AUTOIMMUNE HEPATOBILIARY DISEASE: HOW TO IMPROVE TREATMENT EFFICACY

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1 AUTOIMMUNE HEPATOBILIARY DISEASE: HOW TO IMPROVE TREATMENT EFFICACY AISF Pre-Meeting 2015 Rome, 18 Feb Ana Lleo, MD PhD Liver Unit and Center for Autoimmune Liver Diseases Humanitas Clinical and Research Center

2 Il sottoscritto dichiara di non aver avuto negli ultimi 12 mesi conflitto d interesse in relazione a questa presentazione e che la presentazione contiene discussione di farmaci in studio o ad uso off-label

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4 Primary Biliary Cirrhosis: guidelines UDCA in a dose of mg/kg/day orally is recommended for patients with PBC who have abnormal liver enzyme values regardless of histologic stage (Class I, Level A).

5 Primary Biliary Cirrhosis: guidelines UDCA in a dose of mg/kg/day orally is recommended for patients with PBC who have abnormal liver enzyme values regardless of histologic stage (Class I, Level A). Pares A, Gastroenterology 2006

6 Primary Biliary Cirrhosis: unmet clinical needs Non-response to UDCA: criteria Author Endpoint criteria Non-response Barcelona ALP 40% decrease or normalization 39% Paris I ALP < 3 x ULN AST< 2 x ULN Bil < 1 x ULN 39% Paris II ALP < 1.5 x ULN AST< 21.5x ULN Bil < 1 x ULN 52% Toronto ALP < 1.67 x ULN 43%

7 Primary Biliary Cirrhosis: unmet clinical needs To assess the proportion of patients achieving: ALP <1.67x ULN (& 15% reduction) bilirubin ULN Responder Non-Responder The Global PBC Study Group (N=4845) confirmed ALP <1.67 xuln and normal bilirubin after 1 year of UDCA highly predictive of outcome 1 Lammers W, Lleo A et al. Gastroenterology. 2014

8 Primary Biliary Cirrhosis: multi-faceted pathophysiology Lleo A, J Hepatol 2012

9 Primary Biliary Cirrhosis: the future? Obeticholic acid: evaluating clinical outcomes in patients with PBC. Phase 3. Study of bezafibrate in combination with UDCA in PBC. Phase 3. Study of efficacy and safety of Ustekinumab in patients with PBC who had an inadequate response to UDCA Study of NGM282 extended treatment in patients with PBC. Apical Sodiumdependent Bile Acid Transporter Inhibitor (ASBTi), open label. UDCA plus budesonide versus UDCA alone in PBC High-protein high-fiber diet in patients with PBC Study of Abatacept to treat PBC (CTLA-4) Umbilical cord mesenchymal stem cells for patients with PBC IBAT Inhibitor A4250 for Cholestatic Pruritus ClinicalTrials.gov

11 Nuclear Receptors (FXR, PPARs): at the crossroad of metabolism, inflammation and regeneration Karpen, Trauner J Hepatol 2010

12 Farnesoid Receptor (FXR) protects against toxic effects of hydrophobic bile acids Courtesy of U. Beuers

13 Primary Biliary Cirrhosis: OCA Phase 2: Efficacy of OCA in Patients with PBC and inadequate response to UDCA Hirschfield G et al. Gastroenterology 2014

14 Primary Biliary Cirrhosis: OCA POISE: Phase 3 Trial Design If on UDCA: Continue UDCA Placebo (n=73) Randomization Strata Subjects stratified 1:1:1 by: 1) ALP >3x ULN and/or AST >2x ULN and/or total bilirubin >ULN (Paris I) 2) Not receiving UDCA treatment Screening OCA 10 mg (n=73) Titrate to OCA 10 mg (n=33) OCA 5 mg Remain at OCA 5 mg (n=37) 0 W2 M3 M6 M9 M12 OCA Titration at 6 Months: Patients in OCA titration arm titrated from 5 mg to 10 mg at Month 6 if they met any of the following criteria at the Month 6 assessment: 1. The primary endpoint (ALP >1.67x ULN or bilirubin >ULN) was not achieved; and 2. No evidence of tolerability issues, e.g. pruritus

