1. H. Bryan Brewer, Jr., MD Medstar Heart Institute
Update on HDL Infusions And Atherosclerosis Regression in the ACS Patients
H. Bryan Brewer, Jr., MD Medstar Heart Institute
Washington, DC

2. H. Bryan Brewer, MD
Consulting: Merck and Company, Inc., Roche, Sanofi-Aventis, Genentech, Pfizer, Inc., AstraZeneca
Honoraria: Merck and Company, Inc., Roche, Sanofi-Aventis, Eli Lilly and Company, and Pfizer, Inc.
Stocks, Stock Options, other ownership interest: The Medicines Company, InfraReDx, Inc, HDL Therapeutics

3. Acute HDL Therapy: Focus on Infusion of Preβ-HDL
Liver
Intestine
LDLr
CETP
LDL
CD36 SR-A
ABCA1
SR-BI
LCAT
A-I
αHDL
A-I
αHDL
Preβ-HDL
Lipid Filled Macrophage in the Heart
Acute HDL Therapy: Key - Infusion of Preβ-HDL
A-I

4. Acute HDL Infusion Therapy
2 Step Process for Production of Recombined HDL (rHDL)
Phospholipids
Synthesized ApoA-I 1
243 aa
rHDL
A-I
Clinical Trials
rHDL

5. HDL Infusions in ACS Patients
I. ApoA-I Milano

6. ApoA-I Milano Clinical Trial: Evaluation of Coronary Atherosclerosis by IVUS
Infusion of ApoA-I Milano Resulted in Regression of Atherosclerosis in Patients with the Acute Coronary Syndrome
Subjects: Acute Coronary Patients
Infusions: 5 Weekly Infusions ApoA-I Milano Infusion (15 mg/kg, n=12; 45 mg/kg, n=24; Saline Infusions)
Results: Regression – 14.1% Decrease in Total Atheroma Volume
Nissen et al JAMA 2003:290,
Nissen et al JAMA 2003:290,

7. Reduction in Atheroma Volume in Acute Coronary Syndrome Patients Following HDL Infusions
46 Acute Coronary Patients: 5 Weekly Infusions ApoA-I Milano Infusion; 11 Saline Infusions 2 4 6 8 10 14 16 - +
A-I Milano*
-14.10 - -
Change in Total Atheroma Volume (mm)3 - 12
-5.34 -
*Nissen S et al JAMA 2003;290:

8. ApoA-I Milano acquired by Pfizer
Medicines Company licensed ApoA-I Milano and is currently developing MDC0-216 in Phase I Trial

9. HDL Infusions in ACS Patients
I. ApoA-I Milano
II. CSL

10. Acute HDL Infusion Therapy:CSL111
2 Step Process for Production of CSL111 (ApoA-I/PL,rHDL) using Cholate Detergent
Phospholipids
Isolated ApoA-I from plasma 1
243 aa
Cholate Detergent
Clinical Trials
CSL111
CSL111 (αHDL)
A-I
Cholate

11. Gel Electrophoresis of CSL111 (rHDL)
Patel, S. et al. J Am Coll Cardiol 2009;53:

12. Reduction in Atheroma Volume in Acute Coronary Syndrome Patients Following HDL Infusions
183 Acute Coronary Patients: 4 Weekly Infusions, 123 Patients Received CSL111 rHDL Infusion; 60 Patients Control Infusions 2 4 6 8 10 14 16 - +
A-I Milano*
-14.10
-5.34
ERASE**
**Tardif JC et al. JAMA 2007;297: - -
Change in Total Atheroma Volume (mm)3 - 12
-5.34 -
*Nissen S et al JAMA 2003;290:

13. CSL has reformulated CSL111 and are currently developing CSL112

14. Phase I CSL112 (αHDL3) Infusions in Humans4 8 12 16 20 24
Hours
Cholesterol (mg/dl)
Free Cholesterol
Cholesteryl esters
Diditchenko S et al Presented at ISA 2012 Australia

15. HDL Infusions in the ACS Patient
I. ApoA-I Milano
II. CSL
III. Cerenis

16. Acute HDL Infusion Therapy:CER-001 ApoA-I/PL/ Sphingomyelin
2 Step Process for Production of CER-001 (ApoA-I,PL/Sphingomyelin) (αHDL)
Synthesized ApoA-I 1
243 aa
Phospholipids
+ Sphingomyelin
A-I
Clinical Trials
Cerenis-001
ApoA-I/PL/ Sphingomyelin
(αHDL)

17. Acute HDL Infusion Therapy
Effect of Cerenis CER-001 Infusion on Plasma Lipoproteins 4 8 12 16 20 24
Hours
Cholesterol (mg/dl)
Free Cholesterol
Cholesteryl esters

18. CHI SQUARE Clinical Trail
IVUS Analysis of the Effect of Cerenis CER-001 on Coronary Atherosclerosis
Control Arm
6 Infusions
? mg/kg
n =500+ 18

