1. Emerging targets in HDL modification: Relevant data from development programs Prof. John Kastelein Academic Medical Centre Amsterdam, The Netherlands

2. 2 Novel Approaches to Modify Lipids and Lipoproteins  Low Density Lipoprotein  High Density Lipoprotein  Triglyceride Rich Lipoproteins  Inflammation  Lipoprotein a

3. 3 New Approaches for Raising HDL What is in development? Cholesterol Ester Transfer Protein (CETP) inhibitors ER-Niacin / Laropiprant combination ApoA1 based strategies LCAT replacement strategies ABCA1 agonists

4. 4 The Verdict is Still Out on CETP Inhibition as a Mechanism

5. 5 New Approaches for Raising HDL What is in development? Cholesterol Ester Transfer Protein (CETP) inhibitors ER-Niacin / Laropiprant combination ApoA1 based strategies LCAT replacement strategies ABCA1 agonists

6. 6 Nicotinic Acid Treatment of Dyslipidemia and Atherosclerosis  First used as lipid-altering agent in 1955  Well understood safety profile  Broad spectrum of lipid effects*  ↓LDL-C (15%–25%)  ↑HDL-C (20%–35%)  ↓TG (20%–40%)  ↓Apo B, non-HDL-C, Lp(a)  Cardiovascular (CV) benefits  ↓ CV events (Coronary Drug Project)  ↓ Plaque progression (angiographic and IMT studies)  Niacin added to a statin may address residual CV risk

7. 7 Most Patients on ER Niacin Therapy Do Not Reach a 2-g Dose 0 20 40 60 80 100 4 weeks N = 14,386 8 weeks n = 6, 349 12 weeks n = 5, 277 24 weeks n = 5, 402 1 year n = 2, 104 Users, % > 1500 mg 1001–1500 mg 751–1000 mg 501–750 mg  500 mg

8. 8 Effectiveness of 2 g vs 1 g of ER Niacin  Lipid-modifying efficacy generally seen with at least 1 g/day  Use of 2 g versus 1 g provides:  About twice the LDL-C reduction  About twice the HDL-C elevation  Several times the reduction of TG LDL-CHDL-CTG 1 g/day–9+15–11 2 g/day–17+26–35 NIASPAN™ US Prescribing information. Mean % change from baseline

9. 9 Niacin Flushing Pathway: Two Separate Steps and Sites of Action Illustrations are artistic renditions. PGD 2 =prostaglandin D 2 ; PLA 2 =phospholipase A 2 ; DP1=prostaglandin D 2 receptor 1. Benyó Z et al. Mol Pharmacol. 2006;70:1844–1849; Morrow JD et al. J Invest Dermatol. 1992;98:812–815; Cheng K et al. Proc Natl Acad Sci USA. 2006;103:6682–6687. 1. Epidermal Langerhans Cells Niacin binds PGD 2 is produced and released 2. Dermal Blood Vessels PGD 2 binds to DP1 Vasodilation results

10. 10 An Overview of the Niacin-Induced Flushing Pathway Niacin Receptor (+) Arachidonic Acid Phospholipids PGG 2 PGH 2 PGF 2α PGI 2 PGE 2 TXA 2 PLA 2 PGD Synthase Arachidonic Acid Pathway Epidermal Langerhans CellsDermal Blood Vessel PGD 2 DP1 PG=prostaglandin; PLA 2 =phospholipase A 2 ; TXA 2 =thromboxane A 2. Dashed arrows are normal parts of the arachidonic acid pathway that may or may not occur in Langerhans cells. Maciejewski-Lenoir D et al. J Invest Dermatol. 2006;126:2637–2646; Narumiya S et al. Physiol Rev. 1999;79:1193–1226; Cheng K et al. Proc Natl Acad Sci USA. 2006;103:6682–6687; Morrow JD et al. Prostaglandins. 1989;38:263–274. Prostaglandin D 2 Receptor 1 (DP1) Pathway PGD 2 Vasodilation and Flushing

11. 11 Lipid/Flushing Study: Lower Incidence of Moderate or Greater Flushing vs ER Niacin Percentage of patients with moderate or greater flushing symptoms across weeks 1–24 Average number of days per week with moderate or greater flushing symptoms across weeks 1–24 ER niacin (n = 508) ER niacin/laropiprant (n = 763) O Placebo (n = 268)

