1. Slide 1 Downloaded from www.ezetrol.aewww.ezetrol.ae Cholesterol Absorption and the Mechanism of Action of Ezetimibe

2. Slide 2 Downloaded from www.ezetrol.aewww.ezetrol.ae Ezetimibe: First New Therapy for Hyperlipidemia in 15 years Niacin, 1955 Bile acid sequestrants, 1961 Fibrates, 1967 Statins (HMG-CoA reductase inhibitors), 1987 Cholesterol absorption inhibitor (ezetimibe), 2002 Adapted from Bays H Expert Opin Investig Drugs 2002;11:1587–1604; Mahley RW, Bersot TP. In: Goodman and Gilman’s The Pharmacological Basis of Therapeutics 10th ed. New York: McGraw Hill, 2001:971–1002; Ginsberg HN, Goldberg IJ. In Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill, 1998:2138–2149; Van Itallie TB et al N Eng J Med 1961;265:469–474; Altschul R et al Arch Biochem 1955;54:558–559.

3. Slide 3 Downloaded from www.ezetrol.aewww.ezetrol.ae Two Sources of Cholesterol: Synthesis and Absorption Fecal bile acids and neutral sterols (~700 mg/day) Extrahepatic tissues *And extrahepatic tissue Adapted from Champe PC, Harvey RA. In Biochemistry. 2nd ed. Philadelphia: Lippincott Raven, 1994; Glew RH. In Textbook of Biochemistry with Clinical Correlations. 5th ed. New York: Wiley-Liss, 2002:728–777; Ginsberg HN, Goldberg IJ. In Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill, 1998:2138–2149; Shepherd J Eur Heart J Suppl 2001;3(suppl E):E2–E5; Hopfer U. In Textbook of Biochemistry with Clinical Correlations. 5th ed. New York: Wiley-Liss, 2002:1082–1150; Bays H Expert Opin Investig Drugs 2002;11:1587–1604. Biliary cholesterol (~1000 mg/day) Absorption (~700 mg/day) Liver Synthesis* (~800 mg/day) Intestine Dietary cholesterol (~300–700 mg/day)

4. Slide 4 Downloaded from www.ezetrol.aewww.ezetrol.ae The Efficiency of Cholesterol Absorption Regulates the Variation of Plasma Cholesterol Levels LDL-C=low-density lipoprotein cholesterol *p<0.02 vs. lowest decile; **Number of subjects in each group is 14. Adapted from Kesäniemi YA, Miettinen TA Eur J Clin Invest 1987;17:391–395. LDL-C (mmol/L)** 0 3.04.05.0 % Cholesterol absorption 0 40 45 50 *

5. Slide 5 Downloaded from www.ezetrol.aewww.ezetrol.ae Cholesterol Absorption in the Intestine 1000 mg NPC1L1 ACAT=acyl-coenzyme A:cholesterol acyltransferase; NPC1L1=Niemann-Pick C1 Like 1 Adapted from Champe PC, Harvey RA. In Biochemistry. 2nd ed. Philadelphia: Lippincott Raven, 1994; Ginsberg HN, Goldberg IJ. In Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill, 1998:2138–2149; Shepherd J Eur Heart J Suppl 2001;3(suppl E):E2–E5; Hopfer U. In Textbook of Biochemistry with Clinical Correlations. 5th ed. New York: Wiley-Liss, 2002:1082–1150; Davis JP et al Genomics 2000;65:137–145. Resins Plant stanols 300–700 mg

6. Slide 6 Downloaded from www.ezetrol.aewww.ezetrol.ae Niemann-Pick C1 Like 1 NPC1L1, identified in 2000, was a gene of unknown function related to Niemann- Pick C1 protein DNA sequence analysis predicted features of a hypothetical cholesterol transporter –Membrane protein expressed on cell surface –Homologous to Niemann-Pick C1 (a protein known to be involved in cholesterol movement) –Expression regulated by cholesterol –Sterol sensing domain Protein expression is restricted to the enterocytes of the proximal small intestine SSD OUT IN Adapted from Altmann SW et al Science 2004;303:1201–1204; Davis JP et al Genomics 2000;65:137–145.

