RU2798830C2 - Treatment of myocardial infarction with regenerated high-density lipoprotein - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to methods of increasing reverse cholesterol transport (RCT) in a patient after acute myocardial infarction (MI). A method of increasing reverse cholesterol transport (RCT) in a human after an acute myocardial infarction (MI) includes intravenously administering to a patient, within seven (7) days after the acute MI, a reduced high-density lipoprotein (rHDL) formulation containing an apolipoprotein or a fragment thereof, a lipid, stabilizer, where the stabilizer is sucrose, and, optionally, detergent, taken in a certain amount and ratio; wherein the patient is administered an angiographic contrast agent after an acute myocardial infarction and prior to the initial administration of the rHDL formulation; and subsequent intravenous administration of the rHDL formulation to the human weekly for at least four (4) weeks; which leads to an increase in reverse cholesterol transport (RCT) in humans without causing significant changes in liver and/or kidney function. A method for increasing reverse cholesterol transport (RCT) in a human patient following an acute myocardial infarction (MI) comprises intravenously administering to the patient, within seven (7) days following the acute MI of a reduced high-density lipoprotein (rHDL) formulation containing apoA-I, phosphatidylcholine, stabilizer, where the stabilizer is sucrose, and sodium cholate, taken in a certain amount and ratio; wherein the patient is administered an angiographic contrast agent after an acute myocardial infarction and prior to the initial administration of the rHDL formulation; subsequent intravenous administration of the rHDL formulation to a human weekly for at least four (4) weeks; resulting in an increase in reverse cholesterol transport (RCT) in a human patient without causing significant changes in liver and/or kidney function, while a significant change in liver function is defined based on an ALT value greater than 2 or 3 times the upper limit of normal (ULN); or an increase in the level of total bilirubin to an indicator at least 1.5–2 times higher than the ULN; and a significant change in kidney function is defined as a serum creatinine greater than or 1.2–1.5 times baseline and/or an eGFR significantly less than 90 ml/min/m², including less than 90 ml/min/1.73 m².

EFFECT: above method allows to improve the RCT in the period when reverse cholesterol transport is significantly impaired after acute MI or it is used as an improved way to increase RCT in the treatment of acute MI.

37 cl, 15 dwg, 24 tbl, 3 ex

Description

FIELD OF TECHNOLOGY TO WHICH THE INVENTION RELATES

The present invention relates to the treatment of acute myocardial infarction. More specifically, the present invention relates to the use of a particular low toxicity reduced high density lipoprotein formulation for the treatment of acute myocardial infarction. Also described is the use of such a composition for the treatment of patients who have not previously or recently suffered from acute myocardial infarction (MI), to reduce the risk of a serious adverse cardiovascular event (SAE) in such patients.

BACKGROUND OF THE INVENTION

Despite advances in treatment strategies for acute myocardial infarction (MI), patients remain at high risk of recurrent ischemic events, especially in the weeks following the event ¹ . Recurrences are more often the result of additional plaque rupture or erosion, and are associated with serious complications and death ^2,3 . Although they can occur at the site of the vessel associated with MI, they are equally likely to occur at another site anywhere in the coronary artery tree ² . Although low high-density lipoprotein (HDL-C) cholesterol is a risk factor for serious adverse cardiovascular events (SAEs) ^4-12 , it remains unclear whether raising HDL levels reduces the likelihood of ESOS, since several treatments that increase HDL-C levels have not been associated with improved clinical outcomes ^13-17 . These studies may have been limited by failure to provide patients with significant risk reduction, off-target toxicity, or failure to raise functional HDL. Reverse cholesterol transport (RTC), an ex-vivo measure of HDL function, measures the ability of HDL to cause excess cholesterol to be removed from atherosclerotic plaques for transport to the liver. RT is a factor correlated with SNSS that is independent of HDL-C, and it is possible that improving clinical outcomes could be more effective by identifying pharmacological agents acting shortly after acute MI that lead to improved reverse cholesterol transport and thus , to less plaque and stabilize unstable plaques than with treatments that only raise HDL levels ^18-20 . It is important to note that most of the failed studies to increase HDL-C levels evaluated chronic pharmacotherapy and did not initiate treatment immediately after myocardial infarction (MI), during a period of time when reverse cholesterol transport is significantly impaired ^21-23 .