12. 12 ER Niacin/Laropiprant Lipid Efficacy (Weeks 12-24) Mean % change from Baseline HDL-C LDL-C TG (median) -1.2 19.8 18.8 -0.5 -18.1 -18.9 3.6 -21.2 -21.7 * * * * p<0.001 vs. Placebo Maccubbin et al. J Clin Lipidol 2007; 1: 323

13. 13 Factorial Study: Lipid Efficacy  ER niacin/laropiprant (n = 160)  Simvastatin (all doses pooled; n = 565)  ER niacin/laropiprant + simvastatin (all doses pooled; n = 520) Primary end point TG -33.3 -21.6 -14.7 0 4 812 % Change -40 -30 -20 -10 0 Weeks on Treatment HDL-C 27.5 23.4 0 4 812 % Change 0 10 20 30 Weeks on Treatment 6.0 LDL-C -17.0 -37.0 -47.9 0 4 812 % Change -60 -50 -40 -30 -20 -10 0 Weeks on Treatment

14. 14 ER niacin/laropiprant 2 g/40mg Placebo Patient PopulationSubjectsPrimary End Point  Age 50-80 History of MI or cerebrovascular atherosclerotic disease or PAD or diabetes mellitus with any of the above or with other evidence of symptomatic CHD  25,000  UK (n=8500), Scandinavia (n=6000) and China (n=10500)  Major vascular events (non-fatal MI or coronary death, non- fatal or fatal stroke or revascularisation) All patients receive either simvastatin 40mg or ezetimibe/simvastatin 10/40 mg HPS2-THRIVE (Heart Protection Study 2 – Treating HDL to Reduce Vascular Events)

15. 15 New Approaches for Raising HDL What is in development? Cholesterol Ester Transfer Protein (CETP) inhibitors ER-Niacin / Laropiprant combination ApoA1 based strategies LCAT replacement strategies ABCA1 agonists

16. 16 Where to Intervene in HDL-C Metabolism? Hovingh et al. Current Opinion in Lipidology 2005

17. 17 ApoA1 Based Therapies  ApoA1 Mimetics, such as APL-180 Novartis  Full-length ApoA1, such as ApoA1 Cerenis Therapeutics  Pre-Beta HDL, as generated by delipidation, HDL Therapeutics Inc.  Reconstituted HDL, CSL Ltd.  ApoA1 Milano, The Medicines Company  Trimeric ApoA1, Borean Pharma and now Roche  RVX-208, as developed by Resverlogix

18. 18 ApoA-I is made in the Liver and Small Intestines. Liver Small Intestines

19. 19 RVX-208 is an orally active, novel, and synthetic small molecule (<400 kDa) that shares similarities with the Quinazoline family of compounds. IT IS NOT RESVERATROL NOR A DERIVATIVE! RVX-208

20. 20 RVX-208 increases ApoA-I production, thus triggering HDL synthesis, especially pre-beta HDL known for its potent cholesterol efflux activity. ApoA -I Pool  -HDL 3 pre-  HDL  -HDL 2 RVX-208 Enhanced R.C.T.

21. 21 Schematic of Phase 1a Protocol Cohorts 1- 6 (42 treated and 14 placebo) Cohort 7 (12 treated and 4 placebo) Cohorts 8 - 9 (12 treated and 4 placebo) Cohort 10 (6 treated and 2 placebo) Single dose of RVX-208 (1-20 mg/kg), fasted Single dose of RVX-208 (4 mg/kg), fed Multiple doses x 7 days of RVX-208 (4 or 1 mg/kg), b.i.d., fasted Single dose x 7 days of RVX-208 (3 mg/kg), q.d., fasted A B C D 80 Subjects This color denotes multiple day dosing of RVX-208

22. 22 Efficacy of RVX-208 in Humans Phase 1b/2a ApoA-I, % Change vs. Placebo All SubjectsLow HDLNormal HDL DAY 8Day 28Day 8Day 28Day 8Day 28 1mg/kg5.11 ** 6.48*5.7*7.8*4.535.2 3mg/kg7.96***10.31***6.5**10.6**9.3***10.0* * p<0.05, ** p<0.01, *** p<0.001

23. 23 RVX208 α1-HDL Comparison vs. High Dose Statins α1-HDL Strongest Predictor from Framingham Offspring Study ** p<0.008 All Subjects Low HDL Subjects **

24. 24 Cerenis HDL (CER-001) Homogeneous Drug Product Traditional rHDL complexes Proprietary charged Cerenis rHDL complexes Validated, scaleable GMP process for producing proprietary charged lipoprotein complexes HDL GMP run

