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The Science of HBV Cure Meeting – June 8, 2019
Update on Inarigivir: a novel RIG-I agonist to stimulate
Innate Immunity and promote functional cure in
chronic HBV
Nezam Afdhal MD, DSc
Chief of Gastroenterology, Hepatology and Nutrition, BIDMC
Charlotte and Irving Rabb Professor of Medicine,
Harvard Medical School
1
Forward Looking Statements
This presentation includes forward-looking statements within the meaning of the
Private Securities Litigation Reform Act of 1995. Forward-looking statements
include, among other things, statements, other than historical facts, regarding: the
progress, scope, duration or results of clinical trials and preclinical studies of
inarigivir soproxil (“inarigivir”), SB 9225 or any of our other product candidates or
programs, such as the size, design, population, conduct, cost, objective or
endpoints of any clinical trial, or the timing for initiation or completion of or
availability of results from any clinical trial (including our Phase 2 clinical trials of
inarigivir in patients with chronic Hepatitis B virus); the potential benefits that may
be derived from any of our product candidates; our future operations, financial
position, revenues, costs, expenses, uses of cash, capital requirements or our need
for additional financing; or our strategies, goals, milestones, prospects, beliefs,
intentions, plans, expectations, forecasts or objectives. Words such as
“anticipates,” “believes,” “plans,” “expects,” “projects,” “future,” “intends,” “may,”
“will,” “should,” “could,” “estimates,” “predicts,” “potential,” “continue,”
“guidance,” and similar expressions sometimes identify forward-looking
statements. Any forward-looking statement involves known and unknown risks,
uncertainties and other factors that may cause our actual results, levels of activity,
performance or achievements to differ materially from those expressed or implied
by such forward-looking statement, and, therefore, you are cautioned not to place
undue reliance on any forward-looking statement. These factors include, but are
not limited to: whether our cash resources will be sufficient to fund our continuing
operations for the period anticipated; the components, timing, costs and results of
our clinical trials, preclinical studies and other development activities involving our
product candidates; whether certain top-line results from our clinical trials
materially change as more information becomes available; whether results
obtained in preclinical studies and clinical trials will be indicative of results
obtained in future clinical trials; whether inarigivir, SB 9225 or any of our other
product candidates will advance through the clinical trial process on a timely basis
and receive approval from the United States Food and Drug Administration or
equivalent foreign regulatory agencies; and whether, if inarigivir or any of our
other product candidates obtain regulatory approval, it will be successfully
distributed and marketed. These and other risks and uncertainties that we face are
described in our most recent Annual Report on Form 10-K, filed with the Securities
and Exchange Commission (SEC) on March 11, 2019, and in other filings that we
make with the SEC from time to time.
All forward-looking statements speak only as of June 8, 2019 and should not be
relied upon as representing our views as of any other date. We specifically disclaim
any obligation to update any forward-looking statement, except as required by
applicable law. All trademarks, service marks, trade names, logos and brand names
identified in this presentation are the properties of their respective owners.
This presentation also contains estimates and other statistical data generated by
independent parties and by us relating to market size and statistics. These
estimates involve a number of assumptions and limitations, and you are cautioned
not to give undue weight to such estimates.
2
Inarigivir – Hepatic-Selective Immunomodulator with a Dual Mechanism
of Action
RIG-I
RIG-I
TYPE III
IFNs
OATP1
DAA EFFECT
TARGETING
REPLICATION
COMPLEX
HBV pgRNA
5’ 3’
HBV pgRNA
5’ 3’
HBV polymerase
Reverse
transcription
Viral
replication
ε ε
INARIGIVIR
Hepatocyte
RIG-I ACTIVATION
AND BINDING TO
HBV PGRNA
NNRTI
Dual antiviral effect against HBV
Inarigivir is a RIG–I Agonist designed to:
• Restore hepatic-selective innate and
adaptive immune response1
stimulating the production of type I and
III IFNs without systemic toxicity
• Inhibit the HBV replication complex via
a direct acting antiviral effect as a nonnucleoside
reverse transcript inhibitor
(NNRTI)
