APDW 2016PosterNo.a90312

SYN-010,aProprietaryModified-ReleaseFormulationofLovastatinLactone,LoweredBreathMethaneandImprovedStoolFrequencyinPatientswithIBS-CResultsofamulti-center,randomized,double-blind,placebo-controlled,4-weekacutePhase2aandan8-weekfollow-onextensionPhase2study

VinceWacher¹;KlausGottlieb¹,JosephSliman¹,OliviaCoughlin¹,HeatherMcFall¹,AliRezaie²,MarkPimentel².

¹SyntheticBiologics,Inc.,Rockville,MD,UnitedStates.²Gastroenterology,Cedars-SinaiMedicalCenter,LosAngeles,CA,UnitedStates

BACKGROUND• Agrowingbodyofclinicalandpreclinicalevidencehasdemonstratedthatelevatedintestinalmethaneproductionreducesmotilityandisanunderlyingcauseofsymptomsinirritablebowelsyndromewithconstipation(IBS-C)¹.

• MethaneinhumansisproducedalmostentirelybyMethanobrevibactersmithii(M.smithii),anarcheon thatpredominantlyresidesinthecolonbutisalsofoundinthesmallintestineofsomepatients;intestinalmethaneproductioncanbeestimatedusinganon-invasivemethanebreathtest¹.

• MethaneproductionbyM.smithii inhumanstoolisinhibitedbythelactoneformoflovastatin,butnotbyitscholesterol-loweringβ-hydroxyacidmetabolite,indicatingadistinctmodeofactionforlovastatinlactoneasanIBS-Ctherapy².

• Lovastatinlactoneanditsβ-hydroxyacidmetabolitewerenotmicrobicidalinrats,suggestingthatlovastatincanexertitsantimethanogeniceffectwhileavoidingsignificantperturbationstotheintestinalmicrobiome³.

• SYN-010 isaproprietary,modified-releaseformulationoflovastatinlactoneintendedtoactintheintestinetoreducemethaneproductionandalleviatesymptomsinpatientswithIBS-C.

¹GottliebK(2015)AlimentPharmacol Ther 43:197-212²MarshE(2015)AmJGastroenterol 110(Suppl 1):S753³MoralesW(2015)Gastroenterology148(Suppl 1):S-779-80

SYN-010Modified-ReleaseLovastatinLactone• TheSYN-010modified-releasecapsuleisdesignedtoavoiddrugreleaseinthestomach(reducingconversionofmethane-inhibitinglovastatinlactonetothenon-inhibitingβ-hydroxyacid)thendeliverdifferentpulsesoflovastatinlactonetothesmallandlargeintestineinproportionwiththeanticipatedlevelsofM.smithiiineachlocation(Figure1).

• SystemicabsorptionoflovastatinisnotrequiredforthetreatmentofIBS-C:releaseoflovastatinlactonelowerintheintestinaltract,andreducedconversionofthemorepoorly-absorbedlovastatinlactonetothemorereadily-absorbedβ-hydroxyacid,areexpectedtodecreasesystemicexposuretolovastatinspecies.

Duodenum CecumJejunum IleumStomach Colon

Pulse1 Pulse2

Figure1: DualpulsereleaseprofileofSYN-010modified-releaselovastatinlactonecapsules.Thereleaseprofilewasevidentinapharmacokineticstudyinhealthyvolunteers,wherecontinueddrugreleaseover24h(wellintothecolon)wasalsoobserved.

NORELEASE

SYN-010

CLINICALTRIALDESIGN• Sixty-three(63)IBS-Cpatientswithhighbreathmethane(CH4 >10ppm)atScreeningwereenrolledinamulticenter,randomized,controlled,double-blindedclinicaltrial(RCT)inwhichtheyreceivedSYN-01021mg,SYN-01042mgorPlacebooncedailyfor4weeks.• Fifty-four(54)subjectswhocompletedStudy1continuedintoanopen-labelextension(EXT)inwhichallsubjectsreceivedSYN-01042mgoncedailyforanadditional8weeks.• Breathmethaneproductionwasmeasuredusingalactulosebreathtestatbaseline(day1),thendays7,28,35and84(Figure2).

