Clinical use of RANKL Inhibitor in Osteoporosis Thawee Songpatanasilp, M.D.,M.Sc.,Ph.D. Associate Professor in Orthopaedics Phramongkutklao College of Medicine

Disclosures Songpatanasilp T. has received research grants, consultancies, and/or speaker’s honoraria from GSK, Eli Lilly, MSD, Novartis, Pfizer, Servier, J&J, Roche,Takeda and Actavis

Osteoporosis Treatment 2015: We have many effective drugs Many Limitations: Real or perceived intolerance Concerns about safety, especially the long-term safety of bisphosphonates Inconvenient or awkward dosing regimens Poor adherence to therapy No agent restores skeletal structure or strength to normal levels i.e., no “cure” for osteoporosis

RANK Ligand is an Essential Mediator of Osteoclast Formation, Function and Survival RANK Ligand (RANKL) Signaling protein expressed by osteoblasts/bone lining cells1 Binds to RANK and promotes osteoclast formation, function and survival2 RANK Expressed by osteoclasts and their precursors1 Activated by RANK Ligand binding1 Osteoprotegerin (OPG) Protein secreted by osteoblasts/bone lining cells1 Natural inhibitor of RANK Ligand2 Blocks RANK Ligand signaling to balance bone remodeling2 1. Boyle WJ, et al. Nature 2003;423:337–342. 2. Kostenuik PJ. Curr Opin Pharmacol 2005;5:618–625.

Many factors stimulate osteoblast expression of RANK Ligand CFU-M RANKL RANK Glucocorticoids PTH Prefusion Osteoclast PGE2 Vitamin D IL-11 IL-6 Multinucleated Osteoclast IL-1 PTHrP TNF- Many different factors can affect osteoclast activity, but RANK ligand is required to mediate or permit their effects on bone resorption. Several factors (eg, PTH, TNF, IL-1) stimulate the expression of RANK ligand by cells of the osteoblast lineage and other cells (eg, activated T cells), resulting in increased bone loss.1-3 Evidence from gene deletion and other studies indicates that RANK ligand is an essential mediator of osteoclast activity.1,2 RANK ligand is a key factor regulating osteoclastogenesis and bone resorption.1,2 Consistent with this are the following observations: Within bone, most receptors for hormones, growth factors, and cytokines are present on osteoblasts rather than osteoclasts, regardless of whether the predominant action of these factors is bone formation or bone resorption.2 Most osteotropic growth factors, hormones, and cytokines upregulate RANK ligand mRNA expression in osteoblast cell lines and primary cell cultures.1,2 The anti-osteoclast effects of osteoprotegerin (OPG), the natural endogenous inhibitor of RANK ligand, occur in normal animals and are consistent across various disease models.2 This reproducibility supports the idea that most osteoclast activating factors act indirectly via RANK ligand.2 TNF- = tumour necrosis factor-alpha PTHrP = parathyroid hormone-related peptide PTH = parathyroid hormone IL-1, IL-6, IL-11 = interleukins-1, 6, and 11 PGE2 = prostaglandin E2 References: Boyle WJ, et al. Osteoclast differentiation and activation. Nature. 2003;423:337-342. Kostenuik PJ, Shalhoub V. Osteoprotegrin: a physiological and pharmacological inhibitor of bone resorption. Curr Pharm Des. 2001;7:613-635. Hofbauer LC, Schoppet M. Clinical Implications of the Osteoprotegerin/RANKL/RANK system for bone and vascular diseases. JAMA. 2004;292:490-495. Activated Osteoclast Estrogen Osteoblast CFU-M = colony-forming unit macrophage Adapted from Boyle WJ, et al. Nature. 2003;423:337-342. Hofbauer LC, Schoppet M. JAMA. 2004;292:490-495. 6