15 Primary Biliary Cirrhosis: OCA POISE: Significant Reductions in ALP Within 2 Weeks % Drop in ALP *p< vs. placebo * p-values from an ANCOVA model with baseline value as a covariate and fixed effects for treatment and randomization strata factor. Data are least squares mean(se)

16 Primary Biliary Cirrhosis: OCA Placebo (n=73) Titration OCA (n=70) 10 mg OCA (n=73) n (%) n (%) n (%) Pruritus 28 (38%) 39 (56%) 50 (68%) Fatigue 10 (14%) 11 (16%) 17 (23%) Nasopharyngitis 13 (18%) 17 (24%) 13 (18%) Nausea 9 (12%) 4 (6%) 8 (11%) Diarrhoea 8 (11%) 2 (3%) 8 (11%) Arthralgia 3 (4%) 4 (6%) 7 (10%) Headache 13 (18%) 12 (17%) 6 (8%) Oropharyngeal pain 1 (1%) 5 (7%) 6 (8%) Cough 5 (7%) 4 (6%) 6 (8%) Constipation 4 (5%) 5 (7%) 5 (7%) Oedema peripheral 2 (3%) 2 (3%) 5 (7%) Influenza 4 (5%) 5 (7%) 4 (5%) Abdominal pain upper 5 (7%) 5 (7%) 4 (5%) Back pain 8 (11%) 4 (6%) 4 (5%) Upper respiratory tract infection 8 (11%) 4 (6%) 4 (5%) Urinary tract infection 8 (11%) 4 (6%) 4 (5%) Rash 3 (4%) 3 (4%) 4 (5%)

17 Primary Biliary Cirrhosis: OCA Highly statistically significant improvement in a biochemical endpoint strongly correlated with clinical outcome At 12 months, nearly 50% of patients are responders on primary endpoint Titration from 5 to 10 mg based on clinical response 1. improved tolerability, 2. minimized dropouts due to pruritus (only 1 dropout after titration), and 3. showed comparable efficacy to 10 mg OCA Long term safety and efficacy is currently being evaluated in an open label extension study (95% of patients at end of study entered the extension)

18 Primary Biliary Cirrhosis: Fibrates Bile duct protection UDCA UDCA+BF UDCA Nakai et al, Am J Gastroenterol 2000 Honda et al, Hepatology 2013 UDCA+BF

19 Primary Biliary Cirrhosis: Fibrates A substantial body of observational evidence has demonstrated that fibrate treatment ameliorated liver biochemical tests in patients with an incomplete response to UDCA treatment. Fibrate treatment has anticholestatic, anti-inflammatory, and antifibrotic properties in in-vitro and animal studies. These beneficial effects are mostly mediated via PPARa and PPARg, and possibly via PXR. The results of larger, multicenter, prospective, double- blind studies of fibrates plus UDCA, such as the BEZURSO trial that is now being conducted, are eagerly anticipated.

20 FXR PPARS Endogenous ligands Bile acids Fatty acids Drug ligands Obeticholic acid Other bile acid-mimetics Non bile acid ligands Fibrates Glitazones (γ) GFT-505 (αδ) Serum biochemistry Improved Improved Liver histology QOL Survival free of LTx No data (fibroscan) No data (surrogate parameters improved) Few cases improved (Fibroscan no change) No data Side effects Pruritus Myopathy, gallsones

22 Primary Biliary Cirrhosis: ASBTi Bile acids are synthesized in the liver from cholesterol Recovered from GI tract via the apical sodium bile acids transporter (ASBT) and returned to liver Facilitate digestion and absorption of dietary fats and fat-soluble vitamins. Regulate lipid and glucose metabolism Excess bile acids are associated with liver damage and pruritus

23 Primary Biliary Cirrhosis: ASBTi ASBT inhibition: Reduces serum bile acid levels Decreases serum and hepatic cholesterol Lowers plasma glucose Reduces insulin resistance Apical Sodium-dependent Bile Acid Transporter Inhibitor (ASBTi)

24 Primary Biliary Cirrhosis: ASBTi ASBT inhibition: Reduces serum bile acid levels Decreases serum and hepatic cholesterol Lowers plasma glucose Reduces insulin resistance Apical Sodium-dependent Bile Acid Transporter Inhibitor (ASBTi) SHP625 (LUM001) is a highly potent and selective, minimallyabsorbed ASBT inhibitor CLARITY: Phase 2, 13 week double blind, placebo-controlled study in combination with UDCA (n=60) US/CA/UK CASCADE: Phase 2, 2 year open label extension study (n=60)

