cholesterol

-6

-35

-56 -58

-72-80

-90

-70

-50

-30

-10

10

Pooled Placebo 20 mg/Q4W 40 mg/Q4W 20 mg/Q2W 60 mg/Q4W 20 mg/QW

LSM

ean

% c

hang

e in

Lp(

a)

P-values represent comparison to pooled placebo

Primary endpoint: Mean percent change (95% CI) in Lp(a) from baseline to week 25-27

P-values from an ANCOVA model with treatment as fixed factor and log-scale baseline as a covariate. Adjusted % change = (ratio of endpoint/baseline – 1) ×100. CI, confidence interval; Lp(a), lipoprotein(a); LS, least squares

P=0.0032

P<0.0001 P<0.0001

P<0.0001P<0.0001

Primary efficacy endpoint was not affected by baseline Lp(a) levels, statin or PCSK9i use

Absolute change in Lp(a) from baseline to week 25-27

20 mg/Q4W

N=48

40 mg/Q4W

N=48

20 mg/Q2W

N=48

60 mg/Q4W

N=47

20 mg/QWN=48

Pooled placebo

N=47Absolute change from baseline in Lp(a), mg/dL Mean (SD)

Absolute change from baseline in Lp(a), nmol/L Mean (SD)

-38.4 (37.7)

-95.9(94.4)

-46.8 (28.7)

-116.9 (71.7)

-52.1 (26.4)

-130.3(66.1)

-59.8 (27.0)

-149.5 (67.4)

-75.1 (32.1)

-187.8 (80.3)

-6.1 (13.8)

-15.2 (34.6)

AKCEA-APO(a)-LRx dose/regimen

Primary endpoint: Mean percent change (SEM) in Lp(a) from baseline to week 25-27

PAT, primary analysis timepoint; QW, once a week; Q2W, every 2 weeks; Q4W, every 4 weeks; SEM, standard error of the mean.

-90-80-70-60-50-40-30-20-10

0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28

Mea

n pe

rcen

t cha

nge

(±SE

M)

for L

p(a)

ove

r tim

e

WeeksPAT

(25-27)

60 mg/Q4W

20 mg/QW

40 mg/Q4W

20 mg/Q2W

Pooled placebo

20 mg/Q4W

Secondary endpoint: Percent of patients achieving Lp(a) ≤50 mg/dL (≤ 125 nmol/L) at PAT

6.4%

25.0%

62.5% 64.6%

80.9%

97.7%

0

10

20

30

40

50

60

70

80

90

100

Pooled Placebo 20 mg/Q4W 40 mg/Q4W 20 mg/Q2W 60 mg/Q4W 20 mg/QW

Perc

ent o

f pat

ient

s ach

ievi

ng L

p(a)

≤5

0 m

g/dL

(≤12

5 nm

ol/L

)

P-values represent comparison to pooled placebo

P=0.029

P<0.0001P<0.0001

P<0.0001

P<0.0001

Secondary endpoints: Percent change from baseline at week 25-27

P-value vs pooled placebo: * p<0.05; ** p<0.01; *** p<0.001

%change is at primary analysis timepoint. LDL-C, low-density lipoprotein cholesterol; QW, once a week; Q2W, every 2 weeks; Q4W, every 4 weeks.

Treatment (dose/regimen)

OxPL-apoB OxPL-apo(a) LDL-C ApoB

AKCEA-APO(a)-LRx

20 mg Q4W40 mg Q4W20 mg Q2W60 mg Q4W20 mg QW

-26.8**-42.4***-52.8***-65.5***-81.8***

-24.8-37.5*-38.6*

-53.5***-61.2***

-5.2-20.4***

-11.1*-6.9*

-20.5**

-1.9-12.8***

-7.6*-4.0*

-14.5***Pooled placebo 22.4 -17.6 1.2 2.0

Summary of treatment emergent adverse events (TEAE)

Event, N (%) 20 mg/Q4WN=48

40 mg/Q4WN=48

20 mg/Q2WN=48

60 mg/Q4WN=47

20 mg/QWN=48

Pooled Rx N=239

Pooled placebo

N=47

At least one TEAE* 46 (95.8) 41 (85.4) 41 (85.4) 43 (91.5) 42 (87.5) 213 (89.1) 39 (83.0)

At least one serious TEAE 6 (12.5) 7 (14.6) 3 (6.3) 6 (12.8) 3 (6.3) 25 (10.5) 1 (2.1)

At least one related serious TEAE** 1 (2.1) 0 (0.0) 0 (0.0) 1 (2.1) 0 (0.0) 2 (0.8) 0 (0.0)

At least one TEAE leading to treatment discontinuation 2 (4.2) 0 (0.0) 1 (2.1) 3 (6.4) 5 (10.4) 11 (4.6) 2 (4.3)

TEAE leading to death*** 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.1) 1 (2.1) 2 (0.8) 0 (0.0)

AKCEA-APO(a)-LRx dose/regimen

* The most frequent TEAE: Injection site erythema (25% in pooled Rx group)** Auto accident; Malaise*** Auto accident (same patient); Depression/suicide

Adverse Events Leading to Treatment Discontinuation

Treatment (dose/regimen)

Adverse Event

AKCEA-APO(a)-LRx

20 mg Q4WUreterolithiasis

Malaise

20 mg Q2W Arthralgia, Myalgia

60 mg Q4W

Lung neoplasm malignant

Road traffic accident

Myalgia, Paraesthesia, Swelling face, Nausea

20 mg QW

Intraductal proliferative breast lesion

Depression/suicide

Post-injection: throat tightness, hot flush, discomfort, dizziness

Myalgia

Injection site erythema

Pooled placeboAnxiety

Cyst

4.6%

4.3%

Changes in platelet-count, LFTs and renal function categories by treatment group

*2 occurrences across the study (regulatory standard)

**LFTs- No patient met a Liver Safety Stopping Rule; However, 1 patient at the End of Treatment visit had AST 103 U/L (ULN =34 U/L, 3X ULN 102 U/L) and ALT 72 U/L (ULN = 41 U/L), with no change in total bilirubin, INR or Hy’s Law.

***Renal Function - 1 patient had unrelated pre-renal azotemia and 1 patient had unrelated incomplete 24 hour urine collection, creating an artifactual safety alert. Both continued on treatment.

n (%) 20 mg/Q4WN=48

40 mg/Q4WN=48

20 mg/Q2WN=48

60 mg/Q4WN=47

20 mg/QWN=48

Pooled RxN=239

Pooled Placebo

N=47

Platelet count, mm3

<140,000* 3 (6.3) 8 (16.7) 3 (6.4) 3 (6.3) 8 (16.7) 25 (10.5) 7 (14.9)

No confirmed platelet value <100,000 mm3

LFTs >3X ULN** 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.1) 0 (0.0) 1 (0.4) 0 (0.0)

24 hr CrCl decrease > 40% from baseline***

0 (0.0) 1 (2.1) 1 (2.1) 0 (0.0) 0 (0.0) 2 (0.8) 0 (0.0)

Conclusions• This trial achieved its primary endpoint and all of its secondary

endpoints. AKCEA-APO(a)-LRx significantly reduced Lp(a), OxPL-apoB, OxPL-apo(a), LDL-C and apoB levels

• 98% of patients achieved Lp(a) levels ≤50 mg/dL at the highest dose

• There were no safety concerns related to platelet counts, liver function or renal function

• This study provides a rationale for the initiation of a phase 3 outcomes trial to test the “Lp(a) hypothesis”, namely that lowering Lp(a) levels will reduce cardiovascular events

THANK YOU!