OPG Is a Decoy Receptor That Prevents RANK Ligand Binding to RANK and Inhibits Osteoclast Formation, Function, and Survival RANKL RANK OPG CFU-GM Prefusion Osteoclast Hormones Growth Factors Cytokines Osteoclast Formation, Function, and Survival Inhibited The body naturally produces a protein called OPG to neutralize the effects of RANK Ligand and defend against bone loss.1,2 When RANK Ligand is bound and neutralized by OPG, osteoclasts cannot form,3,4 function,3 or survive.5 OPG, a natural endogenous inhibitor of RANK Ligand, acts as a decoy receptor by binding with RANK Ligand, thereby inhibiting osteoclastogenesis and the survival of preexisting osteoclasts.1,2,6,7 OPG, a member of the TNF receptor family, binds to RANK Ligand and neutralizes its effects, thereby inhibiting bone resorption.1,2,6,7 OPG is an important inhibitor of the terminal differentiation and function of osteoclasts.1,2,6,7 Boyle WJ, et al. Nature. 2003;423:337-342. Simonet WS, et al. Cell. 1997;89:309-319. Fuller K, et al. J Exp Med. 1998;188:997-1001. Yasuda H, et al. Proc Natl Acad Sci U S A. 1998;95:3597-3602. Lacey DL, et al. Am J Pathol. 2000;157:435-448. Lacey DL, et al. Cell. 1998;93:165-176. Bekker PJ, et al. J Bone Miner Res. 2001;16:348-360. Osteoblasts Bone Resorption Inhibited Bone Formation Adapted from Boyle WJ, et al. Nature. 2003;423:337-342. Hofbauer LC, Schoppet M. JAMA. 2004;292:490-495.

Denosumab Binds RANK Ligand and Inhibits Osteoclast Formation, Function, and Survival OPG Denosumab CFU-GM Prefusion Osteoclast Hormones Growth Factors Cytokines Osteoclast Formation, Function, and Survival Inhibited Denosumab is the first fully human monoclonal antibody in clinical development that specifically targets RANK Ligand, an essential mediator of osteoclast formation, function, and survival.1,2 Lewiecki EM. Exper Opin Biol Ther. 2006;6:1041-1050. McClung ER, et al. N Engl J Med. 2006;354:821-831. Osteoblasts Bone Resorption Inhibited Bone Formation Adapted from Boyle WJ, et al. Nature. 2003;423:337-342. Hofbauer LC, Schoppet M. JAMA. 2004;292:490-495.

Bone type affinity Trabecular >>> Cortical Bisphosphonates Differences in Pharmacokinetics & Pharmacodynamics Bone type affinity Bisphosphonates 50%-70% in circulation are uptake by bone Surface dependent Remodeling dependent Interchanging between bone surface-blood determine bony surface half life Trabecular >>> Cortical

Bone type affinity Denosumab Cortical = Trabecular No bone uptake Differences in Pharmacokinetics & Pharmacodynamics Bone type affinity Denosumab No bone uptake Reached everywhere that blood vessels going to Cortical = Trabecular Key Points1: Context: Antiresorptives differ in the extent to which they suppress remodeling. Since remodeling is surface dependent, the degree to which antiresorptives suppress remodeling could be due, in part, to differences in their accessibility to bone surfaces. Hypothesis: Differences in distribution and mechanism of action between denosumab and alendronate will result in a greater reduction in intracortical porosity with denosumab. Study Population: Postmenopausal women aged 61±5 years were randomized double-blind to denosumab 60 mg Q6M (N=83), alendronate 70 mg QW (N=82), or placebo (N=82) for 12 months. Methods: Trabecular bone volume fraction (BV/TV) and porosity in both the compact and the trabecularized cortex (outer and inner transitional zones) were measured from HRpQCT distal radius images obtained at baseline, 6 months, and 12 months using Strax 1.0 software. Results: Both denosumab and alendronate improved trabecular BV/TV compared with placebo at 6 and 12 months. Alendronate reduced porosity at month 6 in the compact and trabecularized cortex compared with placebo; however, at month 12 there was no evidence of a difference with alendronate relative to placebo in any of these cortical compartments. Denosumab reduced porosity at both 6 and 12 months in all cortical compartments compared with baseline and placebo. Conclusions: Access to cortical bone by therapeutic agents is a challenge because of its surface/bone volume configuration. The broader distribution of denosumab compared with alendronate is associated with greater and more uniform reductions in porosity throughout the cortex. Reference: 1. Zebaze RM, Libanati C, Austin M, Bilezikian JP, Seeman E. Antiresorptive Action Is Dependent on Access to Remodeling Upon Cortical and Trabecular Surfaces: Comparison of Denosumab and Alendronate. American Society For Bone and Mineral Research, Minneapolis, Minnesota; October 12–15, 2012. Poster Presentation FR 0389 and SA 0389. Adapted from Zebaze RM et al. Bone. 2014;59:173–179.