7. Slide 7 Downloaded from www.ezetrol.aewww.ezetrol.ae NPC1L1 Expression Localized to the Surface of Enterocytes Adapted from Altmann SW et al Science 2004;303:1201–1204. Anti-NPC1L1 Rat jejunum Rat NPC1L1 Mouse NPC1L1 Human NPC1L1 0 100 Relative level of NPC1L1 mRNA 10 Tissues Liver Testis Small intestine Gall bladder Heart Stomach Ovary Lung Muscle Colon Brain Kidney Thyroid Adrenal Spleen

8. Slide 8 Downloaded from www.ezetrol.aewww.ezetrol.ae Ezetimibe: Localization at Site of Cholesterol Absorption Localizes at brush border of small intestine and prevents uptake of cholesterol into enterocytes Decreases delivery of intestinal cholesterol to liver resulting in – Up-regulation of LDL-C–receptor synthesis – Increased cholesterol clearance from the blood Adapted from van Heek M et al Br J Pharmacol 2000;129:1748–1754; Brown WV Am J Cardiol 2001;87(suppl):23B–27B; Sparrow CP et al J Lipid Res 1999;10:1747–1757. Absorption of cholesterol in intestine (hamster) Ezetimibe localization at intestinal brush border (rat)

9. Slide 9 Downloaded from www.ezetrol.aewww.ezetrol.ae Metabolism of Ezetimibe Rapidly metabolized to an active glucuronide metabolite Both parent drug and metabolite inhibit cholesterol absorption Glucuronide metabolite more potent than parent drug in inhibiting cholesterol absorption Repeated enterohepatic circulation results in long duration of action Adapted from van Heek M et al Br J Pharmacol 2000;129:1748–1754; Patrick JE et al Drug Metab Dispos 2002;30:430–437. OH OGluc O F N F Glucuronidation Glucuronide OH O F N F Ezetimibe

10. Slide 10 Downloaded from www.ezetrol.aewww.ezetrol.ae Cholesterol Absorption in NPC1L1 (–/–) Mice and in (+/+) Mice Treated with Ezetimibe *p<0.001 vs. +/+ and +/– +/+=wild-type mice; +/–=heterozygous mice; –/–=NPC1L1 null mice Adapted from Altmann SW et al Science 2004;303:1201–1204. 0 10 60 % Cholesterol absorption 20 30 40 +/–+/++/+ Ezetimibe –/– Ezetimibe 50 –/– * * * –69%

11. Slide 11 Downloaded from www.ezetrol.aewww.ezetrol.ae Effect of Ezetimibe on Atherogenesis in Apolipoprotein E Knockout Mice* ControlEzetimibe 5 mg/kg/day *Mice fed 0.15% cholesterol diet for six months Adapted from Catapano AL Eur Heart J Suppl 2001;3(suppl E):E6–E10; Davis HR Jr et al Arterioscler Thromb Vasc Biol 2001;21:2032–2038. Cross-sectional area of carotid arteries

12. Slide 12 Downloaded from www.ezetrol.aewww.ezetrol.ae Cholesterol Absorption Study Randomized, double-blind, placebo-controlled, two-period, crossover trial Primary objective: to assess the effect of ezetimibe on intestinal cholesterol absorption Secondary objectives: to assess the effect of ezetimibe on cholesterol synthesis and plasma concentrations of noncholesterol sterols Subjects: 18 male patients with mild to moderate hypercholesterolemia Entry criteria –Age, 18–55 years –LDL-C, 3.4–4.7 mmol/L (130–180 mg/dL) –TG, <2.8 mmol/L (250 mg/dL) –Dietary cholesterol intake, 200–500 mg/day TG=triglycerides Adapted from Sudhop T et al Circulation 2002;106:1943–1948.

13. Slide 13 Downloaded from www.ezetrol.aewww.ezetrol.ae Effect of Ezetimibe on Cholesterol Absorption Adapted from Sudhop T et al Circulation 2002;106:1943–1948. 0 10 20 30 40 50 70 80 54% Reduction in cholesterol absorption with ezetimibe Placebo % Cholesterol absorption at week 2 Ezetimibe 60 49.8% 22.7% Individual absorption rates Mean absorption rates

14. Slide 14 Downloaded from www.ezetrol.aewww.ezetrol.ae Effects of Ezetimibe on Plasma Lipids HDL-C=high-density lipoprotein cholesterol *Median values; **p<0.001 Adapted from Sudhop T et al Circulation 2002;106:1943–1948. Mean % change from baseline at 2 weeks Placebo Ezetimibe LDL-CHDL-CTG* Total cholesterol –25 –20 –15 –10 –5 0 5 –1.9 –15.1** 1.9 –5.2 2.7 0.5 –7.9 –20.4**