25 Primary Biliary Cirrhosis: ASBTi ASBT inhibition: Reduces serum bile acid levels Decreases serum and hepatic cholesterol Lowers plasma glucose Reduces insulin resistance Apical Sodium-dependent Bile Acid Transporter Inhibitor (ASBTi) SHP625 (LUM001) is a highly potent and selective, minimallyabsorbed ASBT inhibitor CLARITY: Phase 2, 13 week Enrollment double blind, placebo-controlled study in combination with UDCA (n=60) US/CA/UK CASCADE: Phase 2, 2 year complete open label extension study (n=60)

26 Primary Biliary Cirrhosis: others Anti-IL2 Phase 2 Anti-CD20 Phase 2 Anti-CXCL10 Phase 2 Anti-TNF Case Report MSC Phase 2

27 Primary Biliary Cirrhosis: IL-12 IL12 Genetic defect Anti-IL12 Clinical trial Invernizzi et al Nature Genetics 2010 Ongoing trials Invernizzi P, Lleo A, et al. Nat Genetics 2010

28 Primary Sclerosing Cholangitis: unmet clinical needs A progressive fibroinflammatory cholangiopathy Ponsioen et al. Gut 2002

29 Primary Sclerosing Cholangitis: unmet clinical needs Last remaining black box of modern hepatology Michael Manns 2011 Ascending cholangitis Chronic liver failure Cholangiocarcinoma (10-15% lifetime prevalence) Gallbladder cancer (risk > x 160 times that gen pop)

30 Primary Sclerosing Cholangitis: guidelines UDCA in a dose of mg/kg/day orally is recommended for patients with PBC who have abnormal liver enzyme values regardless of histologic stage (Class I, Level A).

31 Primary Sclerosing Cholangitis: guidelines UDCA in a dose of mg/kg/day orally is recommended for patients with PBC who have abnormal liver enzyme values regardless of histologic stage (Class I, Level A). No currently identified medical treatment has been consistently shown to slow progression of disease

32 Primary Sclerosing Cholangitis: guidelines UDCA in a dose of mg/kg/day orally is recommended for patients with PBC who have abnormal liver enzyme values regardless of histologic stage (Class I, Level A). No currently identified medical treatment has been consistently shown to slow progression of disease

33 Primary Sclerosing Cholangitis: the future? Hirschfield et al. Lancet 2014 Liaskou et al. Hepatology 2011 Trivedi et al. J. Autoimmun. 2013

34 Primary Sclerosing Cholangitis: the future? Microbiome Bile acid metabolism Nuclear receptors Immune System Lymphocyte homing Complications Hirschfield et al. Lancet 2014 Liaskou et al. Hepatology 2011 Trivedi et al. J. Autoimmun. 2013

35 Primary Sclerosing Cholangitis: the future? Obeticholic acid A Phase 2, Randomized, Double-Blind, Placebo-Controlled, Dose- Finding, Clinical Trial Evaluating the Efficacy and Safety of OCA in PSC Norursodeoxycholic Acid in the Treatment of PSC Evaluation of the efficacy of different doses of nor UDCA vs. placebo for the treatment of Primary Sclerosing Cholangitis (PSC). Identification of optimal dose(s)for the treatment of PSC. A Trial of BTT1023 in patients with PSC human monoclonal antibody against the vascular adhesion protein (VAP-1) A Single Arm, Two-stage, Multi-centre, Phase II Clinical Trial Investigating the Safety and Activity of the Use of BTT1023 Study of NGM282 extended treatment in patients with PSC. Apical Sodiumdependent Bile Acid Transporter Inhibitor (ASBTi), open label. Simtuzumab (GS-6624) in the prevention of progression of liver fibrosis in subjects with PSC ClinicalTrials.gov