SUMMARY OF THE INVENTION

The invention relates generally to the use of reduced HDL (vHDL) formulations for the treatment of patients following an acute myocardial infarction (MI). Specifically, the invention relates to the treatment of patients with MI with intermittent infusions of vHDL, which result in an increase in the reverse transport of cholesterol and do not cause a significant change in liver or kidney function. In some embodiments, the MI patient has normal renal function. In some embodiments, the MI patient has mild renal insufficiency. In some embodiments, the MI patient has moderate renal impairment. The invention generally also relates to the use of vHDL formulations to reduce the risk of a serious adverse cardiovascular event (SAE) in patients who have not had a previous MI or who have recently had a MI (i.e., who did not have a MI within seven days prior to start of treatment). In a specific embodiment, such patients have moderate renal insufficiency. In some embodiments, such patients have mild renal insufficiency. In some embodiments, such patients have normal renal function. Treatment of patients who have previously or recently failed MI may include intermittent infusions of HDL, may result in increased reverse cholesterol transport, and, in preferred embodiments, does not cause a significant change in hepatic or renal function.

One aspect of the invention relates to a method for increasing reverse cholesterol transport (RTC) in a human patient after an acute myocardial infarction (MI), comprising the steps of:

within approximately seven (7) days after MI, administration to a patient of a reduced high-density lipoprotein (vHDL) formulation containing apolipoprotein, or a fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the ratio between apolipoprotein and lipid is from about 1:20 up to about 1:120 (mol:mol); And

subsequent administration of the vHDL formulation to the patient, preferably for at least about four (4) weeks;

which leads to an increase in reverse cholesterol transport (RTC) without causing a significant change in liver or kidney function in humans.

Accordingly, the dose used within seven (7) days of acute MI is the starting dose of the reduced high density lipoprotein (vHDL) formulation. Subsequently, the patient is administered at least three (3) additional doses of the vHDL formulation, for a total of at least four doses (including the initial dose), preferably over at least about four (4) weeks from administration, inclusive of the initial dose. The treatment period can be defined as the time from the initial dose of vHDL to one week after the last dose.

A related aspect of the invention relates to a reduced high-density lipoprotein (vHDL) formulation comprising an apolipoprotein, or fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the ratio of apolipoprotein to lipid is from about 1:20 to about 1:120 (mol :mole), for use to increase reverse cholesterol transport (RTC) in a human patient following an acute myocardial infarction (MI), wherein the vHDL formulation is administered to the human patient within approximately seven (7) days following the acute MI, followed by patient, preferably for at least about four (4) weeks.

Another aspect of the invention relates to a method for the treatment of acute myocardial infarction (MI) in a human patient, comprising the steps:

within approximately seven (7) days after MI, administration to a patient of a reduced high-density lipoprotein (vHDL) formulation containing apolipoprotein, or a fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the ratio between apolipoprotein and lipid is from about 1:20 up to about 1:120 (mol:mol); And

subsequent administration of the vHDL formulation to the patient, preferably for at least about four (4) weeks;

which results in the treatment of acute myocardial infarction (MI) in a patient without causing a significant change in liver or kidney function in the patient.

Accordingly, the dose used within seven (7) days of acute MI is the starting dose of the reduced high-density lipoprotein (vHDL) formulation. Subsequently, the patient is administered at least three (3) additional doses of the vHDL formulation, for a total of at least four doses (including the initial dose), preferably for at least about four (4) weeks from administration, inclusive of the initial dose. The treatment period can be defined as the time from the initial dose of vHDL to one week after the last dose.

A related aspect of the invention relates to a reduced high-density lipoprotein (vHDL) formulation comprising an apolipoprotein, or fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the ratio of apolipoprotein to lipid is from about 1:20 to about 1:120 (mol :mol), for use in the treatment of acute myocardial infarction (MI) in a human patient, wherein the vHDL formulation is administered to the human patient within approximately seven (7) days following the acute MI, followed by administration to the patient, preferably for at least approximately four (4) weeks.

