Hemophilia the Challenge for GeneTherapy

Hemophilia the Challenge for GeneTherapy

Hemophilia The Challenge for Gene Therapy MEMBER OF THE STEERING COMMITTEE FOR THE UNIQURE AMT-060 TRIAL: > Dr. Wolfgang Miesbach Hemophilia Center Clinic of the Johann Wolfgang Goethe University Frankfurt, Germany 2

Frankfurt Hemophilia Center Background > One of the largest hemophilia treatment centers in Germany > Treatment of patients with hemophilia, von Willebrand disease and other defects since 1970 s > Treatment of patients with thrombophilia or patients with ITP or TTP > Comprehensive care center (24 h care) > Extensive experience with surgical procedures in hemophilia patients 3

Hemophilia A and B FEATURES HEMOPHILIA A HEMOPHILIA B PREVALENCE 1 : 5,000 males 1: 30,000 males COMMON CLINICAL SYMPTOMS Haemarthroses, muscle haematoma Haemarthroses, muscle haematoma BLEEDING FREQUENCY/YEAR 12 30 12 30 (?) FVIII/FIX HALF-LIFE (H) 12 18 CLONING FACTOR GENE 1984 1982 MOLECULAR MASS PRIMARY STRUCTURE 265 kda 2332 amino acids 68 kda 265 amino acids MOST FREQUENT GENE DEFECT Intron 22 inversion Missense mutation INHIBITOR INCIDENCE (%) 25 30 3 5 4

Severe Hemophilia Spontaneous Bleeds, Joint Damage, Compliance MAIN MANIFESTATIONS > Joint bleeds > Chronic arthropathy > Disability SIGNIFICANT MEDICAL NEED > Frequent infusions of FIX / FVIII > Infusions are painful, require venous access > Prophylaxis is available only in countries that can afford it > Compliance > In-spite of current best standard of care patients still have bleeds 5

Current Treatment Approach COAGULATION FACTOR LEVELS SEVERITY OF DISEASE BLEEDING SYMPTOMS FVIII/IX < 1 % Severe Spontaneous FVIII/IX < 5 % Moderate Spontaneous and after trauma FVIII/IX > 5 % Mild After trauma or surgery CURRENT REPLACEMENT REGIMEN RISK OF BLEEDING INCREASES AT < 1% Collins, 2009 6

Non-adherence in Hemophilia Zappa S et al. Haemophilia 2012 May; 18(3):e140 153 7

Frequency of Discontinuation & Restarting of Prophylaxis In Adults with Severe Hemophilia COUNTRY PATIENTS DISCONTINUING PROPHYLAXIS (%) PATIENTS RESTARTING PROPHYLAXIS (%) USA 27/76 (36) 9/23 (39) EUROPE 92/218 (42) 26/92 (28) THE NETHERLANDS 18/58 (31) 0 DENMARK 10/22 (42) n.a. SWEDEN 3/42 (7) n.a. 8

Decrease the Burden of Treatment > Dosing interval > Route of administration > Immunogenicity > Safety profile > Long-acting therapies > Subcutaneous, intravenous etc. > Inhibitor development > Portability, devices, cost > Optimize individual treatment 9

Hemophilia Ideal Target for Gene Therapy > Molecular level well understood > Patients and treaters can be readily identified in specialist centers > Animal model exists > Single gene carried by various vectors > Correction of deficiency > 2% offers prospects of reducing bleeding tendency > Factor level in blood can be monitored easily 10

Factor IX Factor IX Hemophilia Gene Versus Replacement Therapy REPLACEMENT THERAPY 5% GENE THERAPY No spontaneous intermittent bleedings 5% 11

AAV8/FIX Single Intervention Reduces Need for Prophylactic Treatment (1) SUSTAINED, DOSE DEPENDENT EFFECT OVER > 4 YEARS AFTER A SINGLE INTERVENTION: > 4/6 high dose patients did not require further FIX treatment; 4/7 on prophylaxis could stop prophylaxis % Expression of normal 12 11 10 9 8 7 6 5 4 3 2 1 Low-dose Mid-dose High-dose Presented in New England Journal of Medicine 12/2011 Oral Presentation Patient 1 2 3 4 5 6 7 8 9 Patient 10 Disease Severity Mild Moderate Severe (1) Third party trial conducted by St. Jude s Children Research Hospital and UC London 12