38 Primary Sclerosing Cholangitis: norudca Trauner M, J Hepatol 2013

40 Primary Sclerosing Cholangitis: Vedolizumab α4β7 integrin antibody

42 Primary Sclerosing Cholangitis: Simtuzumab A Phase 2b, dose-ranging, randomized, double-blind, placebo-controlled trial evaluating the safety and efficacy of simtuzumab Simtuzumab (GS-6624) humanized mab with an immunoglobulin IgG4 isotype specific to human LOXL2, which inhibits LOXL2 enzymatic activity. Lysyl oxidase like-2 (LOXL2) is an extracellular matrix enzyme that 1.has the potential to catalyze the oxidative deamination of the έ-amine group, covalent cross-linking of proteins such as collagen I and elastin leading to remodeling of the extracellular matrix 2. plays a central role in the development of pathologic stroma in fibrotic diseases by activating and recruiting fibroblasts to the pathologic site

43 Primary Sclerosing Cholangitis: Complications Cholangiocarcinoma Liver transplantation Stenosis Stenting Versus Balloon Dilatation

44 Autoimmune hepatitis Immunosuppressive treatment should be instituted in patients with: 1- AST or ALT levels greater than 10-fold ULN, 2- at least five-fold ULN + γ-globulin level at least 2-fold ULN, 3- and/or histological features of bridging necrosis or multilobular necrosis (Class I, level A) Due to a high mortality (60% at 6 month) if untreated. Kirk et al. 1980; Murray-Lyon et al Regimen: Prednisone (starting with 30 mg daily and tapering down) in combination with azathioprine (1-2 mg/kg) or a higher dose of prednisone alone (starting with mg daily and tapering down). The combination regimen is preferred, (Class I, Level A)

45 Autoimmune hepatitis: unmet clinical needs Despite immune suppression 40% of patients experience relapse and 9% undergo liver transplantation Costimuli Tr APC Th0 Class II IL4 IL12 Liver cell Th1 Class I IFNγ IL2 CTL M IL1 TNFα NK Th2 IL4 IFNγ IL10 IL13 B P

46 Autoimmune hepatitis: defective Tregs Longhi MS et al - Impairment of CD4(+)CD25(+) regulatory T-cells in autoimmune liver disease. J Hepatol. 2004;41:31-7 Costimuli Tr APC Th0 Longhi MS, et al. Effect of CD4+CD25+ regulatory T-cells on CD8 T-cell function in autoimmune liver disease. J Autoimmunity 2005;25:63-71 Longhi MS, et al. Functional study of CD4+CD25+ regulatory T-cells in health and autoimmune hepatitis. J Immunol. 2006;176: Longhi MS, et al. Expansion and de novo generation of potentially therapeutic regulatory T cells inpatients with autoimmune hepatitis. Hepatology. 2008;47: Longhi MS, et al. Vigorous activation of monocytes in juvenile autoimmune liver disease escapes the control of regulatory T-cells. Hepatology. 2009; 50: Longhi MS, et al. Auto-antigen-specific regulatory T-cells, a potential tool for immunetolerance reconstitution in type-2 autoimmune hepatitis. Hepatology. 2011; 53: Longhi MS, et al. Inhibition of interleukin-17 promotes differentiation of CD25 cells into stable T regulatory cells in patients with autoimmune hepatitis. Gastroenterology 2012;14: Liberal R, et al. The impaired immune regulation of autoimmune hepatitis is linked to a defective Galectin-9/Tim-3 pathway. Hepatology 2012;56:

47 CD4 CD25 Autoimmune hepatitis: defective Tregs

48 Autoimmune hepatitis: the future? CD4 and CD8 autoepitopes defined Correlation with disease activity Impairment of regulatory T cells Expand regulatory T cells Attempt new modes of treatment

49 AIH: first-in-human clinical trial T-regs T-regs T-regs semi-mature Courtesy of D. Vergani T-regs T-regs + DCs

50 Conclusions 1) There is a strong autoimmune component with a plausible mechanism for environmental triggering through neoantigen formation in a genetically susceptible individual 2) Cholestasis is an important modifier of the disease process and may drive ongoing bile duct destruction after an initial immune response 3) The mechanisms of injury, response and repair for BEC are complex but may offer important therapy opportunities

51 Acknowledgments Humanitas Clinical & Research Center - Pietro Invernizzi - Marco Carbone - Francesca Bernuzzi - Ilaria Bianchi - Mauro Podda - Chiara Raggi University of California - Davis - M. Eric Gershwin - Christopher L. Bowlus University of Birmingham - David H. Adams - Simon Afford

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