• Target cccDNA and is only oral agent
to demonstrate reduction in HBV DNA,
HBV RNA and HBsAg
• Potential backbone immunomodulator
for combinatorial treatments of HBV
1 Sato et al. Immunity. 2015;42:123-132.
3
14 healthy volunteers
Inarigivir 400 mg /Daily
0 4h 12h
Day 1 Day 12
11 Days 400 mg
Samples 0 2h 6h 24h
Cytokines in sera (IFN-a, IP-10, TNF-a, IFN-g, IL-6, IL-12p70)
PBMC for flow cytometry analysis (T, NK, myeloid cells activation)
PBMC for Nanostring analysis
HEALTHY VOLUNTEERS TRIAL DESIGN
4
Results summary
• Serum cytokine levels of IFN-a, IFN-g, TNF-a, IL-6 and IL-12p70 were
undetectable while IP-10 levels declined after inarigivir treatment.
• As early as 2h post treatment, phenotypic analysis showed uniform up- regulation of activation markers on monocytes (CCR2, CD16, CD86) and
dendritic cells (CD86).
• The frequency of peripheral NK and CD8+ T cells declined and was
associated with reduction of activating receptor NKG2D (NK cells) and
increase of activation markers CD39 and HLA-DR (T cells).
• Measurements of immune cell activation before and after the first and
final dose demonstrated a similar response with no evidence of
tolerance.
5
Conclusion
• Inarigivir transiently modifies expression of activation markers on
circulating immune cells in a uniform and non-tolerance inducing
manner, without an associated increase of serum cytokines.
• These findings validate inarigivir’s ability to activate intracellular
innate immune pathways with a safety profile that demonstrates
minimal serum cytokine activation and toxicity.
6
PRIMARY
ENDPOINT
SECONDARY
ENDPOINTS
Safety and HBV
DNA reduction at
12 weeks
PK, change in serum HBV DNA, HBsAg,
HBV RNA, HBcrAg and HBeAg from
baseline to weeks 12 and 24
Up to 80
non-cirrhotic
HBV subjects,
randomized 4:1
between inarigivir and
placebo Inarigivir - 200 mg
Placebo
Inarigivir - 100 mg
Inarigivir - 50 mg
Inarigivir - 25 mg
Tenofovir 300 mg daily
All patients switch to tenofovir 300
mg monotherapy
12 weeks (inarigivir monotherapy QD)
12 weeks
Inarigivir monotherapy 12 weeks followed by switch to Tenofovir 300 mg for 12 weeks
Cohort 1
Cohort 2
Cohort 3
Cohort 4
ACHIEVE Phase 2 Dose Escalation Study
Pbo
Epos
Pbo
Eneg
E+ve
25mg
E-ve
25mg
E+ve
50mg
E-ve
50mg
E+ve
100 mg
E-ve
100 mg
E+ve
200 mg
E-ve
200 mg
n 8 8 9 7 11 5 13 4 8 7
Age 35 48 37 43 36 47 34 46 42 52
M:F 7:1 5:3 5:5 3:3 9:2 5:0 7:6 3:1 4:4 2:5
ALT 85 53 82 75 75 65 75 90 54 73
HBV DNA 7.64 4.75 7.86 5.69 7.79 4.55 8.20 5.95 7.88 4.95
HBV RNA 6.44 2.23 6.36 4.2 6.58 1.54 7.23 2.77 6.68 2.86
HBsAg 4.17 2.79 4.32 3.17 4.13 2.96 4.38 2.68 4.15 2.72
GT A 1 1
GT B 2 6 4 3 3 4 4 3 2 5
GT C 6 1 5 1 7 1 8 1 6 2
GT D 2 1 1
Mean Baseline Demographics by IRIG Dosing Cohort and HBeAg status
* 9 HBeAg negative patients had undetectable HBV RNA at baseline 8
IRIG Dose (mg)
Log10
Primary Endpoint: Mean Change from Baseline
in HBV DNA to Week 12 in Placebo (PL) and IRIG cohorts
-0.02
-0.58
-0.73
-0.95
-1.54
9
Week 12 PL or IRIG
Week 24 TDF 300mg
Mean change
(per cohort)
Log10
HBeAg positive patients: Change from Baseline
in HBV DNA at Week 12 and Week 24
P< 0.01: IRIG 50, 100 and
200mg vs PL
PL 25mg 50mg 100mg 200mg PL 25mg 50mg 100mg 200mg
TDF 300mg switch
WEEKS 0 – 12 WEEKS 12 - 24
10
Week 12 PL or IRIG
Week 24 TDF 300mg
Log10
HBeAg negative patients: Change from Baseline
in HBV DNA at Week 12 and Week 24
P< 0.01: IRIG 100mg and
200mg versus PL
PL 25mg 50mg 100mg 200mg PL 25mg 50mg 100mg 200mg
TDF 300mg switch
WEEKS 0 – 12 WEEKS 12 - 24