AAV8/FIX Long-term Follow-up KEY POINTS: > 92% reduction of factor IX concentrate units used > Median annual bleeding episodes dropped from 15.5 to 1.5 (90%) Nathwani AC NEJM 2014; 371:1994 13

Inhibitor Formation in Hemophilia B > Inhibitors occur in 2-5% of patients with severe Hemophilia B on prophylactic therapy > Hepatic adeno associated viral (AAV) gene transfer in non-clinical studies may induce FIX specific immune tolerance (Cao et al, 2007; Dobrzynski et al, 2006; Mingozzi et al, 2003) > Clinical trials with liver directed AAV gene therapy support that FIX specific immune tolerance can be achieved > Whether pre-existing inhibitor can be reversed with AAV gene therapy remains to be determined 14

Clinical Trial with AAV5-FIX 15

Target Product Profile AAV5-FIX for the Treatment of Hemophilia B TARGET INDICATION: > Prevention of bleeding episodes (and to reduce the need for Factor IX replacement therapy) in patients with hemophilia B, plasma FIX activity <2% and with a history of frequent bleeding episodes requiring treatment with exogenous FIX or continuous FIX prophylaxis TARGET EXPRESSION LEVEL: <5% > Supported by non-clinical data: > NHP data support starting dose expression level close to 5% > Linear dose-response in NHP supports doubling potential of circulating FIX TARGET CLINICAL BENEFIT: 90% REDUCTION IN CONSUMPTION AND BLEEDING RATE > Supported by long-term follow-up data from Nathwani published in 2014 16

Target Product Profile AAV5-FIX for the Treatment of Hemophilia B TARGET SAFETY PROFILE > Absence of organ toxicity and no need for immune suppression rescue treatment > Supported by AAV5 safety data obtained at similar dose levels in AIP patients > Immune tolerance of endogenous expressed FIX protein without inhibitor response against FIX > Supported by non-clinical and clinical data suggesting immune tolerance can be achieved with gene therapy > Favorable long-term safety profile > Supported by long-term follow-up with UCL FIX gene cassette by Nathwani > Risk of carcinogenicity negligible > Established for AAV with Glybera 17

Objectives 18

AAV5/FIX Phase I/II Dose Escalation Study Protocol Based on Cross Referencing POPULATION AAV8 mammalian AAV5 insect cell > 10 patients (severe bleeding phenotype) > Severe (< 1% FIX) on prophylactic therapy > Moderate ( 2% FIX) on-demand therapy Dose (gc/kg) High (2.0 10 13 ) Mid (2.0 10 12 ) Low (2.0 10 11 ) ST Jude ST Jude ST Jude uniqure uniqure CROSS REFERENCING >St. Jude FIX safety data >Porphyria AAV5 safety data OBJECTIVES > Assess safety/tolerability > Define FIX expression level KEY EFFICACY ASSESSMENTS > Factor IX activity > FIX product consumption > Annual bleeding rate > Health related quality of life TIMELINES > Study begin Q1/15 > Study results Q4/15, interim Q2 / Q3 19

Other Relevant Design Details Intra-cohort Staggering 20

Inter-cohort Staggering Allows for Fast Trial Execution 21

Development Timelines Hemophilia B PRELIMINARY RESULTS Phase 1/2 INITIATE Phase 3 MID 2015 2016/17 1Q2015 MID 2016 START DOSING Phase 1/2 CLINICAL TRIAL REPORT Phase 1/2 22