Another aspect of the invention relates to a method for reducing the risk of a serious adverse cardiovascular event (SAE) in a human patient who has not had a previous MI, or who has not experienced an MI within seven days prior to treatment, comprising the steps:

administering to a patient a reduced high-density lipoprotein (vHDL) formulation containing apolipoprotein, or a fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the ratio between apolipoprotein and lipid is from about 1:20 to about 1:120 (mol:mol) ,

which results in a reduced risk of ESOS in a patient, in some embodiments, without causing a significant change in liver or kidney function in a person.

A related aspect of the invention relates to a reduced high-density lipoprotein (vHDL) formulation comprising an apolipoprotein, or fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the ratio of apolipoprotein to lipid is from about 1:20 to about 1:120 (mol :mole), for use in a method for reducing the risk of SNOS in a human patient who has not had a previous MI, or has not experienced an MI within seven days prior to treatment, and, in some embodiments, without causing a significant change in liver or kidney function in person.

Another aspect of the invention relates to a method for increasing RTC in a human patient who has not had a previous MI, or has not experienced an MI within seven days prior to treatment, comprising the step of:

administering to a patient a reduced high-density lipoprotein (vHDL) formulation containing apolipoprotein, or a fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the ratio between apolipoprotein and lipid is from about 1:20 to about 1:120 (mol:mol) ,

which leads to an increase in reverse cholesterol transport (RTC) and, in some embodiments, without causing a significant change in liver or kidney function in a person.

A related aspect of the invention relates to a reduced high-density lipoprotein (vHDL) formulation comprising an apolipoprotein, or fragment thereof, a lipid, a stabilizer, and optionally a detergent, wherein the apolipoprotein to lipid ratio is from about 1:20 to about 1:120 (mol :mole), for use in a method of increasing reverse cholesterol transport (RTC) in a human patient who has not had a previous MI, or has not had an MI within seven days prior to treatment, and, in some embodiments, without causing a significant change in function human liver or kidney.

In embodiments where the patient has not had a prior MI, or has not experienced an MI within seven days prior to treatment, the patient may have normal renal function, moderate renal impairment, or may have mild renal impairment. In specific embodiments, the patient has moderate renal insufficiency as in Example 2.

Preferably, the methods described herein result in an increase in reverse cholesterol transport (RTC) in humans.

In some embodiments of the above aspects, the total RTX is increased in the range of 1.5 to 2 times.

In some embodiments of the above aspects, ABCA1 dependent RTX is increased in the range of 3 to about 5 fold.

Preferably, in the above aspects, in which the patient has recently experienced an acute MI, the patient is initially administered with HDL within 5 days of the acute MI. In some embodiments, the human patient is initially administered the vHDL formulation no earlier than 12 hours after an acute MI or after administration of an angiographic contrast agent.

Preferably, subsequent administration of the vHDL formulation is weekly, preferably for at least four (4) weeks.

If the patient has not had a previous MI, or has not had an MI within seven days prior to starting treatment, the initial administration of the vHDL formulation can be done at any time, and subsequent administrations can then be made at appropriate time points, e.g., over time period 1, 2, 3 or 4 weeks or longer. Preferably, subsequent administration of the HDL formulation is weekly, preferably for four (4) weeks or longer.

Preferably, in accordance with the above aspects, the formulation of vHDL is administered by intravenous (IV) infusion.

Preferably, the apolipoprotein is apoA-I. Preferably, the amount of apoA-I in vHDL is at least 2 g, or at least 4 g, or at least 6 g. In a particular embodiment, the amount of apoA-I in vHDL is 2 g to 8 g. of the embodiments, the amount of apoA-I in the composition of vHDL is 6 g.

Preferably, the stabilizer is sucrose. Preferably, sucrose is present in the vHDL formulation at a concentration of from about 1.0% to less than 6.0% by weight.