Week 12 PL or IRIG
Week 24 TDF 300mg
Mean change
(per cohort)
18 of 22 (82%) patients undetectable at week 24 11
Week 12 PL or IRIG
Week 24 TDF 300mg
Log10
HBeAg positive patients: Change from Baseline
in HBV RNA at Week 12 and Week 24
P< 0.01: IRIG 50, 100 and
200mg vs PL
PL 25mg 50mg 100mg 200mg PL 25mg 50mg 100mg 200mg
TDF 300mg switch
WEEKS 0 – 12 WEEKS 12 - 24
Week 12 PL or IRIG
Week 24 TDF 300mg
Mean change
(per cohort)
12
Log10
PL 25mg 50mg 100mg 200mg PL 25mg 50mg 100mg 200mg
TDF 300mg switch
WEEKS 0 – 12 WEEKS 12 - 24
HBeAg negative patients: Change from Baseline
in HBV RNA at Week 12 and Week 24
P =0.05: All cohorts combined
versus PL at week 12
3 placebo and 6 IRIG undetectable
HBV RNA at baseline. 1 placebo became
replicative and detectable at week 12
Week 12 PL or IRIG
Week 24 TDF 300mg
Mean change
(per cohort)
13
Positive Predictors of Response to IRIG
• HBV DNA and HBV RNA
• HBeAg negative – pre-core mutations > core promoter
mutations alone
• Baseline HBsAg < 4log10
• Baseline IP-10 > 310ng/L
• Reduction in IP-10 > 110ng/L between baseline and week
12
• HBsAg
• Genotype B > C
• Good responses genotype A / D but numbers small
14
Baseline HBsAg cutoff of 4log10 Predictor of HBV DNA and
HBV RNA Response to IRIG at Week 12
Change from Baseline
to Week 12 log10
HBV DNA
HBV RNA
Mean change
Baseline HBsAg <4log10 >4log10 <4log10 >4log10
P < 0.001 for both HBV DNA
and HBV RNA
24 HbeAg +ve and 1 HBeAg-ve > 4log10
16 HBeAg +ve and 21 HBeAg -ve < 4log10 15
Genotype A B C D
HBsAg change in log10
Percentage of responders
within each Genotype
GT A 100%
GT B 33%
GT C 10%
GT D 75%
HBsAg Response (> 0.5log10) by Genotype
Genotype response data consistent with
that seen with IFN therapy
16
Week 12
>0.5log10
Week 24
>0.5log10
Total
Responders
Placebo /TDF 1* 2* 2 *ALT flare
> 400 IU/ml
IRIG 25mg/TDF 4# 6 8 # 2 non
sustained of
which 1 dose
reduced
IRIG 50mg/TDF 1$ 2 2 $ 1 non
sustained and
dose reduced
IRIG 100mg/TDF 1 2 2 1 non-sustained
with a flare
IRIG 200mg/TDF 1 3 3 2 GT C patients
Secondary Endpoint: Predefined Responders
with HBsAg Reduction of > 0.5log10
• 16 IRIG patients (26%) met
predefined HBsAg loss criteria
for response at week 12 or 24
• Response in 7 HBeAg negative
(mean 0.7log10) and 9 HBeAg
positive (mean 0.9log10)
• Overall mean responder
reduction of 0.8log10 (range 0.5 –
1.4log10)
17
Mean Change in HbsAg
Week 12: 0.4log10
Range 0.1 – 0.9log10
Week 24: 0.72log10
Range 0.15 - 1.4log10
HBeAg +
HBeAg -
Quantitative HBsAg in Responder Patients > 0.5log10 Reduction
at Week 12 or Week 24 from Baseline
HBsAg
log10
WEEK 0 12 24
Inarigivir Tenofovir
11 of 16 patients had
evidence of HBsAg
reduction in
weeks 0 – 12 on IRIG
18
19 year old Asian male, GT B,
HBeAg positive, IL28b CC
IRIG 200mg Responder – Transcription Inhibition
Continued on TDF Switch
log10
WEEK
• Responder at week 12 all parameters 0.5 – 1 log10
mini ALT flare to 150 IU/ml on switch to TDF with further
reduction
19
Two distinct populations of HBeAg-ve patients for HBsAg response
• 7 responders (HbsAg >0.5log reduction) and 12 non-responders (< 0.1 log
reduction) to IRIG
• Non-responders are a clear subset of non-transcriptionally active patients
(low / undetectable HBV RNA and HBcrAg) despite elevated ALT and HBV
DNA
• Non-replicative subset less likely to have early HBsAg response and should
be accounted for in novel treatment trials
• Rapid cessation of viral production in all IRIG patients – Will duration have
an impact for HBsAg loss?