FREEDOM Fracture Reduction Evaluation of Denosumab in Osteoporosis every 6 Months Phase 3 RCT Postmenopausal women age 60-90 (mean 73 yrs) with lumbar or total hip T-score < -2.5 and >= -4.0 Mean T-score: spine -2.8; hip -1.8 Prevalent vertebral fracture 23% Denosumab 60 mg q 6 months vs. placebo Endpoints Primary: new vertebral fractures at 36 months Secondary: time to first hip and non vertebral fractures Cummings SR, et al. N Engl J Med 2009;361:756-65

Denosumab Reduced Risk of Vertebral, Non-vertebral and Hip Fractures at 36 Months FREEDOM Trial RRR = 20% P = 0.01 RRR = 68% P < 0.001 Placebo Denosumab Incidence at Month 36 (%) . RRR = 40% P = 0.04 (Primary Endpoint) (Secondary Endpoint) (Secondary Endpoint) RR = risk reduction Adapted from: Cummings SR, et al. N Engl J Med 2009;361:756–765.

(Subset from FREEDOM)

Denosumab Compared With Zoledronic Acid in Postmenopausal Women With Osteoporosis Previously Treated With Oral Bisphosphonates: Efficacy and Safety Results From a Randomized Double-blind Study* PD Miller,1 N Pannacciulli,2 JP Brown,3 E Czerwinski,4 BS Nedergaard,5 MA Bolognese,6 J Malouf,7 HG Bone,8 JY Reginster,9 A Singer,10 C Wang, * present in ASBMR 2015, Seattle

Percentage change in Total hip BMD in head to head study vs various BPs

Denosumab: Safety and Tolerability Overall, no increased risk of adverse events or serious adverse events in clinical trials Increased incidence of (FREEDOM trial-3 years) skin rash (1.3% vs 0.7%) cellulitis (12/3808 vs 1/3805) No renal or cardiovascular effects noted Deaths: 90 in placebo group; 70 with DMab (p=0.06) Less than 1% of patients developed binding antibodies over 2-8 years; none have developed neutralizing antibodies Cummings SR, McClung MR et al. N Engl J Med. 2009;361:756-65.

Denosumab with Impaired Renal Function Differences in Clinical Outcomes Denosumab with Impaired Renal Function Post-hoc analysis of FREEDOM study Treatment response evaluated in subgroups of renal function 73 women had an eGFR of 15 to 29 ml/min (Gr 4) 2817 between 30 to 59 ml/min (Gr 3) 4069 between 60 to 89 ml/min (Gr 2) 842 had an eGFR ≥ 90ml/min (Gr 1) Treatment efficacy did not differ by kidney function. Bisphosphonates should not be used in patients with eGFR below 30 ml/min Jamal S, McClung, Miller PD et al. J Bone Miner Res. 2011;26:1829-35.

Long-term antiresorptive therapy: Rare complications Osteonecrosis of the jaw Atypical femoral fractures Estimated market exposure to denosumab was 1,960,405 patient-years as of May 10, 2014 and there were1 47 spontaneous reports adjudicated as consistent with ONJ 5 spontaneous reports adjudicated as consistent with AFF Osteonecrosis of the jaw: Range of incidence reported on treatment is:2 Oral bisphosphonates 1.04-69 per 100,000 patient-years IV bisphosphonates 0-90 per 100,000 patient-years Denosumab 0-30.2 per 100,000 patient-years. Key points: Osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFFs) can potentially occur after long-term treatment with potent antiresorptive therapy such as bisphosphates and denosumab1 Estimated market exposure to denosumab was 1,960,405 patient-years as of May 10, 2014 and there were2 – 47 spontaneous reports adjudicated as consistent with osteonecrosis of the jaw (ONJ) – 5 spontaneous reports adjudicated as consistent with atypical femoral fractures (AFF) Osteonecrosis of the jaw: The majority of cases (>90%) have occurred in cancer patients receiving a six-to-ten-fold higher doses of BPs than that used to treat osteoporosis.3 The incidence in the osteoporotic population is only slightly higher than the frequency observed in the general population.3 Range of incidence reported on treatment is:3 oral bisphosphonates 1.04-69 per 100,000 patient-years IV bisphosphonates 0-90 per 100,000 patient-years denosumab 0-30.2 per 100,000 patient-years. Atypical femoral fractures: Cases of atypical femoral fractures (AFFs) have been reported in patients with osteoporosis taking bisphosphonates and denosumab.1 However, they also occur in patients with no exposure to these medications and although there is thought to be an association between there use and AFF, a direct causal relationship has not yet been demonstrated.1 References: Shane E, Burr D, Abrahamsen B et al. J Bone Miner Res. 2014;29:1-23. Geller M et al. Poster. ASBMR 2014 Annual Meeting, Houston, TX; September 12–15, 2014 Khan AA, et al. J Bone Miner Res 2014 [Epub ahead of print] . 1. Geller M et al. Poster presented at: American Society of Bone and Mineral Research Meeting; September 12–15 2014; Houston, US. 2. Khan AA, et al. Can Fam Physician. Jul 2008; 54(7): 1019–1021

