THE SAPPHIRE STUDY - United Therapeuticsir-scienceday.unither.com/...SD2018_SAPPHIRE_Jordan_Shin_Final_0… · THE SAPPHIRE STUDY Jordan Shin MD, PhD Medical Director, Lung Biotechnology

PROGENITOR NO CORUNDUM

THE SAPPHIRE STUDY

Jordan Shin MD, PhD Medical Director, Lung Biotechnology PBC

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UTHR Science Day 2018 / SAPPHIRE / Jordan Shin

SAFE HARBOR STATEMENT

Remarks today concerning United Therapeutics may include forward-looking statements which represent United Therapeutics’ expectations or beliefs regarding future events. We caution that such statements involve risks and uncertainties that may cause actual results to differ materially from those in the forward-looking statements. Consequently, all such forward-looking statements are qualified by the cautionary language and risk factors set forth in United Therapeutics’ periodic and other reports filed with the SEC.

There can be no assurance that the actual results, events or developments referenced in such forward-looking statements will occur or be realized. United Therapeutics assumes no obligation to update these forward-looking statements to reflect actual results, changes in assumptions or changes in factors affecting such forward-looking statements.

This presentation and any related discussions or statements are intended to educate investors about our company. Sometimes that process includes reporting on the progress and results of clinical trials or other developments with respect to our products. This presentation and any related discussions or statements are not intended to promote our products, to suggest that our products are safe and effective for any use other than what is consistent with their FDA-approved labeling, or to provide all available information regarding the products, their risks, or related clinical trial results. Anyone seeking information regarding the use of one of our products should consult the full prescribing information for the product available on our website at www.unither.com.

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Illegitimi non carborundum

RUNNING DOWN THE CORRIDORS OF INDIFFERENCE

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Illegitimi non carborundumMOCK LATIN

» Carborundum: industrial abrasive » General “Vinegar” Joe Stilwell (WWII)


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» Carborundum: industrial abrasive » General “Vinegar” Joe Stilwell (WWII) » Progenitor

» NO » Corundum


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» Carborundum: industrial abrasive » General “Vinegar” Joe Stilwell (WWII) » Progenitor

» NO » Corundum

» EPCs » Nitric Oxide » Sapphire


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HISTORY OF NO

1992

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HISTORY OF NO

1992 NOBEL PRIZE 1998

Robert F. Furchgott, PhD

Ferid Murad, MD, PhD

Louis J. Ignarro, PhD

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HISTORY OF NO

1992 NOBEL PRIZE 1998




Salvador Moncada, MD, PhD, FRS

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HISTORY OF NO

1992NOBEL PRIZE 1982 NOBEL PRIZE 1998

Nobel Prize: 1998

Dr. John R. Vane, FRS




Salvador Moncada, MD, PhD, FRS

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WHY IS NO BENEFICIAL IN PAH?

VASOCONSTRICTION THROMBOSIS REMODELING

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NO DEFICIENCY PLAYS AN IMPORTANT ROLE IN THE PATHOBIOLOGY OF PAH

NO PRODUCTION IS DECREASED IN PAH1

eNOS IS DOWNREGULATED BY TRANSCRIPTIONAL AND POST-TRANSLATIONAL MODIFICATIONS

» Profiling

AUGMENTATION OF ENDOGENOUS NO SIGNALING PROVIDES MEANINGFUL BENEFIT IN PAH

» PDE5 inhibition and sGC activators

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NO DEFICIENCY PLAYS AN IMPORTANT ROLE IN THE PATHOBIOLOGY OF PAH2

» eNOS is expressed widely in normal lungs

» Loss of NO production occurs via:

» transcriptional down regulation » post-translational modification

» Net result is loss of NO effect

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NO DEFICIENCY PLAYS AN IMPORTANT ROLE IN THE PATHOBIOLOGY OF PAH3

L-Arginine L-CitrulineNOS

↓NO

sGC

cGMPGMP

↑PDEs

PDE5 inhibitor

VASODILATION AND ANTIPROLIFERATION

Pro-endothelin FragmentsECE

↑Endothelin

Endothelin-receptor antagonists

↑ET-A receptor ↑ET-B receptor

VASOCONSTRICTION AND PROLIFERATION

Arachidonic acid ProstaglandinsCOX

↓Prostacyclin (PGI2)

AC

Prostacyclin derivatives

cAMP

VASODILATION AND ANTIPROLIFERATION

↓ | Downregulation in PHSmooth muscle ↑ | Upregulation in PH

NO/SGC/CGMP PATHWAY ENDOTHELIN PATHWAYPROSTACYCLIN PATHWAY

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HYPOTHESIS FOR SAPPHIRE

SAPPHIRE ALSO TESTS ADDITION OF EPCS AS

PART OF THAT TREATMENT. SO IT IS NO + EPCS

RESTORING HIGHER LEVELS OF NOS ENZYME WILL IMPROVE

PHYSIOLOGY IN PAH

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The endothelial progenitor cell loop in the pathobiology of pulmonary hypertension

