Pegnivacogin (RB006), a Direct Factor IXa Pegnivacogin (RB006), a Direct Factor IXa Inhibitor, Results in Consistent and Near Inhibitor, Results in Consistent and Near Complete Inhibition of Factor IX Activity in Complete Inhibition of Factor IX Activity in Patients with Acute Coronary Syndromes: Patients with Acute Coronary Syndromes: A Prospective RADAR Pharmacokinetic and A Prospective RADAR Pharmacokinetic and Pharmacodynamic SubstudyPharmacodynamic Substudy

Thomas J. Povsic MD, PhD; William A. Wargin PhD;Thomas J. Povsic MD, PhD; William A. Wargin PhD; Mauricio G. Cohen MD;Mauricio G. Cohen MD; Roxana Mehran, MD;Roxana Mehran, MD; Christoph Bode MD;Christoph Bode MD; Joshua Krasnow MD;Joshua Krasnow MD; Merill Krolick Merill Krolick DO; DO; Christopher P. Rusconi PhD;Christopher P. Rusconi PhD; Steven L. Zelenkofske DO;Steven L. Zelenkofske DO; Richard A. Richard A. Becker MD;Becker MD; John H. Alexander MD, MHSJohn H. Alexander MD, MHS

Disclosure Statement of Financial InterestDisclosure Statement of Financial Interest

Within the past 12 months, I or my spouse/partner have had a financial Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. In interest/arrangement or affiliation with the organization(s) listed below. In addition, DCRI receives research funding from Regado Biosciences. addition, DCRI receives research funding from Regado Biosciences.

Affiliation/Financial RelationshipAffiliation/Financial Relationship CompanyCompany

Grant/Research SupportGrant/Research Support Regado BiosciencesRegado Biosciences

Search for the Ideal AnticoagulantSearch for the Ideal Anticoagulant

• Efficacy Ability to prevent thrombosis

• Safety Low risk of bleeding

• Titratability Ability to adjust the level of anticoagulation to individual clinical needs

• Reversibility Ability to safely, rapidly and predictably neutralize the anticoagulant effect when clinically indicated

• Convenience Daily single-bolus injections without need for continuous infusions or routine monitoring

• Assessable Monitoring via established coagulation assays

Aptamers: A Unique Class ofAptamers: A Unique Class ofDirect Protein AntagonistsDirect Protein Antagonists

Single-stranded nucleic acids Single-stranded nucleic acids that adopt a defined shapethat adopt a defined shape

Unique MOA’s for robust Unique MOA’s for robust blocking of protein-protein blocking of protein-protein interactionsinteractions

Selected for specific target Selected for specific target binding propertiesbinding properties

Minimal toxicityMinimal toxicity

Low/no immunogenicityLow/no immunogenicity

IV or subcutaneous injectablesIV or subcutaneous injectables

““Tunable” pharmacokineticsTunable” pharmacokinetics

PEG-conjugated aptamers PEG-conjugated aptamers cleared by nucleolytic breakdown cleared by nucleolytic breakdown in the bloodin the blood

Manufactured by a solid phase Manufactured by a solid phase chemical processchemical process 44

SELEXSELEXTMTM

Pegnivacogin (RB006): Pegnivacogin (RB006): An anticoagulant aptamerAn anticoagulant aptamer

Targets factor IXTargets factor IX

Long half lifeLong half life

Metabolized by Metabolized by nucleases in the bloodnucleases in the blood

Titratable as part of Titratable as part of REG1 systemREG1 system

AptamerAptamer ControllingControlling

AgentAgent

REG1: An aptameric system REG1: An aptameric system

Rusconi CP et al., Rusconi CP et al., Nature 2002;419:90-94Nature 2002;419:90-94

PegnivacoginPegnivacogin AnivamersenAnivamersen

AptamerAptamer

ControllingControlling

AgentAgent

Aptamers Encode Their Own Aptamers Encode Their Own Controlling AgentsControlling Agents

Rusconi CP et al., Rusconi CP et al., Nature 2002;419:90-94Nature 2002;419:90-94

Rationale for Targeting Factor IXaRationale for Targeting Factor IXa

Factor IXa is the proximal driver of clot propagationFactor IXa is the proximal driver of clot propagation

Factor IXa is ~7 fold more thrombogenic then factor Xa and ~60 fold Factor IXa is ~7 fold more thrombogenic then factor Xa and ~60 fold more thrombogenic than thrombin on a molar basismore thrombogenic than thrombin on a molar basis