FREEDOM Extension Study Design International, multicenter, open-label, single-arm study Year 1 2 3 4 5 6 7 8 9 10 R A N D O M I Z T Denosumab 60 mg SC Q6M (N = 3902) Denosumab 60 mg SC Q6M (N = 2343) Long-term Denosumab Treatment Calcium and Vitamin D Placebo SC Q6M (N = 3906) Denosumab 60 mg SC Q6M (N = 2207) Cross-over Denosumab Treatment Year 1 2 3 4 5 6 7 Key Inclusion Criteria for the Extension: Completed the FREEDOM study (completed the 3-year visit, did not discontinue investigational product, and did not miss > 1 dose) Not receiving any other osteoporosis medications Amgen Corporate Template

Effects of Denosumab Treatment on L-Spine and Total-hip BMD Through 10 Years (All Participants) Long-term Denosumab (N = 2210) Placebo Cross-over Denosumab (N = 2089) Long-term Denosumab (N = 2210) Placebo Cross-over Denosumab (N = 2089) L-Spine Total-Hip All Participants All Participants FREEDOM Extension FREEDOM Extension 21.7%c 9.2%c b b b 16.5%c b b b b 7.4%c b b b b b a Percentage Change From Baseline b b a Percentage Change From Baseline a b b a b a b a a b b a a a a a a a a a Study Year 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 Study Year BMD data are LS means and 95% confidence intervals. *Subjects who completed the year-10 visit and missed ≤ 1 dose in FREEDOM and ≤ 1 dose in the Extension, and had an Extension baseline and ≥ 1 post-baseline BMD measurement during the Extension. aP < 0.05 vs FREEDOM baseline. bP < 0.05 vs FREEDOM and Extension baselines. cPercentage change while on denosumab treatment.

Effects of Denosumab Treatment on Femoral Neck and 1/3 Radius BMD Through 10 Years Placebo Cross-over Denosumab Long-term Denosumab Femoral Neck 1/3 Radius FREEDOM Extension 9.0%d FREEDOM Extension b b b a b 7.1%d b a b 2.7%d b b a a a b a c Percentage Change From Baseline a Percentage Change From Baseline b a c 2.3%d a b c a b a a a a a a a a a Study Year 1 2 3 4 5 6 7 8 9 10 Study Year 1 2 3 4 5 6 7 8 9 10 BMD data are LS means and 95% confidence intervals. aP < 0.05 vs FREEDOM baseline. bP < 0.05 vs FREEDOM and Extension baselines. cP < 0.05 vs Extension baseline. dPercentage change while on denosumab treatment.

Cumulative Subject Incidence of New Vertebral and Nonvertebral Fractures: Long-term Denosumab Group Placebo Virtual Twin Placebo Long-term Denosumab New Vertebral Nonvertebral RR (95% CI) = 0.62 (0.47–0.80) RR (95% CI) = 0.54 (0.43–0.68) n 264 86 149 N 3691 3702 2116 n 293 238 172 N 3606 3902 2343 n = number of subjects with ≥ 1 fracture. N = number of randomized (FREEDOM) or enrolled (Extension) subjects. Percentages are Kaplan-Meier estimates. RR < 1 favors long-term denosumab over virtual twin placebo. n = number of subjects with ≥ 1 fracture. N = number of subjects with an evaluation. RR < 1 favors long-term denosumab over virtual twin placebo.

