Optimization of Lipid Parameters Evan A Stein MD PhD Director Emeritus Metabolic & Atherosclerosis Research Center Voluntary Professor of Pathology & Laboratory Medicine University of Cincinnati Disclosure Information: Consultant to Regeneron, Sanofi, Amgen, Genentech/Roche and Adnexis/BMS for PCSK9 inhibitor development

Optimization of Lipid Parameters: Unanswered questions LDL cholesterol Non-statin added to statin versus statin alone Is there any additional CVD benefit HDL cholesterol Triglycerides (VLDL, IDL)

Annual Major* CVD Event Rate (%) Relationship Between Absolute LDL-C Levels and CVD Risk From Randomized Clinical Trials 4S PBO 4S Rx TNT 80mg TNT 10mg SEARCH 80mg SEARCH 20mg HPS Rx HPS PBO CARE PBO LIPID PBO CARE Rx LIPID Rx IDEAL A80mg 6 5 4 Annual Major* CVD Event Rate (%) 3 2 1 40 60 80 100 120 140 160 180 200 220 LDL-C mg/dL *Defined as coronary death, confirmed nonfatal acute MI, or cardiac arrest with resuscitation or stroke. 1 mmol/L = ~40 mg/dL. Stein EA, Raal FJ. Best Pract Res Clin Endocrinol Metab. 2014;28(3):309-24.

Relationship between Absolute Reduction in LDL-C and Relative Reduction in CVD Events From Randomized Outcome Trials 50 JUPITER 40 4S 30 ASCOT-LLA WOSCOPS Reduction in Major* CVD Event Rate (%) HPS TNT CARE LIPS 20 LIPID IDEAL ASPEN PROVE-IT PROSPER 10 A to Z ALLHAT-LLT SEARCH 10 20 70 40 50 60 70 80 Reduction in LDL-C mg/dL *defined as coronary death, confirmed nonfatal acute MI, or cardiac arrest with resuscitation or stroke. 1 mmol/L = ~40 mg/dL. Stein EA, Raal FJ. Best Pract Res Clin Endocrinol Metab. 2014;28(3):309-24.

IMPROVE-IT: Study Design Patients stabilized post ACS ≤ 10 days: LDL-C 50–125*mg/dL (or 50–100**mg/dL if prior lipid-lowering Rx) Standard Medical & Interventional Therapy Ezetimibe / Simvastatin 10 / 40 mg Simvastatin 40 mg Follow-up Visit Day 30, every 4 months Duration: Minimum 2 ½-year follow-up (at least 5250 events) Primary Endpoint: CV death, MI, hospital admission for UA, coronary revascularization (≥ 30 days after randomization), or stroke N=18,144 Uptitrated to Simva 80 mg if LDL-C > 79 (adapted per FDA label 2011) *3.2mM **2.6mM 90% power to detect ~9% difference Cannon CP AHJ 2008;156:826-32; Califf RM NEJM 2009;361:712-7; Blazing MA AHJ 2014;168:205-12

IMPROVE-IT: LDL-C and Lipid Changes Median Time avg 69.5 vs. 53.7 mg/dL 1 Yr Mean LDL-C TC TG HDL hsCRP Simva 69.9 145.1 137.1 48.1 3.8 EZ/Simva 53.2 125.8 120.4 48.7 3.3 Δ in mg/dL -16.7 -19.3 +0.6 -0.5 Cannon CP presented AHA late breaking clinical trials Nov 19, 2014

IMPROVE-IT: Primary Endpoint - ITT Simva — 34.7% 2742 events EZ/Simva — 32.7% 2572 events HR 0.936 CI (0.887, 0.988) p=0.016 Cardiovascular death, MI, documented unstable angina requiring rehospitalization, coronary revascularization (≥30 days), or stroke NNT= 50 Cannon CP presented AHA late breaking clinical trials Nov 19, 2014