25. 25 CER-001-CLIN-001 : 15 mg/kg LCAT Activation

26. 26 CER-001 Mobilizes Cholesterol in Rabbits: Comparison with ETC-216 CER-001 is at least 10 to 20 time more potent to mobilize cholesterol than ETC-216 * ETC-216 data were extracted from Marchesi M. et al (2004) J Pharmacol Exp Ther, 311(3): p. 1023-31

27. 27 CHI SQUARE Study Design  4 Treatment Groups  Placebo  Low dose CER-001  Mid dose CER-001  High dose CER-001  6 doses per subject  125 subjects enrolled per group  Estimated 75 - 80% completion rate ==> ~98 subjects w/ follow-up IVUS per group

28. 28 N = 126Placebo N = 126Low dose N = 126Mid dose N = 126High dose Observation Period 2 to 5 weeks 504 Subjects Randomized 50 Sites Canada, US, France, Netherlands Core IVUS Lab Montreal Heart Up to 1000 Subjects Screened w/ Baseline IVUS following Acute ACS Event Screen Period 2 weeks IVUS Visit Screening Follow-Up IVUS Visit Infusion VisitsInterim Visit Therapy Period 5 weeks Long Term Follow-up 6 months Follow-Up Visit CHI-SQUARE Study Design

29. 29 CER-001-CLIN-001 Overall Conclusions  Administration of a single intravenous infusion of CER-001 at doses up to 45 mg/kg over 1 or 2 hours has been safe and well-tolerated  CER-001 exhibits the desired effect of cholesterol mobilization and is significantly more effective than earlier complexes

30. 30 Step 1 Collected~1 litre of plasma Step 2 Plasma enriched through process Step 3 Re-infused preβ enriched plasma Used patients own HDLUsed patients own HDL Cholesterol removed from αHDL to yield preβ-HDLCholesterol removed from αHDL to yield preβ-HDL Preβ enriched plasma is re-infused into patientPreβ enriched plasma is re-infused into patient IVUS clinical trial using selective delipidated HDL Walksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35.

31. 31 Treatment arm (N=14) Control arm (N=14) 1:1 randomization (N=28) Day 0 12345678 Week IVUSIVUS Treatment or control plasma infusion IVUS Clinical Trial Using Selective Delipidated HDL Walksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35.

32. 32 -14 Change in total atheroma volume Change in 10mm most diseased segment 4 2 0 -2 -4 -6 -8 -10 -12 -12.18 -6.24 -1.73 2.8 Change in atheroma volume (mm 3 ) Preβ-HDL infusion Control infusion Results of the IVUS Clinical Trial Using Selective Delipidated HDL Waksman R, et al. J Am Coll Cardiol 2010; 55 : 2727-35.

33. 33 Conclusion Therapies that raise levels of ApoA-I and pre-beta HDL carry a strong promise for the future of cardiovascular disease prevention

34. 34 New Approaches for Raising HDL What is in development? Cholesterol Ester Transfer Protein (CETP) inhibitors ER-Niacin / Laropiprant combination ApoA1 based strategies LCAT replacement strategies ABCA1 agonists

35. 35 LDL Peripheral tissues SR-BI LDL-R CETP mature HDL (large, α -HDL) nascent HDL (small, pre β -HDL) LCAT Kidney Liver Small HDL Clearance LCAT Product Gradient Drives Reverse Cholesterol Transport

36. 36 >75 gene mutations have been described resulting in two phenotypes >200 cases reported worldwide Familial LCAT Deficiency (FLD) Complete absence of LCAT activity in plasma Corneal opacities, anemia, proteinuria, renal failure Glomerulosclerosis a major cause of morbidity and mortality Fish Eye Disease (FED) Partial deficiency of LCAT activity in plasma Corneal opacities Current Treatments Dietary fat restriction ACE inhibitor, ARB’s Dialysis Kidney transplantation Corneal transplantation LCAT Deficiency in Humans

37. 37 LDL Peripheral tissues SR-BI LDL-R CETP mature HDL ( α -HDL) nascent HDL (Pre β -HDL) LCAT Lp-X Kidney Liver Decreased Increased Impaired RCT in Familial LCAT Deficiency

38. 38 Conclusion In the next five years, we will prove or disprove that additional LDL lowering with other agents than statins is effective and we will show or not show that the HDL hypothesis is true.