FVIIIa/FIXa activation of FX is the rate limiting step in thrombin FVIIIa/FIXa activation of FX is the rate limiting step in thrombin generationgeneration

FIXa concentration is lower than Xa and thrombin, making high levels FIXa concentration is lower than Xa and thrombin, making high levels of target inhibition more readily achievableof target inhibition more readily achievable

High Factor IX levels are associated with increase in ACS and venous High Factor IX levels are associated with increase in ACS and venous thromboembolismthromboembolism

Foreign materials directly activate Factor IXForeign materials directly activate Factor IX

Factor IX depletion (Hemophilia B) characterized by aPTT Factor IX depletion (Hemophilia B) characterized by aPTT prolongation proportional to degree of diseaseprolongation proportional to degree of disease

8888

CLIN101: Pegnivacogin Provides CLIN101: Pegnivacogin Provides Predictable and Durable AnticoagulationPredictable and Durable Anticoagulation

Time (hrs)Time (hrs)

Ac

tiv

ate

d P

art

ial

Th

rom

bo

pla

sti

n T

ime

(s

ec

on

ds

)A

cti

va

ted

Pa

rtia

l T

hro

mb

op

las

tin

Tim

e (

se

co

nd

s)

Dyke, C et al, Dyke, C et al, CirculationCirculation 2006 2006

90 mg pegnivacogin90 mg pegnivacogin

60 mg pegnivacogin60 mg pegnivacogin

30 mg pegnivacogin30 mg pegnivacogin

15 mg pegnivacogin15 mg pegnivacogin

PlaceboPlacebo

120120

100100

9090

8080

7070

6060

5050

4040

3030

2020

00 11 22 33

1010

aPTT is Reflective of FIX DepletionaPTT is Reflective of FIX Depletion

CLIN101 and 102:CLIN101 and 102:Combined Dosing AnalysisCombined Dosing Analysis

1111

1 mg/kg pegnivacogin

n = 600

1 mg/kg pegnivacogin

n = 600

Heparin ± IIb/IIIan = 200

Heparin ± IIb/IIIan = 200

75% reversaln=100

75% reversaln=100

50% reversaln=100

50% reversaln=100

25%reversaln=200

25%reversaln=200

Unblinded Txt Assignment

Blinded Assignment of Anivamersen

Femoral Cardiac Catheterization / PCI

100% reversaln=200

100% reversaln=200 Std. CareStd. Care

ACS-NSTEMIn=800

Planned Catheterization < 24 h

ACS-NSTEMIn=800

Planned Catheterization < 24 h

RADAR Design:RADAR Design:

RADAR PK/PD Substudy:RADAR PK/PD Substudy:ObjectivesObjectives

Verify adequacy of a 1 mg/kg pegnivacogin dose Verify adequacy of a 1 mg/kg pegnivacogin dose to achieve:to achieve:

• Target plasma concentrations of 18-30 Target plasma concentrations of 18-30 g/mlg/ml• Near complete factor IX inhibition in an ACS cohortNear complete factor IX inhibition in an ACS cohort

Assess stability of anticoagulation during the Assess stability of anticoagulation during the treatment periodtreatment period

Unblinded Txt Assignment

ACS-NSTEMIn=800

Planned Catheterization < 24 h

ACS-NSTEMIn=800

Planned Catheterization < 24 h

Substudy Design:Substudy Design:

Pre-dosePre-dose

Pegnivacoginn = 30

N = 20 heparin naive

Pegnivacoginn = 30

N = 20 heparin naive

Post-dosePost-dose Pre-cathPre-cath Post-cathPost-cath

1 mg/kg pegnivacogin1 mg/kg pegnivacogin

Plasma collected, frozen, centrally analyzedPlasma collected, frozen, centrally analyzed

RADAR PK/PD Substudy:RADAR PK/PD Substudy:Patient PopulationPatient Population

NN %%

AgeAge 66.9 ± 9.766.9 ± 9.7

MaleMale 1111 52%52%

WhiteWhite 1616 76%76%

DiabetesDiabetes 99 43%43%

CRICRI 33 14%14%

+ Troponin+ Troponin 1010 48%48%

h/o CADh/o CAD 1414 67%67%

Δ ST segΔ ST seg 33 14%14%

Prior MIPrior MI 77 33%33%

Prior CPIPrior CPI 88 38%38%

Prior CABGPrior CABG 44 19%19%

RADAR PK/PD Substudy:RADAR PK/PD Substudy:Timing of SamplingTiming of Sampling

Median (min).Median (min). [25 [25thth, 75, 75thth]]