Relationship between Absolute Reduction in LDL-C and Relative Reduction in CVD Events From Randomized Outcome Trials + IMPROVE-IT 50 JUPITER 40 4S 30 ASCOT-LLA WOSCOPS Reduction in Major* CVD Event Rate (%) HPS TNT CARE LIPS 20 LIPID IDEAL ASPEN PROVE-IT PROSPER 10 A to Z IMPROVE-IT ALLHAT-LLT SEARCH 10 20 70 40 50 60 70 80 Reduction in LDL-C mg/dL Cannon CP presented AHA late breaking clinial trials Nov 19, 2014 *defined as coronary death, confirmed nonfatal acute MI, or cardiac arrest with resuscitation or stroke. 1 mmol/L = ~40 mg/dL. Stein EA, Raal FJ. Best Pract Res Clin Endocrinol Metab. 2014;28(3):309-24.

IMPROVE-IT: Conclusions First trial to show incremental CVD benefit when adding non-statin agent (ezetimibe) to statin therapy Reaffirms the LDL hypothesis Demonstrates even lower LDL-C is even better (achieved LDL-C 53 vs 70 mg/dL at year 1) Confirms ezetimibe safety profile Results further question recent ACC/AHA guidelines Adapted from Cannon CP presented AHA late breaking clinical trials Nov 19, 2014

PCSK9 Inhibitor Cardiovascular Outcomes Trials Evolocumab (AMG 145) Alirocumab (SAR236553 /REGN727) Bococizumab (RN 316) Sponsor Amgen Sanofi / Regeneron Pfizer Trial FOURIER ODYSSEY Outcomes SPIRE I SPIRE II Sample size 22,500 18,000 12,000 6,300 Patients MI, stroke or PAD 4-52 wks post-ACS High risk of CV event Statin Atorva ≥20 mg or equiv Evid-based med Rx Lipid-lowering Rx LDL-C mg/dL(mmol/L) ≥70 (≥1.8) 70-99 (1.8-2.6) ≥100 (≥2.6) PCSK9i Dosing Q2W or Q4W Q2W Endpoint 1: CV death, MI, stroke, revasc or hosp for UA, Key 2: CV death, MI, or stroke CHD death, MI, ischemic stroke, or hosp for UA CV death, MI, stroke, or urgent revasc Completion 12/2017 1/2018 8/2017 www.clinicaltrials.gov

Optimization of Lipid Parameters: Unanswered questions LDL cholesterol Non-statin added to statin versus statin alone Is there any additional CVD benefit HDL cholesterol Niacin CETP inhibitors Triglycerides

AIM HIGH: Rationale Conventional LDL-C lowering with statins fails to substantially address the high ‘residual’ cardiovascular risk due to non-LDL lipids. Does adding niacin, which raises HDL cholesterol (in addition to lowering LDL-C and triglycerides) provide additional clinical benefit? AIM-HIGH Investigators. N Engl J Med 2011;365:2255-67

AIM HIGH: Background Randomised, placebo-controlled, double-blind trial in 3,414 high- risk patients aged at least 45 years and with established vascular disease AND: Atherogenic dyslipidemia LDL-C <4.1 mmol/L (160 mg/dL) HDL-C <1.0 mmol/L (40 mg/dL) in men and <1.3 mmol/L (50 mg/dL) in women Triglycerides 1.7-4.5 mmol/L (150-400 mg/dL) Patients randomized to ER niacin (1.5-2 g) vs.placebo on top of optimal statin therapy. Primary outcome: Composite end point of CHD death, nonfatal MI, ischemic stroke, hospitalization for acute coronary syndrome or symptom-driven vascularisation AIM-HIGH Investigators. N Engl J Med 2011;365:2255-67