In a specific embodiment, a method is provided for increasing reverse cholesterol transport (RTC) in a human patient following an acute myocardial infarction (MI), comprising the steps of: within approximately seven (7) days following the acute MI, administering to the patient a reduced high-density lipoprotein (vHDL) formulation, containing at least 6 g of apoA-I, phosphatidylcholine, a stabilizer and sodium cholate at a level selected from the group consisting of about 0.5-1.5 g/l and/or about 0.010-0.030 g/g apoA-I, and from about 1.0% to less than 6.0% by weight of sucrose, while the ratio between apoA-I and phosphatidylcholine is from about 1:20 to about 1:120 (mol:mol); and then administering the vHDL formulation to a human for at least four (4) weeks; resulting in an increase in reverse cholesterol transport (RTC) in a human patient without causing a significant change in liver and/or kidney function in a person, with an ALT value greater than approximately 2 or 3 times the upper limit of normal is an indication of a significant change in liver function (VPN); or an increase in the level of total bilirubin to a value of at least 1.5-2 times the ULN; and a sign of a significant change in kidney function is a serum creatinine level greater than, or approximately, 1.2-1.5 times the baseline value, and / or an eGFR significantly less than 90 ml / min / m ² (for example, much less than 90 ml/min/1.73 m ² ). For example, a significant change in kidney function may be indicated by an eGFR that is significantly less than 90 ml/min/1.73 m ² . Additionally or alternatively, a patient may be considered to have no significant change in kidney function if the eGFR after treatment with vHDL is within 30, 20, or 10 ml/min/1.73 m ² of the eGFR before treatment, as described in more detail below.

In a related specific embodiment, a reduced high-density lipoprotein (vHDL) formulation is provided containing at least 6 g of apoA-I, phosphatidylcholine, a stabilizer, and sodium cholate at a level selected from the group consisting of about 0.5-1.5 g/ l and/or about 0.010-0.030 g/g of apoA-I, and from about 1.0% to less than 6.0% by weight of sucrose, while the ratio between apoA-I and phosphatidylcholine is from about 1:20 to about 1 :120 (mol:mol), for use to increase reverse cholesterol transport (RTC) in a human patient within approximately seven (7) days following an acute MI, wherein the vHDL formulation is subsequently administered to the human patient for at least approximately four (4) weeks, resulting in an increase in reverse cholesterol transport (RTC) in a human patient without causing a significant change in liver and/or kidney function in a human; in this case, a sign of a significant change in liver function is an ALT value of more than about 2 or 3 times the upper limit of normal (ULN); or an increase in the level of total bilirubin to a value of at least 1.5-2 times the ULN; and a sign of a significant change in kidney function is a serum creatinine level greater than, or approximately, 1.2-1.5 times the baseline value, and / or an eGFR significantly less than 90 ml / min / m ² (for example, substantially less than 90 ml/min/1.73 m ² ). For example, a significant change in kidney function may be indicated by an eGFR that is significantly less than 90 ml/min/1.73 m ² . Additionally or alternatively, a patient may be considered to have no significant change in kidney function if the eGFR after treatment with vHDL is within 30, 20, or 10 ml/min/1.73 m ² of the eGFR before treatment, as described in more detail below.

In the following embodiment, a method is provided to reduce the risk of SRSS and/or increase RTC in a human patient who has not had a previous MI, or has not experienced an MI within seven days prior to treatment, comprising the steps of: administering a reduced high-density lipoprotein (vHDL) formulation to the patient containing at least 6 g of apoA-I, phosphatidylcholine, a stabilizer and sodium cholate at a level selected from the group consisting of about 0.5-1.5 g/l and/or about 0.010-0.030 g/g apoA-I , and from about 1.0% to less than 6.0% by weight of sucrose, while the ratio between apoA-I and phosphatidylcholine is from about 1:20 to about 1:120 (mol:mol), which leads to a reduced risk of SNES and/or increased RCT in the patient. In some embodiments, this reduction in SRSS risk and/or increase in RCT in the patient occurs without causing a significant change in liver and/or kidney function in the individual.