Future Competitive Environment Product Pipeline Preclinical FIX-CTP; OPKO Health Phase 1 Other rfix Phase 2 ALN-AT3SC; Alnylam CB 2679d, Catalyst, ISU Abxis IXinity; Emergent Phase 3 Concizumab; Novo Nordisk N9-GP; Novo Nordisk CSL 654; CSL Pre-reg Gene therapy BAX 335; Baxter AMT 060; uniqure AAV8-hFIX19; Spark AAV10FIX; Dimension FIX gene editing; Shire BAX 817; Baxter LR769; revo, LFB Bypassing agents PF-05280602, Catalyst, Pfizer CSL 689 CSL 23

Global Perspectives of Gene Therapy Level of Prophylactic Treatment Varies with Country Economy and Health Care System % HAEMOPHILIA INDIVIDUALS ON PROPHYLAXIS < 18 YEARS % HAEMOPHILIA INDIVIDUALS ON PROPHYLAXIS > 18 YEARS 100 Germany >95% Germany 50% US 40% US 15% Countries Countries Source: WFH presentation by Mark Brooker, Prague, October 2012 24

Summary of uniqure s Hemophilia B program All Elements in Place to Advance Rapidly into Pivotal > Full freedom to operate > 2 year AAV5 safety data from Porphyria trial > 4.5 year FIX cassette safety and efficacy data from St Jude trial > Industrial grade/scale manufacturing GENE CASSETTE FIX Cassette excl. license from St. Jude VECTOR AAV5 excl. license from NIH MANUFACTURING Safe, robust, scalable, proprietary 25

Summary Gene Therapy for Hemophilia > AAV based liver directed gene therapy can secure long term expression of FIX at therapeutically relevant levels (NEJM 2011) > > 90% Reduction in bleeding risk and consumption can be achieved (NEJM 2014) > Hemophilia patients are increasingly aware of the potential life changing benefits of gene therapy 26

Harald Petry, Ph.D.

Hemophilia A > Hemophilia A is a genetic, recessive disorder caused by production of dysfunctional or insufficient amount of factor VIII (FVIII) protein, a key protein involved in the blood coagulation cascade > Patients suffer from spontaneous bleeding in the large joints and soft tissue and are at risk for intracranial hemorrhage. Recurrent episodes of joint bleeding can lead to crippling arthropathy, particularly in severely affected patients > The majority of hemophilia cases are inherited X-linked recessive trait and therefore most frequently affects males. However cases due to spontaneous mutations also arise (up to 30%) > Hemophilia comprises the majority of hemophilia patients (80%), with incidence of ~1:10,000 to 1:50,000 males affecting 400,000 people worldwide 28

Packaging of FVIII Gene and Cellular Processing How Packaging of a Too-large FVIII Gene was Expected to Work HLP-coFVIII-N6 5.7 kb paav-hlp-cofviii-n6 HLP A1 A2 B / N6 A3 C1 C2 spa OVERSIZED raav Annealing of plus and minus genomes Transcription of the transgene protein expression Reassembly of the intact gene cassette during concatemer formation 29

AAV2/5-FVIII 4 e 13 AAV5-FVIII 1,2 e 14 pvd S/X Packaging of FVIII Gene and Cellular Processing How packaging of a Too-large FVIII Gene Actually Worked µg AAV DNA 5 4 3 PACKAGED DNA concatemers concatemers HH HT EXPECTED CONCATAMERIC STRUCTURES 5 + _ 3 5 3 raav vector 5 kb dsdna-concatamers M full length mrna Active protein 30

Achievements in 2014, Plans for 2015 On the Way to Phase I > A partially deleted B-domain FVIII variant has been shown to increase secretion of FVIII as compared to wild type or to FVIII with complete B-domain deletion > A raav5-based FVIII including this partial deletion has been generated in house and Proof of Concept has been demonstrated (i.e. production of active FVIII protein in vitro and in vivo) > Plans for 2015 > Screening of five proprietary FVIII constructs ongoing, first mouse results expected in December 2014 > NHP studies with own FVIII: pilot experiment planned to start in January in parallel generation of an antibody to discriminate between human and monkey FVIII > Generation of smaller expression cassettes to increase quality of the product. HEMOPHILIA A 31

04 Gene Therapy for Acquired Diseases: Congestive Heart Failure Patrick Most, M.D. 32