AIM-HIGH: Design Purpose: “[A] rigorous test of the HDL hypothesis…” Subjects: N=3414 men/women (85%/15%) w/ prior CVD event and HDL-C 35 (<42/53) LDL-C 74 (algorithm), TG 163 (100-400) [median (range)] Randomized Therapy Extended-release niacin (1500-2000 mg hs) vs “Placebo” (immediate-release niacin 100-150 mg hs) Open-label titration/addition (keep LDL-C in 40-80 mg/dL) Simvastatin 5-80 mg/d Ezetimibe 10 mg/d + extended release niacin (1500-2000 mg) The design of the AIM-HIGH study, shown in this slide, was really to test whether raising HDL with a niacin-based therapy conferred improvement in cardiovascular risk. It included 3,400 men and women, all of whom had established cardiovascular disease and metabolic syndrome, who were then randomized to niacin in the form of extended-release therapy vs placebo. The idea here was that everybody in the study on treatment had to have their LDL driven to below 80, and that was attained initially with statin therapy. Simvastatin being used, and then you had the option of adding ezetimibe. Again, the purpose here was to maintain similar LDL levels across both groups and then just look at the effect of niacin in the second group. The titration of LDL-C was done with simvastatin and then ezetimibe in both groups as needed. The titration of ER niacin was done only in the assigned group and the purpose was to reach maximum tolerated dose up to 2g/d. AIM-HIGH Investigators. N Engl J Med. 2001;365:2255-267. AIM-HIGH Investigators. Am Heart J. 2011;161:471-477.e2.

AIM HIGH: Change in lipids Median (% change from baseline) ER niacin + simvastatin Simvastatin Median Δ between groups, mg/dL LDL-Cholesterol 62 (-13.6%) 67 (-7.6%) -5 (-6%) HDL-Cholesterol 42 (25%) 38 (11.8%) +4 (+13%) Triglycerides 120 (-30.8%) 152 (-9.9%) -32 (-21%) AIM-HIGH Investigators. N Engl J Med 2011;365:2255-67

AIM-HIGH: Results Primary Outcome 1o Endpoint: CHD Death, nonfatal MI, ischemic stroke, high-risk ACS, hospitalization for coronary or cerebrovascular revascularization This slide, however, does not show any change in the primary endpoint, which was MACE, or major adverse cardiovascular events, and they were virtually identical between the groups. Boden WE. N Engl J Med. epub 15 Nov 2011; doi 10.1056/NEJMoa1107579.

AIM HIGH: Key outcomes Endpoint Niacin (%) Placebo (%) Hazard ratio (95% CI) with niacin p-value Primary* 16.4 16.2 1.02 (0.87-1.21) 0.80 CHD death/nonfatal MI/ischaemic stroke/high risk ACS 10.0 9.3 1.08 (0.87-1.34) 0.49 CHD death/nonfatal stroke/ischaemic stroke 8.1 9.1 1.13 (0.90-1.42) 0.30 *composite of coronary heart disease (CHD) death, nonfatal myocardial infarction (MI), ischaemic stroke, hospitalisation for acute coronary syndrome (ACS) or symptom-driven coronary or cerebral revascularisation AIM-HIGH Investigators. N Engl J Med 2011;365:2255-67

The HPS2-THRIVE Collaborative Group N Engl J Med 2014; 371:203-2102 Effects of Extended-Release Niacin with Laropiprant in High-Risk Patients The HPS2-THRIVE Collaborative Group N Engl J Med 2014; 371:203-2102 HPS2-THRIVE: Randomized placebo-controlled trial of ER niacin and laropiprant in 25,673 patients with pre-existing cardiovascular disease.

Effects of ER niacin/laropiprant on lipids Year of FU LDL-C (mg/dL) HDL-C Triglycerides 1 -12 6 -35 4 -7 -31 STUDY AVERAGE -10 -33 (mmol/L) (-0.25) (0.16) -0.37 “Based on previous observational studies and randomized trials, it was anticipated such lipid differences might translate into a 10-15% reduction in vascular events” Eur Heart Journal 2013

Effect of ERN/LRPT on MAJOR VASCULAR EVENTS 20 Risk ratio 0.96 (95% CI 0.90 – 1.03) Logrank P=0.29 15 15.0% 14.5% Patients suffering events (%) 10 Placebo ERN/LRPT 5 1 2 3 4 Years of follow-up