Figure2Phase2aclinicaltrialsofSYN-010.• ClinicalTrials.govidentifiers:

NCT02495623(RCT)andNCT02493036(EXT).

• Dayswherealactulosebreathtestwasconductedareindicatedwithatriangle(q).

Objectives• Primaryobjective• RCT: DeterminetheeffectsofSYN-010onintestinalmethaneproductionbymeasuringchangesinbreathmethaneAUCfrombaselinetoday7usingalactulosebreathtest(Figure3).• EXT: EvaluatethesustainabilityofSYN-01042mgeffectsonbreathmethaneproduction.

• Secondaryobjectives• RCTandEXT:evaluatepotentialchangesfrombaselineinIBS-Cclinicalsymptoms¹:• Weeklynumberofcompletespontaneousbowelmovements(CSBMs),and• Weeklyaverageworstabdominalpainscoreandweeklyaveragebloatingscore.

Figure3Exemplarybreathmethaneandhydrogenconcentrationvstimeprofilesduringalactulosebreathtest.• Subjectsfollowedarestricteddietinthedaysprecedingthe

test,thenfastedforatleast12hpriortoprovidingthefirstbreathsample.

• Breathwascollectedbyexhalingintoacoatedtesttubeandsamplesanalyzedbygaschromatography;time0samplesweretakenpriortoingestionofalactulosesolution.

• Areaundertheconcentrationvstimecurve(AUC)wascalculatedusingthelineartrapezoidalmethod.

• Breathhydrogenlevelsincreaseasthelactuloseismetabolizedbyintestinalbacteria;however,breathmethanelevelstendtoremainstableduringthetest.

¹Studieswerenotprospectivelypoweredforformalstatisticalevaluationofclinicalendpoints

RESULTS• Studycohortswerewell-matcheddemographically,althoughCohort2hadaloweraverageweeklynumberofCSBMsatbaselinethanbothCohorts1and3(Table1).

• SYN-010waswell-toleratedover12weeksoftreatmentandthefewreportedadverseeventswereallofmildormoderateintensity(Table2).• Noseriousadverseeventswerereportedandnodrug-relateddiarrheawasobserved.

• BreathmethaneAUCwashighlyvariable,butwasreducedfrombaselineinSYN-010treatmentgroups,withgreatesteffectsobservedforSYN-01042mg(Figure4)¹.

• WeeklynumberofCSBMswasincreasedfrombaselineintheSYN-01021mgtreatmentgroupduringtheRCT(P<0.05vsPlacebo)andinsubjectstransferredfromPlacebotoSYN-01042mgintheEXT(Figure5)¹.• RegressionanalysisforallsubjectswhocompletedtheEXTdemonstratedaninversecorrelationbetweenbreathmethaneAUCandweeklynumberofCSBMs(Figure6).• LessrescuemedicationwasusedinSYN-010treatmentgroupsthanthePlacebogroupduringtheRCT(Figure7).

• AbdominalPainscores(Figure8)andBloatingscores(Figure9)werereducedfrombaselineinSYN-010treatmentgroups,withgreatestreductionsobservedforSYN-01042mgduringtheRCTandsubjectstransferredfromPlacebotoSYN-01042mgintheEXT¹.