19. HDL Infusions in ACS Patients
I. ApoA-I Milano
II. CSL
III. Cerenis
IV. HDL Therapeutics

20. Synthesis of Ligands for the ABCA1 Transporter
2 Step Process for Production of rHDL
1 Step Process for Synthesis of Preβ-HDL
αHDL
Limitations of 2 Step Procedure
1. Low Yield
2. Safety
4. Cost
3. Preβ-HDL binds to the the ABCA1 Transporter, αHDL does not bind.
5. Regulatory Hurdles 1
243 aa
Synthesized ApoA-I
Phospholipids
Selective HDL Delipidation
A-I
Preβ-HDL
A-I
Clinical Trials
Selective HDL Delipidation
Clinical Trials
rHDL
rHDL

21. HDL Selective Delipidation
Increase Preβ Levels by Converting αHDL to Preβ-HDL
A-I
A-I
A-I
αHDL
Preβ-HDL
”Loaded Dump Truck”
“Unloaded Dump Truck” 21 21

22. Preβ Enriched Plasma Obtained by HDL Selective Delipidation
Plasma Bag 1 Plasma Collected
Preβ Enriched Plasma Obtained By Selective HDL Delipidation
A-I
αHDL Preβ-HDL 20% %
Plasma Bag 2 Preβ Enriched Plasma
A-I
A-I
αHDL Preβ-HDL 95% %
Preβ-HDL

23. 2-D Gel Electrophoresis of Control Plasma, Sham Treated Plasma and Selective HDL Delipidated Plasma Demonstrating a Shift from aHDL to preb-HDL with Selective HDL Delipidation
a HDL
a HDL
a HDL
Preb-1
Preb-1
Preb-1
Sham Treated
Plasma
Selective HDL
Delipidation
Control Plasma
Analysis performed by Dr. B. Asztalos, Tufts University Boston, MA

24. % Efflux Untreated Control)
ABCA1 AND SR-BI MEDIATED EFFLUX OF CONTROL PLASMA, SHAM TREATED PLASMA AND SELECTIVE HDL DELIPIDATED PLASMA
(% Efflux Treated/% Efflux Untreated Control)
ABCA1 Mediated Efflux
SR-BI Mediated Efflux
25.0
Control Serum
Sham Treated
Selective HDL
Delipidated Serum
20.0
15.0
% Efflux Untreated Control)
(% Efflux Treated/
10.0
5.0
1.0
0.0
Analysis performed by Dr. G. Rothblat

25. Step 1 Collected ~1 Liter of Patients Plasma
HDL Therapeutics Human Trial: Conducted Using Autologous Preβ-HDL Enriched Plasma
Step Collected ~1 Liter of Patients Plasma
Step 2
Cholesterol removed from αHDL to yield preβ-HDL
Step 3 Re-infused Preβ Enriched Plasma 25

26. HDL Selective Delipidation***
Reduction in Atheroma Volume in Acute Coronary Syndrome Patients Following HDL Infusions
28 Acute Coronary Patients: 7 Weekly Infusions, 14 Received Delipidated HDL and 14 Control Plasma Infusions 2 4 6 8 10 14 16 - +
HDL Selective Delipidation***
***Waksman R et al J. Am. Coll Card 2010;55: C
-12.10
A-I Milano*
-14.10
-5.34
ERASE**
**Tardif JC et al. JAMA 2007;297: - -
Change in Total Atheroma Volume (mm)3 - 12
-5.34 -
*Nissen S et al JAMA 2003;290:

27. Acute HDL Infusion Therapy Recombined Particle (rHDL)
Stage of Development
Recombined Particle (rHDL)
ClinicalData
Regulatory Pathway
Safety
ApoA-I Milano MDC-216
Phase I
?OK
αHDL
ApoA-I Milano IVUS decreases Athero
Biologic
CSL111/112
Phase I
? OK
αHDL
CSL-111 IVUS Decreases Athero
Biologic
Phase II
? OK
apoA-I/ PL/SPM ?
Cerenis CER-001
Drug
Phase III
Delipidated HDL Infusions OK
Preβ-HDL
IVUS Decreases Athero
Device

28. HDL Selective Delipidation**
Comparison of Change in Total Atheroma Volume in the HDL Infusion And Statin Saturn Trials 2 4 6 8 10 14 16 - +
HDL Infusion therapy
- 6.4
- 4.4
Atorvastatin
SATURN Trial***
Rosuvastatin
2.2 Years
Statin therapy
-12.10
HDL Selective Delipidation**
5 - 7 Weeks
-14.10
A-I Milano* - -
Change in Total Atheroma Volume (mm)3 - 12
-5.34 -
*Nissen S et al JAMA 2003;290:
**Waksman R et al J. Am. Coll Card 2010;55: C
***Nicholls SJ et al, N Eng J Med 2011;365:

29. Take Home Messages
HDL infusions in ACS patients were associated with marked regression of atherosclerosis.
HDL infusions for weeks had greater regression of atherosclerosis than 2.2 years of statin therapy in the Saturn Trial.
Clinical trials will be required to definitively establish if HDL infusions in ACS patients will decrease clinical cardiovascular events.