HPS2-THRIVE: Summary Significant excesses of serious adverse events (SAEs) due to known and unrecognised side-effects of niacin. Over 4 years, ER niacin/laropiprant caused SAEs in ~30 patients per 1000 No significant benefit of ER niacin/laropiprant on the primary outcome of major vascular events when added to effective statin-based LDL-lowering therapy

Lipid Effects of CETP Inhibitors/Modulators % Change from Baseline CETP Agent Dose (Mg/day) HDL-C (%) LDL-C (%) TG (%) Torcetrapib 60 61 -24 -9 Anacetrapib 100 138 -40 -7 Evacetrapib 500 129 -36 -11 Dalcetrapib 600 31 -2 -3 This slides shows the lipid effects of CETP inhibitor/modulators compared to baseline. Torcetrapib, anacetrapib, and evacetrapib produce greater increases in HDL. Dalcetrapib has a more moderate HDL raising effect of somewhere between 30% to 35%. Both torcetrapib and evacetrapib also have effects on LDL reduction, and none of the CETP inhibitor or modulators really have any pronounced effects on triglycerides. Adapted from Cannon C et al. JAMA. 2011;306:2153-2155. Nicholls SJ et al. JAMA. 2011;306:2099-2109.

ILLUMINATE: Rationale A novel mechanism for raising HDL levels is to inhibit a protein known as cholesteryl ester transfer protein (CETP). This protein transfers cholesterol from the protective HDL fraction to the harmful LDL fraction. Thus, inhibiting CETP retains cholesterol in the protective HDL. Torcetrapib is a drug that inhibits CETP and has been shown in humans to raise the level of HDL cholesterol and lower that of LDL cholesterol. The ILLUMINATE trial was designed to test the hypothesis that inhibiting CETP with torcetrapib would also protect against cardiovascular disease in humans. CETP (cholesteryl ester transfer protein) in human plasma promotes the transfer of cholesterol from high density lipoproteins (HDL) to low density lipoproteins (LDL) and triglyceride-rich lipoproteins such as very low density lipoproteins (VLDLs) and chylomicrons. Consequently, inhibition of CETP has the potential to shift the balance of plasma cholesterol in favour of the protective HDL fraction. Thus, the development of the CETP inhibitors potentially represents a novel class of drug for raising circulating HDL cholesterol levels. In a rabbit model of atherosclerosis, inhibiting CETP by treatment with torcetrapib led to a marked increase in HDL cholesterol and reduction in susceptibility to development of atherosclerosis (1). In human subjects, treatment with torcetrapib increase the concentration of HDL cholesterol and decreased that of LDL cholesterol and apoB (2). These data provide the background to testing the hypothesis that inhibiting CETP with torcetrapib would also protect against cardiovascular disease in humans. References 1. Morehouse LA, Sugarman ED, Bourassa PA, et al. J Lipid Res. 2007;48:1263-1272. 2. Davidson MH, McKenney JM, Shear CL, Revkin JH. J Am Coll Cardiol. 2006;48:1774-1781 Barter P et al. N Engl J Med 2007;357:2109-22.

