Eric BruckertHôpital Pitié-Salpêtrière

Paris

Thérapeutique des hyperchylomicronémies Thérapeutique des hyperchylomicronémies par déficit en LPLpar déficit en LPL

Perspectives de thérapie géniquePerspectives de thérapie génique

Conflict of interest. EB has received fees for presentation and participation to advisory boards from Astra Zeneca, MSD, AMT, GSK, Genzyme, Sanofi Aventis, Novo Nordisk, Lilly, Pfizer, Takeda.

Capillary endothelium Muscle

Lipoprotein Lipase (LPL): Mechanism of action

• LPL is synthesized e.g. in muscle cells and transported and bound to the capillary endothelium

• At the endothelium, LPL breaks down triglycerides from chylomicrons/VLDL; resulting free fatty acids (FFA) are absorbed by underlying tissues for energy and storage

• LPL (w/remnants) (downstream) promotes lipoprotein clearance

HeparanSulphate/GPIHBP1 LPL ApoCII

LPLD is a severe disease

• Pancreatitis (potentially lethal)• Diabetes mellitus • Atherosclerosis ?• Hyperviscosity syndrome

• (Other) Presenting S&S:• Lipaemia • Lipaemia retinalis• Abdominal pain• Hepatosplenomegaly• Xanthomas

Lipemia retinalis

Eruptive xanthomas

• Current management ineffective:- low fat diet does not eliminate complicationsentirely and niacin/fibrates/statins do not lower lipids significantly

Pancreatitis over 350 times more common in LPLD than in healthy

controls

0

50

100

150

200

250

300

350

400

Severe HyperTG (> 10.0 mmol/L)n = 354

Moderate HyperTG (5.0 - 9.0 mmol/L)

n = 487

Alln = 354

LPLD onlyn = 28

15.8 ± 16.3 (0.008)

55.8 ± 56.9(< 0.001)

361.4 ± 401.2(< 0.001)

Od

d R

atio

± S

E(p

-val

ue)

Gaudet et al Atherosclerosis Suppl 2010

fat intake

high levels of newly-formed chylomicrons in circulation post meal

lodging of aggregates in capillaries

- reduced blood flow

- oedema

- increased pressure

acute pancreatitis

Postprandial Chylomicronemia Causes Pancreatitis in LPL Deficiency

How Glybera Works

Persistent Gene

Expression

Systemic LPL Activity

Improved CM

Metabolism

IM Injection Glybera

LPL Protein in Muscle

Glybera: Adeno Associated Virus derived vector

Naturally occurring human gain-of-function LPL gene variant

Reduced Risk of

Pancreatitis

Glybera Administration

Injections ultrasound or electro-physiologically guided Spinal anesthesia

Objectives clinical studies

• To assess safety profile of AMT-010/AMT-011 (Glybera)• Triglyceride levels down on top of a low fat diet

– Bring fasting TG to a level less than or equal to 10 mmol/l (890 mg/dL)OR

– Reduce median fasting plasma triglyceride concentration (vs PREP-study result) by 40%

Secondary objectives• To determine the biologic activity and expression of LPLS447X

• To evaluate potential immune responses against LPLS447X and AAV vector

• To assess shedding of AMT-010/011

Safety Profile

• Glybera was well tolerated– Most adverse events were transient and related to

administration procedure itself (edema, bruising, sensitivity)

– All but 4 of 27 LPLD patients are continuing in (follow up) studies (1 withdrawal for personal reasons, 1 lost to follow up, 2 deaths during long term follow up)

– No functional or biochemical or MRI changes of injected muscle; muscle biopsies show minor signs of cellular infiltrate 3-12 months post injection

• Transient shedding indicating rapid vector clearance

• No clinically relevant immune responses

TG in CT-AMT-011-01 over time

Injected muscle Non-injected muscle

Yet, Persistent LPL expression after TG reversal

3x1011 gc/kg

(subj007)

3x1011 gc/kg

(subj008)

(32 weeks after administration)

(26 weeks after administration)

CT AMT-010

Immunohistochemistry using specific anti-LPL antibody (5D2)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0 5 10 15 20 25

Glybera Reduces Postprandial Chylomicronemia

– Reduced circulating levels of newly-formed chylomicrons (CM) for 24 hours following intake of fat

» indicative of systemic LPL

» providing plausible mechanistic explanation for a reduction in pancreatitis risk

– All tested patients showed a persistent response

Time after meal (hrs)

N=5

N=5

PRE

POST (wk 52)

POST (wk 14)

N=3

CM

-[3H

]-A

ctiv

ity

Bruckert - Glybera | 25 May 2011 | CONFIDENTIAL

SLIDE 13

SLIDE 13

SLIDE 13

Reduction of risk of events adjudicated as definite, probable pancreatitis & abd. pain

•

– Consistent 56 - 67% risk reduction

– p-values 0.001 - 0.007

0 1.00.2 0.4 0.6 0.8 1.2

3 Years

4 Years

5 Years

6 Years

7 Years

8 Years

9 Years

10 Years

Hazard Ratio with 95 % Confidence Interval

2 Years

1 Year

p < 0.001

p = 0.001

p < 0.001

p < 0.001

p < 0.001

p < 0.001

p < 0.001

p < 0.001

p = 0.007

p = 0.019

Reduction of risk of events adjudicated as definite and probable pancreatitis

0 1.00.2 0.4 0.6 0.8 1.2

3 Years

4 Years

5 Years

6 Years

7 Years

8 Years

9 Years

10 Years

Hazard Ratio with 95 % Confidence Interval

2 Years

p = 0.010

p = 0.010

p = 0.008

p = 0.025

p = 0.007

p = 0.017

p = 0.023

p = 0.026

p = 0.043

1 Year p = nsTreatment not selected

– Consistent 62 - 69% risk reduction

– p-values 0.007 - 0.043

Reduction of risk of events adjudicated as definite pancreatitis

0 1.00.2 0.4 0.6 0.8 1.2

3 Years

4 Years

5 Years

6 Years

7 Years

8 Years

9 Years

10 Years

Hazard Ratio with 95 % Confidence Interval

p = 0.087

p = 0.044

p = 0.032

p = 0.077

p = 0.061

p = 0.040

p = 0.042

p = 0.070

2 Years p = ns

1 Year p = ns

Treatment not selected

Treatment not selected

– Consistent 51 - 59% risk reduction

– p-values 0.032 - 0.087

Conclusion

• First gene therapy in hyperchylomicronemia

• Well tolerated

• Transient effect on circulating Tg

• Effect on pancreatitis leading to new hypothesis on the role of chylomicron on pancreatitis