15. Slide 15 Downloaded from www.ezetrol.aewww.ezetrol.ae Effect of Ezetimibe on Sterol Excretion and Cholesterol Synthesis Adapted from Sudhop T et al Circulation 2002;106:1943–1948. Parameter, mg/day (mean ± SD) Cholesterol intake Neutral sterol excretion Acidic sterol excretion Cholesterol synthesis 500 1000 2000 0 2500 3000 +2% p=0.776 +89% p<0.001 1500 313 307 1718 999264 1763 931 308 +72% p<0.001 +17% p=0.068 Placebo Ezetimibe

16. Slide 16 Downloaded from www.ezetrol.aewww.ezetrol.ae Effect of Ezetimibe Plasma Plant Sterols Adapted from Sudhop T et al Circulation 2002;106:1943–1948. Placebo Ezetimibe 0.0 0.1 0.5 Sterol mg/dL (mean ± SD) Sitosterol 0.2 0.3 0.4 Compesterol 0.2310.183 –41% p<0.001 –48% p<0.001 0.4430.312

17. Slide 17 Downloaded from www.ezetrol.aewww.ezetrol.ae Cholesterol Absorption Study: Summary and Conclusions Treatment with ezetimibe 10 mg/day –Reduced intestinal cholesterol absorption by 54% vs. placebo –Reduced LDL-C by 20.4% vs. baseline –Reduced total cholesterol by 15.1% vs. baseline Reductions in plasma plant sterol levels with ezetimibe were more pronounced than reduction in cholesterol, possibly reflecting different absorption rates versus cholesterol or lack of endogenous synthesis Decrease in cholesterol absorption with ezetimibe was accompanied by an increase in cholesterol synthesis Increased cholesterol synthesis during ezetimibe administration underscores the potential value of dual inhibition of cholesterol absorption and synthesis with coadministration of ezetimibe with a statin Adapted from Sudhop T et al Circulation 2002;106:1943–1948.

18. Slide 18 Downloaded from www.ezetrol.aewww.ezetrol.ae Ezetimibe: Summary of Pharmacokinetic Parameters Absorption –Rapidly absorbed after oral administration –Peak plasma concentration of active metabolite in 1–2 hours Elimination –Eliminated principally in feces after extensive enterohepatic recirculation –Elimination half-life of ~22 hours allows once-daily dosing No induction of CYP 450 enzyme system No significant pharmacokinetic interactions with commonly used drugs Bioavailability unaffected by food Pharmacokinetics unaffected by age or gender Adapted from Patrick JE et al Drug Metab Disp 2002;30:430–437; Summary of Product Characteristics, EZETROL™, MSP.

19. Slide 19 Downloaded from www.ezetrol.aewww.ezetrol.ae Key Benefits of Ezetimibe First of a new class of lipid-lowering drugs with unique mechanism of action –Inhibits absorption of dietary and biliary cholesterol –Reduces plasma LDL-C Coadministration with a statin provides Dual Inhibition of cholesterol absorption and cholesterol synthesis –Results in incremental improvement in LDL-C compared with statin alone –Improves TG and HDL-C Favorable safety profile Adapted from Ballantyne CM et al Circulation 2003;107:2409–2415; Bays H Expert Opin Investig Drugs 2002;11:1587–1604; Bays HE et al Clin Ther 2001;23:1209–1230; Davidson MH et al J Am Coll Cardiol 2002;40:2125–2134; Gagné C et al Am J Cardiol 2002;90:1084–1091; Kerzner B et al Am J Cardiol 2003;91:418–424; Kosoglou T et al Br J Clin Pharmacol 2002;54:309– 319; Leitersdorf E Eur Heart J Suppl 2001(Suppl E):E17–E23; Melani L et al Eur Heart J 2003;24:717–728; Shepherd J Eur Heart J Suppl 2001;3(Suppl E):E2–E5; Stein E Eur Heart J Supple 2001;3(Suppl E);E17–E23.

20. Slide 20 Downloaded from www.ezetrol.aewww.ezetrol.ae References Please see notes page.

21. Slide 21 Downloaded from www.ezetrol.aewww.ezetrol.ae Cholesterol Absorption and the Mechanism of Action of Ezetimibe Before prescribing, please consult the manufacturers’ prescribing information. MSP does not recommend the use of any product in any different manner than as described in the prescribing information. Copyright © 2004 MSP Singapore Company, LLC. All rights reserved. 9-05 EZT 2004-W-6131-SSPrinted in USA VISIT US ON THE WORLD WIDE WEB AT http://www.ezetrol.com