Post-DosingPost-Dosing 30 30 [21, 45] [21, 45]

Pre-CathPre-Cath 96.5 96.5 [55.5, 162.8] [55.5, 162.8]

Post-CathPost-Cath 123.5 123.5 [56, 179] [56, 179]

RADAR PK Substudy:RADAR PK Substudy:Pegnivacogin concenrationsPegnivacogin concenrations

RADAR PD Substudy: aPTTRADAR PD Substudy: aPTT

RADAR PD Substudy:RADAR PD Substudy:Fold Increase in aPTTFold Increase in aPTT

RADAR PD Substudy:RADAR PD Substudy:Inferred Degree of FIX InhibitionInferred Degree of FIX Inhibition

RADAR PD SubstudyRADAR PD Substudy

* Non-heparin naïve patients excluded* Non-heparin naïve patients excluded

ConclusionsConclusions• Pegnivacogin (1 mg/kg) achieves:Pegnivacogin (1 mg/kg) achieves:

• Therapeutic plasma concentrationsTherapeutic plasma concentrations• Near complete inhibition of factor IXNear complete inhibition of factor IX• Stable levels of anticoagulation throughout Stable levels of anticoagulation throughout

period of catheterization/PCI period of catheterization/PCI

• Findings consistent with early phase resultsFindings consistent with early phase results

• Higher doses unlikely to be beneficialHigher doses unlikely to be beneficial

• Clinical utility of REG1 awaits RADAR and future Clinical utility of REG1 awaits RADAR and future larger studieslarger studies• Sets the foundation for interpretation of Sets the foundation for interpretation of

RADAR and future clinical trialsRADAR and future clinical trials

Standard CurveStandard Curve

Rationale for Targeting FIXaRationale for Targeting FIXa

TF-bearing cellTF-bearing cell

Activated plateletActivated platelet

PlateletPlatelet

VIIaVIIa

XX

XaXa

VIIaVIIa

IXIX

IXaIXa

IXaIXa

XIaXIa

IXIX

IIII

XX

IIaIIa

IIII

PropagationPropagation

AmplificationAmplification

InitiationInitiation

XaXa IIaIIa

FIXa inhibitorFIXa inhibitor

TFTF VaVa

TFTF

VIIIaVIIIaVaVa

Monroe DM. Arterioscler Thromb Vasc Biol 2002;22:1381-1389. Monroe DM. Arterioscler Thromb Vasc Biol 2002;22:1381-1389.

Sample N Mean (µg/mL)

SD(µg/mL)

Min (µg/mL)

Median (µg/mL)

Max (µg/mL)

Pre 33 0.00 0.00 0.00 0.00 0.00

Post 30 26.08 4.59 17.40 26.35 33.90

Pre-Cath 22 25.61 4.85 15.70 25.10 37.00

Post-Cath 28 23.70 4.48 13.60 23.30 35.90

RADAR PK Substudy:RADAR PK Substudy:

Pegnivacogin ConcentrationsPegnivacogin Concentrations

Sample* N Mean (sec)

SD(sec)

Min (sec)

Median (sec)

Max (sec)

CV%

Pre 21 30.84 3.79 24.50 29.50 41.50 12.30

Post 20 92.95 9.48 80.70 90.90 113.90 10.20

Pre-Cath 13 95.17 27.50 64.30 90.90 177.10 28.90

Post-Cath 19 95.75 16.12 82.90 94.50 158.10 16.83

RADAR PD Substudy:RADAR PD Substudy:

aPTT ResultsaPTT Results

* Non-heparin naïve patients excluded* Non-heparin naïve patients excluded

Sample* N Mean (sec)

SD(sec)

Min (sec)

Median (sec)

Max (sec)

CV%

Pre 21 1.0 0 1.0 1.0 1.0

Post 20 3.03 .38 2.23 3.03 3.80 12.5%

Pre-Cath 13 2.97 .61 2.26 2.85 4.77 19.8%

Post-Cath 19 3.11 .54 2.1 3.01 4.76 17.8%

RADAR PD Substudy:RADAR PD Substudy:

Fold Increase aPTTFold Increase aPTT

* Non-heparin naïve patients excluded* Non-heparin naïve patients excluded