¹StatisticalPvalues,wherereported,arenominal

SubjectDemographics

PARAMETER COHORT 1 COHORT2 COHORT3

Study RCT|EXT RCT|EXT RCT|EXT

SYN-010dose Placebo |42mg_ 21mg|42mg 21mg|42mg

Dosing period,weeks 4|8 4|8 4|8

No.Subjects(Female)¹ 22(17)|17(13) 22(19)|20(17) 19(14)|17(12)

StudyDrugCompliance 99.2% |98.6% 97.9%| 97.9% 98.4%|98.6%

Baseline Parameters(Day1)

Age (years) 46.4±10.3 42.6±6.0 44.7±9.5

White/Black-AfricanAmer./Other² 16/4/2 21/1/0 15/4/0

BMI(kg/m²) 29.4±3.3 26.2±3.1 26.4±3.2

Breathmethane (ppm) 25.3±18.7 24.9±26.2 24.0±15.5

No.CSBMs perweek 0.41±0.73 0.27±0.63 0.53±0.70

BristolStoolFormScale³ 1.67±0.90 1.63±0.99 1.71±0.70

AbdominalPainScore(0-10)³ 5.19±1.77 5.65±1.77 5.43±1.30

Bloating Score(0-4)³ 2.44±0.65 2.52±0.76 2.46±0.56

¹RCTcompleterswereeligibletocontinueintotheEXT,nonewsubjectswereenrolledintheEXT.²Over90%ofsubjectsidentifiedasHispanic.³Weeklyaverage.Dataaremean±SDunlessindicated.

Table1:BaselinedemographicparametersforIBS-CpatientsparticipatingintheSYN-010RCTandEXT

SafetyData

PARAMETER COHORT 1 COHORT2 COHORT3

Study RCT|EXT RCT|EXT RCT|EXT

SYN-010Dose Placebo |42mg_ 21mg|42mg 21mg|42mg

Enrolled (n) 22|17 22|20 22|17

Withdrew(n) 2|1 2|2 2|2

ReportedTEAE(n) 1|2 2|2 2|2

ReportedSAE(n) 0|0 0|0 0|0

DescriptionofTEAE(RelationshiptoTreatment)¹

RCT(4weeks) 01 Gastroenteritis(unlikely)

04 Headache (probable)05 Intermittent rectal

bleeding(unrelated)

07 ElevatedGGT(probable)

08 ElevatedASTcreatinekinase(possible)

EXT (8weeks) 02 Diarrhea(unrelated)²03 Elevated ALT ASTALP

LDHGGT(unlikely)³

05 Proctitis (unrelated)06 FirstdegreeAV block

(unrelated)Legcramp(possible)Headache(possible)

09 Elevatedcreatinekinase(unrelated)

10 Elevatedcreatinekinase(unrelated)

¹NumbersareSubjectID:TEAEswereallofmildormoderateintensity.²Commencedafterlastdoseofstudydrug.³Resultedinwithdrawalfromthestudy.

Table2:Treatmentemergentadverseevents(TEAEs),seriousadverseevents(SAEs)andwithdrawals

SYN-010ReducedBreathMethaneFigure4: ChangeinbreathmethaneAUC(ppm*h)fromday1baseline(mean±SEM;mITT population).Openbars

representtheRCTandclosedbarsrepresenttheEXT.Statisticaltestswereperformedonsquareroottransformedvaluestoaccountforastrongleftskewofthedata¹.

¹NominalPvaluesforwithin-groupchangefromday1(pairedt-test):†P<0.05,‡P<0.005

7 28 35 84 7 28 35 84 7 28 35 84 35 84 DAY

Placebo 42mg 21mg 42mg 42mg 42mg 42mg DOSEEXTSubjectsCombined

COHORT1 COHORT2 COHORT3

SYN-010Increased WeeklyNo.CSBMsFigure5: ChangeinweeklynumberofCSBMsfromday1baseline(mean±SEM;mITT population).Openbars

representtheRCTandclosedbarsrepresenttheEXT.BMs(ifany)werereportedbysubjectseachdayinanelectronicdiary¹.