In a related specific embodiment, a reduced high-density lipoprotein (vHDL) formulation is provided containing at least 6 g of apoA-I, phosphatidylcholine, a stabilizer, and sodium cholate at a level selected from the group consisting of about 0.5-1.5 g/ l and/or about 0.010-0.030 g/g of apoA-I, and from about 1.0% to less than 6.0% by weight of sucrose, while the ratio between apoA-I and phosphatidylcholine is from about 1:20 to about 1 :120 (mol:mol), for use in a method for reducing the risk of SNOS and/or increasing RTS in a human patient who has not had a previous MI, or has not experienced an MI within seven days prior to treatment. In some embodiments, this reduction in SRSS risk and/or increase in RCT in the patient occurs without causing a significant change in liver and/or kidney function in the individual.

It should be understood that the method disclosed herein may include the administration of one or more additional therapeutic agents. Likewise, the reduced high density lipoprotein (vHDL) formulation disclosed herein for use in the specific methods disclosed herein may be administered with one or more additional therapeutic agents. Preferably, one or more additional therapeutic agents can help or contribute to the treatment, prevention, or reduction of the risk of acute myocardial infarction (MI) and/or SRSS, and/or increase reverse cholesterol transport (RTC) in a human patient, but without limitation.

If a reduced high-density lipoprotein (vHDL) formulation disclosed herein is used, or intended to be used, in a particular method described herein with one or more additional therapeutic agents, it may be described as a vHDL formulation of the present invention. for use in this method in combination with one or more additional therapeutic agents (for example, one or more lipid-modifying agents; one or more cholesterol absorption inhibitors; one or more anticoagulants; one or more antihypertensive agents and one or more bile binders acid molecules). It can also be described as one or more therapeutic agents selected from one or more lipid-modifying agents; one or more cholesterol absorption inhibitors; one or more anticoagulants; one or more antihypertensive agents and one or more bile acid binding molecules, for use in this method in combination with the vHDL formulation of the present invention. Also provided is a vHDL formulation of the present invention and one or more additional therapeutic agents (e.g., one or more lipid-modifying agents; one or more cholesterol uptake inhibitors; one or more anticoagulants; one or more antihypertensive agents and one or more bile acid binding molecules). ) for use as a combination formulation in the specific method described herein. Means in a combined formulation may be intended for simultaneous or sequential administration.

One or more additional therapeutic agents may include: one or more lipid-modifying agents; one or more cholesterol absorption inhibitors; one or more anticoagulants; one or more antihypertensive agents; and one or more bile acid binding molecules.

In the text of this application, unless otherwise indicated, "include", "includes" and "including" are used as inclusive and not exclusive terms, so that the specified integer value or group of integer values may include one or more other unspecified integer values. or groups of integers.

It should also be understood that terms in the singular should not be interpreted as referring only to single entities or otherwise excluding more than one or the only number of entities to which the terms refer. For example, the term "protein" includes one protein, one or more proteins, or a plurality of proteins.

As used herein in relation to a human patient, the expression "who has not had a recent MI" means that the patient did not have a MI within seven days prior to the start of treatment. That is, at the time of administration of the vHDL formulation described herein, eight or more days had elapsed since the patient had suffered an MI. In some embodiments, such a patient has not suffered an MI within 8, 9, or 10 days or more, for example, 2, 3, or 4 weeks, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 or 12 months, or 1, 2, 3, 4, 5, 10, 15, 20, 30, 40, 50, 60, 70, 80, or 90 years prior to treatment. Additionally or alternatively, in some embodiments, such patients were not diagnosed with MI that occurred during one of the time periods described above.

As noted above, as used herein, the expression "significant change in liver function" means that the ALT value exceeds approximately 2 or 3 times the upper limit of normal (ULN); or the level of total bilirubin exceeds at least 1.5-2 times the ULN, and is used interchangeably with the expression "significant change in liver function".

As noted above, as used herein, the expression "significant change in kidney function" means that the serum creatinine level is more than, or approximately, 1.2-1.5 times the baseline value, and/or the eGFR is significantly less than 90 ml/min/m ² (for example, significantly less than 90 ml/min/1.73 m ² ). For example, a significant change in kidney function may be indicated by an eGFR that is significantly less than 90 ml/min/1.73 m ² . Additionally or alternatively, a patient may be considered to have no significant change in kidney function if the eGFR after treatment with vHDL is within 30, 20, or 10 ml/min/1.73 m ² of the eGFR before treatment, as described in more detail below. In this document, the expression "significant change in kidney function" is used interchangeably with the expression "significant change in kidney function".