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EPCs MAY ALSO BENEFIT IN PAH4

©2010 by European Respiratory Society

Vascular healing: Disease prevention or reversion

Vascular remodeling: Disease development or progression

ENDOTHELIAL DAMAGEGenetic background HypoxiaInflammationOxidative stressAutoimmunity

PROGENITOR CELL MOBILIZATION

Systemic hypoxemiaVEGFSDF-1a

PROGENITOR CELL HOMING AND ENGRAFTMENTEndothelial healing / intimal hyperplasia

Smooth muscle cell proliferationAngiogenesis

IL-1

SDF-1

IL-6

CCL-2

TNF

IL-8

VEGF

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eNOS: A possible angiogenic cell therapy for PAH

PROOF OF CONCEPT5

A

A

RVSP

(mm

Hg)

CONTROL MCT D21 MCT-eNOS D35

70.060.050.040.030.020.010.0

0

Day 21Day 35

MCTNormal

- +pcDNA

+pVEGF165

+peNOS

*†

*†

ENOS: A POSSIBLE ANGIOGENIC CELL THERAPY FOR PAH

Zhao et al. AJRCMB VOL 35 2006

Days

Control MCT D21 MCT-eNOS D35

8

peNOS

GAPDH

control peNOS

pcDN

AENOS: A POSSIBLE ANGIOGENIC CELL THERAPY FOR PAH

Zhao et al. AJRCMB VOL 35 2006

Days

Control MCT D21 MCT-eNOS D35

8

pVEGF

GAPDHpc

DNAcontrol pVEGF

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STUDY PHACeT6

5 YEARSstudy period

N=7SEVERE PAH

2 CLINICAL SITES

NCT00469027eNOS TRANSFECTED EPCs

PRIMARY OBJECTIVE

Tolerability and safety of injection of genetically engineered progenitor cells [ Time Frame: 5 years ]

Changes in hemodynamic pressures, patient perceived quality of life and exercise capacity [ Time Frame: 3 month post cell delivery ]

SECONDARY OBJECTIVE

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Restoring nitric oxide enzyme in PAH patients using their cells

EXAMPLE

LEUKAPHERESIS

ISOLATE EPCs FROM PATIENT (DAY 0)

Red blood cells

Endothelial progenitor cells(EPCs)

eNOS gene

Transfection

Cell culture flask

How cell therapy works?

CELL THERAPY7

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EXAMPLE

LEUKAPHERESIS


Red blood cells


eNOS gene

Transfection MANUFACTURING PROCESS

1

Cell culture flask

PURIFY EPCs


CELL THERAPY7

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EXAMPLE

LEUKAPHERESIS


Red blood cells


eNOS gene


1

2

Cell culture flask

PURIFY EPCs

EXPAND 2000X & ADD eNOS GENE

(DAY 1-26)


CELL THERAPY7

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EXAMPLE

LEUKAPHERESIS


Red blood cells


eNOS gene


FREEZE CELLS FOR FUTURE USE

1

2

3

Cell culture flask

PURIFY EPCs


(DAY 1-26)


CELL THERAPY7

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EXAMPLE

LEUKAPHERESIS


Red blood cells


eNOS gene


FREEZE CELLS FOR FUTURE USE

1

2

3

Cell culture flask

PURIFY EPCs


(DAY 1-26)

INFUSION

DELIVER MONTHLY DOSES IV


CELL THERAPY7

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Minicircle vs. plasmid DNA transfection of EPCs

CELL THERAPY

PARENTAL PLASMID

Tran

sgene

attB

attP

KanR

pUC ORI

P

SV40 poly-A

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CELL THERAPY

+ ARABINOSEPARENTAL PLASMID

Tran

sgene

attB

attP

KanR

pUC ORI

P

SV40 poly-A

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CELL THERAPY

MINICIRCLE

attR

P

SV40 poly-A

Transgene


Tran

sgene

attB

attP

KanR

pUC ORI

P

SV40 poly-A BACTERIAL

BACKBONE attL

Degradation

32x Sce-I Sites

KanR

pUC ORI

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CELL THERAPY

MINICIRCLE

attR

P

SV40 poly-A

Transgene

0

10

20

30

40

Fold-

increa

se in

eNOS

(norm

alized

to be

ta act

ion)

Empty Vec

tor

PVAX-eNOS

PVAX-eNOS

minicircle-

eNOS

minicircle-

eNOS

24 HOURS 72 HOURS

*

*

BACTERIAL BACKBONE attL

Degradation

32x Sce-I Sites

KanR

pUC ORI


Tran

sgene

attB

attP

KanR

pUC ORI

P

SV40 poly-A

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SAPPHIRE STUDY*Study of Angiogenic Cell Therapy for Progressive Pulmonary Hypertension: Intervention With Repeat Dosing of eNOS-enhanced EPCs