ILLUMINATE - Study Design Patients with CHD or CHD risk equivalents (planned 4.5 years of treatment) Atorvastatin run-in to LDL-C <100 mg/dL (2.6 mmol/L) 4-10 weeks. Torcetrapib + titrated atorvastatin dose. Titrated atorvastatin dose. Patient Population Subjects Primary End Point Men or postmenopausal women Statin eligible Any HDL-C level CHD or risk equivalent (type 2 DM) 15,000 7 countries Major cardiovascular events (MCE) ILLUMINATE (1) was a multicenter, double-blind, parallel-group outcomes study in patients with CHD or CHD risk equivalents. The primary end point was major cardiovascular events (MCE), a composite of CHD death, nonfatal MI, or stroke. Subjects initially entered an atorvastatin run-in period during which atorvastatin treatment was initiated. Subjects previously treated with other statins were switched to an equivalent dose of atorvastatin. The atorvastatin dose was then titrated to a target LDL-C level of <100 mg/dL (2.6 mmol/L). Following attainment of the LDL-C goal, patients were randomized to either torcetrapib/atorvastatin or atorvastatin alone. In both treatment arms, the dose of atorvastatin is that established during the atorvastatin run-in phase. Patients were randomized to treatment irrespective of their baseline HDL-C levels. Follow-up was to be driven by end points (984 events) and estimated to last approximately 4.5 years. Reference 1. Barter P, Caulfield M, Eriksson M et al. New Eng J Med 2007;357:2109-22. Barter P et al. N Engl J Med 2007;357:2109-22.

ILLUMINATE: Terminated on Dec 02, 2006 due to excess mortality and MCE Atorvastatin Group=A (n=7534) Torcetrapib/Atorvastatin Group=T/A (n=7533) T/A increased HDL-C by 72% and reduced LDL-C by 25% Atorva MonoRx Torcet + Atorva Major cardiovascular events 373 464 (P=0.001) Deaths 59 93 (P=0.006) ILLUMINATE was prematurely terminated due to an excess of major cardiovascular events (464 vs. 373, hazard ratio 1.25; 95%CI 1.09 to 1.44, p=0.001) and deaths (93 vs. 59, hazard ratio 1.58; 95%CI 1.14 to 2.19, p=0.006) in the torcetrapib-treated group. The excess of deaths included both cardiovascular and non-cardiovascular causes (1). Reference 1. Barter P, Caulfield M, Eriksson M et al. New Eng J Med 2007;357:2109-22. Barter P et al. N Engl J Med 2007;357:2109-22.

ILLUMINATE: Kaplan-Meier Curves for Death from Any Cause and for the Primary Composite Outcome Figure 2. Kaplan-Meier Curves for Death from Any Cause and for the Primary Composite Outcome. Panel A shows the between-group comparison of patients who died from any cause during the study: 59 patients in the atorvastatin-only group and 93 patients in the torcetrapib group. Panel B shows the between-group comparison of patients who had the primary composite outcome: 373 patients in the atorvastatin-only group and 464 patients in the torcetrapib group. The primary outcome was the time to the first occurrence of a major cardiovascular event, a composite that included four components: death from coronary heart disease, nonfatal myocardial infarction (excluding procedure-related events), stroke, and hospitalization for unstable angina. Analyses in both panels were censored on December 2, 2006. Barter P et al. N Engl J Med 2007;10.1056/NEJMoa0706628

Dal-OUTCOMES: a phase III trial of the CETP inhibitor dalcetrapib in patients with acute coronary syndromes (ACS) Schwartz GC, Olsson AG, Abt M et al. Effects of dalcetrapib in patients with a recent acute coronary syndrome. New Engl J Med 2012; Published online November 5, 2012.

dal-OUTCOMES: Study Aims Low HDL cholesterol is a strong predictor of cardiovascular events after myocardial infarction (MI).1 Dal-OUTCOMES investigated whether treatment with the cholesteryl ester transfer protein (CETP) inhibitor dalcetrapib in patients with a recent ACS (within 4-12 weeks) will reduce the incidence of major cardiovascular events (versus standard therapy).   The primary endpoint was the time to first occurrence of coronary heart disease (CHD) death, nonfatal coronary events (MI, hospitalisation for unstable angina, or resuscitated cardiac arrest) or ischaemic stroke. Schwartz GC, Olsson AG, Abt M et al. New Engl J Med 2012; Published online November 5, 2012 1. Olsson AG, Schwartz GG, Szarek M, et al. Eur Heart J 2005;26:890–6

Schwartz GG et al. N Engl J Med 2012;367:2089-2099. dal-Outcomes: Changes in Mean HDL Cholesterol and LDL Cholesterol Levels. Schwartz GG et al. N Engl J Med 2012;367:2089-2099.