• Non-replicative subset represents a target population for prolonged HBV
DNA suppression after stopping treatment
20
CATALYST 1 - Global Inarigivir HBV Phase 2b Trial
21
Inarigivir 400mg monotherapy & co-administration with Vemlidy® (tenofovir alafenamide)
25mg HBeAg –ve and +ve non-cirrhotic treatment naïve HBV patients
Response-Guided Trial Design
IRIG 400mg
monotherapy
once daily
12 weeks 12 weeks
IRIG 400mg
monotherapy
3x weekly
IRIG 400mg once
daily + Vemlidy®
25mg once daily
IRIG 400mg 3x
weekly + Vemlidy®
25mg once daily
Vemlidy® 25mg
once daily
Responders
Non-responders
IRIG 400mg +
Vemlidy® 25mg
once daily
IRIG 400mg once daily co-administered
with Vemlidy® 25mg once daily
Capability to observe functional cure
Key endpoints:
HBV DNA & RNA reductions,
HBeAg loss & HBsAg decline/loss
Response at 24
weeks:
HBsAg
>0.5log₁₀
decline &
undetectable
HBV DNA
Together with data from Gilead’s trial of inarigivir + Vemlidy®, will inform Phase 3
treatment-naïve strategy for SB 9225 (IRIG + tenofovir disoproxil fumarate) fixed-dose combination
n=20
n=20
n=20
24 weeks
No treatment – follow to
observe
sustained HBsAg loss
IRIG 400mg monotherapy
once daily
CATALYST 2 - Global Inarigivir HBV Phase 2b Trial
22
24 weeks
Up to week 96
n=40
n=20
Capability to observe functional cure
Cohort 1 – “Stop & Shock”
Stop NUC
therapy
“Shock” with inarigivir
Cohort 2 – “Suppress & Shock”
Key endpoints:
ALT Flare
HBsAg loss
fine needle
aspirase (FNA)
Key endpoint:
HBsAg
loss/reduction
+
Intra-hepatic
virology &
Immunology with
Liver FNA
Inarigivir 400mg in virally suppressed –ve, non-cirrhotic chronic
HBV patients
Will inform Phase 3 program in virally-suppressed patients in 2020
IRIG 400mg monotherapy once
daily added to NUC therapy
Continue
NUC
therapy
24 – 48 weeks Up to week 96
No treatment – follow to
observe
sustained HBsAg loss
Conclusion
• IRIG continuing to be developed as a backbone immunomodulator in
combination studies with agents having different MOAs
• IRIG + NUC studies for up to 1 year in progress with focus on
biomarkers for patient heterogeneity and anti-viral response
• CATALYST trials will evaluate sustained response in naive and
suppressed patients
• Triple therapy combinations under development
23
Acknowledgements
Spring Bank Pharmaceuticals, Inc. would like to thank the ACHIEVE
Investigators and their coordinating staff for their participation and the
patients and their families
Locarnini Laboratory at VIDRL for Central Virology
Dr. Michael Beard, University of Adelaide for cytokine analysis
Dr. Danny Wong, University of Hong Kong, HBcrAg analysis
Gilead Sciences for clinical trial collaboration and providing tenofovir
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