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Prevalence of WHO-Functional Classes (FC)8

EPIDEMIOLOGY OF WHO GROUP 1 PAH

FC II-IV

PAH40,000 patients in U.S. have PAH

42%FC II

35%FC III

6%FC IV

17%FC I

83%

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SCOPE OF THE PROBLEM

MAIN INCLUSION CRITERIA

Male or female18-80 years

on appropriate stable therapy for at least 3 months prior to

the screening period

WHO FUNCTIONAL CLASS » Idiopathic or familial PAH

» Scleroderma associated PAH

» Anorexigens/toxins

» Associated with CHD

II III IV

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12-MONTHStreatment period

N=45SYMPTOMATIC PAH

9 CLINICAL SITES

RANDOMIZE 1:1:1 | 3 ARMS

NCT03001414The SAPPHIRE Trial will use autologous progenitor cell-based gene delivery to enhance lung microvascular repair and regeneration in patients with severe symptomatic PAH

SAPPHIRE STUDY

STUDY DESIGN AND TREATMENT

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SAPPHIRE STUDY

STUDY DESIGN AND TREATMENT

12-MONTHStreatment period

9 CLINICAL SITES

RANDOMIZE 1:1:1 | 3 ARMS

NCT03001414The SAPPHIRE Trial will use autologous progenitor cell-based gene delivery to enhance lung microvascular repair and regeneration in patients with severe symptomatic PAH

KEY CLINICAL ASSESSMENTS

TREATMENT PLAN

N=45SYMPTOMATIC PAH

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SAPPHIRE STUDY

KEY CLINICAL ASSESSMENTS

PRIMARY ENDPOINT

6MWD AT 6 MONTHS

» 6MWD at 12 months

» Hemodynamic parameters

» Time to clinical worsening (combined morbidity/mortality)

» RV function by echocardiography

» RV function/lung perfusion by MRI (subgroup)

SECONDARY ENDPOINT

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SAPPHIRE TREATMENT PLAN

COURSE 2

eNOS-EPC 20M cells/dose

Apheresis

Placebo (Saline)

Randomization

ARM 1: PLACEBO ARM 1: TOTAL 80M CELLS

ARM 2: 80M CELLS ARM 2: TOTAL 80M CELLS

ARM 3: 80M CELLS ARM 3: TOTAL 160M CELLS

0 1 2 3 4 5 6 7 8 9 10 11 12-1

CELL MANUFACTURING

1°EP ANALYSISCOURSE 1

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KEY INNOVATIONS

USE OF MINI CIRCLES FOR GENE THERAPY/

RESTORATION

INNOVATIVE CELL AND GENE THERAPY FOR PAH

1 2

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CELLULAR THERAPIES IN THE FUTURE

» Living cells that treat from within, without peak and through and under physiologic control

» CT increase dose interval from minutes to weeks

» CT designed to target only diseased tissue

» Highly specific, delivering pM doses locally rather than uM doses systematically

Brain 10%

Breast 10%

Lung 10%

Head and Neck 7%

Colorectal 7%

Liver 7%GI System 6%

Prostate 6%

Skin 5%

Esophagus 4%

Urinary System 4%

Kidney 3%

Nervous System 3%

Other 10%

Pancreas 3%

Ovary 3%

355 SINGLE GENE

TARGETS

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REFERENCES

1. Tonelli Profiling Nitric Oxide Metabolites in Patients with Idiopathic Pulmonary Arterial Hypertension. Rui Zhang, et al. ERJ Nov 2016, 48 (5) 1386-1395.

2. Am J Physiol Lung Cell Mol Physiol. 2016 Jun 1; 310(11): L1199–L1205. Supporting downregulation of NO.

3. Humbert M, et al. Circulation 2014:130:2189-2208

4. G. P. Fadini et al. Eur Respir J 2010;35:418-425

5. Zhao et al. AJRCMB VOL 35 2006.

6. J Granton et al. Circ Res. 2015 Sep 11;117(7):645-54.

7. Adapted from Callahan et. Al. Severe Immune Complication Committee (SICC), MGH and the U.U. FDA

8. United Therapeutics Internal Market Research.

*The SAPPPHIRE study is being conducted entirely in Canada, and is sponsored by Northern Therapeutics, Inc., a Canadian entity in which UT has a 49.7 percent voting stake and a 71.8 percent financial stake. UT has the exclusive right to pursue this technology in the United States, and plans to seek FDA approval of Aurora-GT if SAPPHIRE is successful.

THANK YOU

Documents

THE SAPPHIRE STUDY - United Therapeuticsir-scienceday.unither.com/...SD2018_SAPPHIRE_Jordan_Shin_Final_0… · THE SAPPHIRE STUDY Jordan Shin MD, PhD Medical Director, Lung Biotechnology