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1: Schematic distribution of study participants.

Figure 2: Time to the occurrence of the first SNSS. Composite of CV deaths, non-fatal MI, ischemic stroke, and hospitalizations for unstable angina. The dotted line at day 112 marks the final visit at the end of the study.

Figure 3: Time to first exploratory SNSS. Composite of deaths from cardiovascular disease, non-fatal MI, and stroke. The dotted line at day 112 marks the final visit at the end of the study.

Figure 4: Days after randomization to death.

Figure 5: ApoA-I profiles after CSL112 infusion in subjects with moderate renal insufficiency (M. RI) or normal renal function (NRP). Values are presented as means (adjusted for baseline) with standard deviation.

Figures 6A-6B: Reverse cholesterol transport (RTC) scores and pre-β1-HDL levels after CSL112 infusion in subjects with moderate renal insufficiency (MRI) or normal renal function (NRF). Values are presented as means (adjusted for baseline) with standard deviation.

Figures 7A-7B: Effect of increasing the dose of CSL112 on reverse cholesterol transport (RTC) and pre-β1-HDL levels in subjects with moderate renal impairment (MRI) or normal renal function (NRF). Individual data points with regression curves are shown.

Figure 8: Conversion of non-esterified cholesterol (HDL-NC) to esterified cholesterol (HDL-EC) after CSL112 infusion in subjects with moderate renal insufficiency (M. RI) and normal kidney function (NFP). Values are presented as means (adjusted for baseline) with standard deviation for a dose of 6 g CSL112.

Figure 9: Distribution of participants in a clinical study. Subjects were considered to have completed the study if they completed all scheduled visits during the study up to and including the safety follow-up period/visit 8.

Figure 10: Boxplots of change in serum creatinine levels from baseline (central laboratory) in AEGIS-I and 2001 grouped by renal function status, visits and treatment option (safety population). eGFR=estimated glomerular filtration rate. Note: The ends of each box correspond to the upper and lower quartiles, the median is marked by a horizontal line inside the box, while the circles (CSL112) and squares (placebo) correspond to the mean values. Two vertical whiskers extend from the lower and upper quartiles to the smallest and largest non-outliers, respectively. Outliers are represented as individual data points outside the ends of each whisker. For better trending, the y-axis has been shortened and, as a result, limit values are not shown. Study CSL112-2001, Visit 7, Day 29 (7-10 days after last infusion) includes data for subjects who discontinued treatment in the study or who terminated early in the study. Subjects with severe renal impairment (eGFR <30 ml/min/1.73 m ² ) were excluded from pooled analyses. Planned study day [X]: AEGIS-I visit/2001 visit - day 2: 2a/3, day 8: 3/4, day 15: 4/5, day 22: 5/6, day 29: 6/7.

Figure 11. Box plots of serum creatinine levels from baseline (central laboratory) in AEGIS-I and 2001 grouped by time between angiography and first dose, renal function status, visits, and treatment option (safety population). A: subgroup: 12 - <24 hours; B: subgroup: 24 - <48 hours; C: subgroup: ≥ 48 hours. eGFR=estimated glomerular filtration rate. Note: The ends of each box correspond to the upper and lower quartiles, the median is marked by a horizontal line inside the box, while the circles (CSL112) and squares (placebo) correspond to the mean values. Two vertical whiskers extend from the lower and upper quartiles to the smallest and largest non-outliers, respectively. Outliers are represented as individual data points outside the ends of each whisker. For better trending, the y-axis has been shortened and, as a result, limit values are not shown. Study CSL112-2001, Visit 7, Day 29 (7-10 days after the last infusion), includes data for subjects who discontinued treatment in the study, or who dropped out of the study early. Subjects with severe renal impairment (eGFR <30 mL/min/1.73 m²) are excluded from pooled analyses. Planned study day [X]: AEGIS-I visit/2001 visit - day 2: 2a/3, day 8: 3/4, day 15: 4/5, day 22: 5/6, day 29: 6/7.