Schwartz GG et al. N Engl J Med 2012;367:2089-2099. dal-Outcomes: Primary Efficacy End Point. Schwartz GG et al. N Engl J Med 2012;367:2089-2099.

Dal-OUTCOMES: Study Termination The second pre-specified interim analysis of the dal-OUTCOMES trial failed to show a difference between dalcetrapib and placebo. Consequently, the independent Data and Safety Monitoring Board (DSMB) recommended termination of the trial due to futility. Dalcetrapib was terminated on 7 May 2012.1 Schwartz GC, Olsson AG, Abt M et al. New Engl J Med 2012; Published online November 5, 2012 1. Roche provides update on Phase III study of dalcetrapib. http://www.roche.com/media/media_releases/med-cor-2012-05-07.htm. 7 May 2012

30,000 patients with occlusive arterial disease in North America, Europe and Asia Background LDL-lowering with atorvastatin Randomized to anacetrapib 100 mg vs. placebo Scheduled follow-up: 4 years Primary outcome: Coronary death, myocardial infarction or coronary revascularization www.revealtrial.org

Optimization of Lipid Parameters: Unanswered questions LDL cholesterol Non-statin added to statin versus statin alone Is there any additional CVD benefit HDL cholesterol Triglycerides Fibrates Omega 3 Fatty Acids

ACCORD Trial: Key question “In the context of good glycemic control, does a therapeutic strategy that uses a fibrate to increase HDL-C and lower triglyceride levels together with statin to lower LDL-C reduce the rate of CVD events compared with a strategy that uses a statin plus a placebo?” HDL Forum March 2010

ACCORD Trial: Design Randomized, double-blind trial 5,518 high-risk patients with controlled type 2 diabetes mellitus at LDL-C goal Randomization to combination fenofibrate-simvastatin treatment versus simvastatin-placebo HDL Forum March 2010

The ACCORD Study Group. N Engl J Med 2010;362:1563-1574. ACCORD Trial: Lipid Changes The ACCORD Study Group. N Engl J Med 2010;362:1563-1574.

The ACCORD Study Group. N Engl J Med 2010;362:1563-1574. ACCORD Trial: Kaplan–Meier Analyses of the Primary Outcome, Expanded Macrovascular Outcome, and Death. The ACCORD Study Group. N Engl J Med 2010;362:1563-1574.

REDUCE-IT REDUCE-IT is the first ever conducted prospective outcomes study in a Western population of the effect of lowering triglycerides in patients who despite statin therapy have above normal triglyceride levels. Started December 2011 and by November 2014, >7,100 patients had been enrolled in REDUCE-IT. The study plan provides for enrollment of an aggregate of approximately 8,000 patients, expected to be completed in 2015. The REDUCE-IT study will be completed after reaching an aggregate number of cardiovascular events. Based on current projections, completion expected in or about 2017 with results expected to be available in 2018. Amarin estimates that mean and median baseline triglyceride levels for patients enrolled in this study will exceed 200 mg/dL.

STRENGTH Trial AstraZeneca is committed to assessing the impact of lowering triglycerides and further evaluating the clinical profile of EPANOVA. A large-scale CVD endpoint trial, STRENGTH (a long–term outcomes study to assess STatin Residual risk reduction with EpaNova in hiGh cardiovascular risk paTients with Hypertriglyceridemia), will evaluate the safety and efficacy of EPANOVA on cardiovascular outcomes in combination with statin therapy in patients with mixed dyslipidemia at increased risk of cardiovascular disease. ClinicalTrials.gov. Outcomes Study to Assess STatin Residual Risk Reduction With EpaNova in HiGh CV Risk PatienTs With Hypertriglyceridemia (STRENGTH). http://clinicaltrials.gov/ct2/show/NCT02104817?term=strength+epanova&rank=1 Accessed April 29, 2014.