Nonvertebral Fracture (%) Yearly Subject Incidence of Nonvertebral Fractures: Long-term Denosumab Group Long-term Denosumab Virtual Twin Placebo RR (95% CI) = 0.58 (0.35–0.89) RR (95% CI) = 0.44 (0.25–0.71) RR (95% CI) = 0.62 (0.36–1.00) RR (95% CI) = 0.50 (0.26–0.84) RR (95% CI) = 0.27 (0.12–0.52) RR (95% CI) = 0.31 (0.13–0.61) RR (95% CI) = 0.55 (0.22–1.17) Nonvertebral Fracture (%) Subject Incidence of 1.8 1.9 1.5 1.6 1.2 1.1 0.8 n 34 27 28 14 16 N 2343 2244 2067 1867 1743 1585 1451 For Extension participants (N = 2343). n = number of subjects with ≥ 1 fracture; N = number of randomized subjects who remained on study at the beginning of each period. RR < 1 favors long-term denosumab over virtual twin placebo.

Exposure-adjusted Subject Incidence of Adverse Events (Rates per 100 Subject-years) Extension Years 1–7 Cross-over Denosumab (N = 2206) Long-term Denosumab (N = 2343) Year 1 2 3 4 5 6 7 Serious infections 1.6 1.5 1.1 1.3 2.2 2.1 1.2 1.7 2.4 2.6 Malignancies 1.9 2.8 2.7 2.5 FREEDOM Years 1–3 Extension Years 1–7 Placebo (N = 3883) Cross-over Denosumab (N = 2206) Long-term Denosumab (N = 2343) All AEs 156.1 96.8 97.0 Infections 30.7 20.7 19.9 Malignancies 1.6 2.0 Eczema 0.6 0.9 Hypocalcemia < 0.1 Pancreatitis Serious AEs 10.4 10.1 10.3 1.3 1.4 1.5 Cellulitis or erysipelas Fatal AEs 0.8 Osteonecrosis of the jaw Atypical femoral fracture N = number of subjects who received ≥ 1 dose of investigational product. Treatment groups are based on the original randomized treatments received in FREEDOM. AEs coded using MedDRA v13.0. Cumulative osteonecrosis of the jaw cases: 6 cross-over, 7 long-term. Cumulative atypical femoral fracture cases: 1 cross-over, 1 long-term. Amgen Corporate Template

Over all summary What are the “good” points of denosumab over other agents now? Best compliance : only sc. injection q. 6 months Low side effects : compared to others Excellent efficacy : BMD gain / fracture reduction…….best for cortical bone Kidney’s friend : can use with safety and efficiency in CKD 4

Indication registered to Thai FDA Denosumab is indicated for Treatment of osteoporosis in postmenopausal women Treatment of osteoporosis in men at risk of fracture Treatment of Bone Loss in Patients Undergoing Hormone Ablation for Cancer (men and women) (Cancer-treatment induced bone loss, CTIBL) Naive Existing oral BP pt

Osteoporosis Who should be treated with Denosumab? Naive Switch high risk PMwomen & men BPs drug holiday period Trend to AE of BPs intolerance to BPs Renal impairment non-responders Trend to low compliance to improve adherence/convenience after hip fracture after TPTD CTIBL Patient

Guideline recommendation First-line recommendation US: American Association of Clinical Endocrinologist (AACE) recommended Prolia as first line for the treatment of osteoporosis in postmenopausal women 1 UK: National Institute for Health and Clinical Excellence (NICE) recommended Prolia as first line for the treatment of osteoporosis in postmenopausal women who has risk of fracture.2 Canada: recommended Prolia as first line for the treatment of osteoporosis in postmenopausal women for reduced risk of hip, vertebral, non-vertebral fracture 3 1.Sutton EE, Riche DM. Ann Pharmacother. 2012 ;46:1000-9 2. Moen MD, Keam SJ. Denosumab: Drugs Aging. 2011 Jan 1;28(1):63-82 3. Josse R, Khan A, Ngui D, Shapiro M. Curr Med Res Opin. 2013 Mar;29(3):205-16

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