¹NominalPvalueforSYN-010vsPlacebo(mixedeffectmodel):**P<0.05¹NominalPvaluesforwithin-groupchangefromday1(pairedt-test):†P<0.05,‡P<0.005,§P<0.0005

Placebo 42mg 21mg 42mg 42mg 42mg 42mg DOSE

7 28 35 84 7 28 35 84 7 28 35 84 35 84 DAY

EXTSubjectsCombined

COHORT1 COHORT2 COHORT3

LowerMethaneAUCCorrelatedwithMoreBMsFigure6: InversecorrelationbetweenbreathmethaneAUCandtheweeklynumberofCSBMsandSBMs(inset)forall

subjectswhocompletedtheEXT(atleast8weeksofSYN-01042mg;mITT population).Lowerbreathmethanecorrelatedwithmorebowelmovements.

¹Linerepresentsleast-squareslinearregressionmodeling

LessRescueMedicationUseinSYN-010GroupsFigure7: SubjectsinSYN-010treatmentgroupsusedlessrescuemedication(bisacodyl)thanthePlacebogroup(RCT

study;mITT population).Rescuemedicationusewasreportedbysubjectseachdayinanelectronicdiary¹.

¹NominalPvaluesforFisher’sexacttestvsPlacebo

SYN-010Reduced AbdominalPainScoreFigure8: Percentagechangeinweeklyaverageworstabdominalpainscore(mean±SEM;mITT population).Openbars

representtheRCTandclosedbarsrepresenttheEXT.Painwasreportedbysubjectseachdayinanelectronicdiaryusingan11pointscale(0-10)¹.

¹NominalPvaluesforwithin-groupchangefromday1(pairedt-test):†P<0.05,‡P<0.005,§P<0.0005

7 28 35 84 7 28 35 84 7 28 35 84 35 84 DAY

Placebo 42mg 21mg 42mg 42mg 42mg 42mg DOSEEXTSubjectsCombined

COHORT1 COHORT2 COHORT3

SYN-010ReducedBloatingSeverityFigure9: Percentagechangeinweeklyaveragebloatingscorefromday1baseline(mean±SEM;mITT population).

OpenbarsrepresenttheRCTandclosedbarsrepresenttheEXT.Bloatingwasreportedbysubjectseachdayinanelectronicdiaryusinga5pointscale(0-4)¹.

¹NominalPvaluesforwithin-groupchangefromday1(pairedt-test):†P<0.05,‡P<0.005,§P<0.0005

7 28 35 84 7 28 35 84 7 28 35 84 35 84 DAY

Placebo 42mg 21mg 42mg 42mg 42mg

EXTSubjectsCombined

42mg DOSECOHORT1 COHORT2 COHORT3

CONCLUSIONS• TheSYN-010modified-releaseformulationoflovastatinlactonewasdesignedtoreduceintestinalmethaneproduction,therebytreatinganunderlyingcauseofconstipationinIBS-C.

• DailydosesofSYN-010werewell-toleratedbyIBS-Cpatientsoverthe12weektreatmentperiod(atleast8weeksofSYN-01042mg).NoSAEswerereportedandtherewerenoincidencesofdrug-relateddiarrhea,whichisanimportantpotentialbenefitofSYN-010asanIBS-Ctherapy.

• BreathmethanewasreducedrelativetobaselineinSYN-010treatmentgroupsandlowerbreathmethanelevelscorrelatedwithincreasednumberofCSBMs,consistentwiththeproposedmethane-inhibitingactionoflovastatinlactone.

• Althoughthesestudieswerenotprospectivelypoweredforformalstatisticalevaluationofclinicalendpoints,compellingimprovementsinCSBMs,abdominalpain,andbloatingwereobservedinSYN-010treatmentgroups.

• TheseresultsvalidatetheneedtoevaluateoptimaldosingofSYN-010inalargerpatientpopulationandaPhase2b/3clinicaltrialofSYN-010isindevelopment.

SYN-010SeekingNormalization ofBowelHabits

SYN-010

LaxativesLubiprostoneLinaclotide

SYN-010

LaxativesLubiprostoneLinaclotide

CONSTIPATIONK NORMALJ DIARRHEAL

þ TreatingtheCause