Figure 12. Boxplots of change in eGFR from baseline (central laboratory) in AEGIS-I and 2001 grouped by kidney function status, visits, and treatment option (safety population). eGFR=estimated glomerular filtration rate. Note: The ends of each box correspond to the upper and lower quartiles, the median is marked by a horizontal line inside the box, while the circles (CSL112) and squares (placebo) correspond to the mean values. Two vertical whiskers extend from the lower and upper quartiles to the smallest and largest non-outliers, respectively. Outliers are represented as individual data points outside the ends of each whisker. Study CSL112-2001, Visit 7, Day 29 (7-10 days after the last infusion), includes data for subjects who discontinued treatment in the study, or who dropped out of the study early. Subjects with severe renal impairment (eGFR <30 mL/min/1.73 m²) are excluded from pooled analyses. Planned study day [X]: AEGIS-I visit/2001 visit - day 2: 2a/3, day 8: 3/4, day 15: 4/5, day 22: 5/6, day 29: 6/7.

Figure 13. Total reverse cholesterol transport, RT (%) in the population of patients receiving CSL112 (6 g) in the study CSL112_2001 (example 3), relative to patients receiving CSL112 in the AEGIS-I study (example 1), at the beginning of the study, during visits 2, 3 and 6.

Figure 14. ABCA1 cholesterol transporter-independent RTC (%) in the population of patients receiving CSL112 (6 g) in the CSL112_2001 study (Example 3), relative to patients receiving CSL112 in the AEGIS-I study (Example 1), at the beginning of the study, during visits 2, 3 and 6.

Figure 15 ABCA1 cholesterol transporter dependent RTC (%) in the population of patients receiving CSL112 (6 g) in the CSL112_2001 study (Example 3), relative to patients receiving CSL112 in the AEGIS-I study (Example 1), at baseline, during visits 2, 3 and 6.

DETAILED DESCRIPTION OF THE INVENTION

In some aspects, the invention is based on the discovery that the administration of reduced HDL (vHDL) formulations may be useful in the treatment of patients with acute MI. More specifically, four (4) weekly infusions of HDL formulations such as CSL112 are effective, well tolerated, and not associated with any significant changes in liver or kidney function or other safety issues. Formulations such as CSL112 result in an increase in reverse cholesterol transport (RTC) after administration to patients. This effect has been demonstrated in acute MI patients with normal renal function and mild renal impairment (see Example 1).

In some aspects, the invention relates to the discovery that the administration of reduced HDL (vHDL) formulations to patients with moderate renal insufficiency (M. RI) results in an increase in reverse cholesterol transport (RTC). Similar effects on RCT were found in healthy subjects and patients with moderate renal insufficiency, the results for which are shown in example 1, after administration of formulations in HDL. In addition, the increase in pre-β1-HDL was more pronounced in patients with moderate renal insufficiency (MI) than in those with normal kidney function (see example 2). These results were obtained for subjects with Mind. PN who had not suffered an MI within seven days prior to the start of treatment. Thus, in some aspects, the invention relates to the discovery that the administration of reduced HDL (vHDL) formulations to patients who have not previously experienced MI, or who have not recently experienced MI, leads to an increase in reverse cholesterol transport (RTC) and, therefore, can be useful in reducing the risk of SNES. Such subjects may have moderate renal impairment, mild renal impairment, or normal renal function. In the following embodiments, the data presented in Example 3 demonstrates the safety and efficacy of administering vHDL to mental subjects. Mon; these patients represent an important, high-risk subgroup of post-MI patients with high unmet need for care.

Without being bound by a specific theory, the clinical significance of the results achieved in patients with Um. Mon, is twofold. First, they confirm that the effect of vHDL on RCT in patients with acute MI can be replicated in patients with Um. Mon. In addition, the fact that an increase in RCT occurred after administration of vHDL in patients who were not patients with acute myocardial infarction supports the use of vHDL to reduce the risk of SRSS based on its ability to increase RCT.

As described herein, in specific aspects, the invention relates to the treatment of human patients after acute MI. MI is typically the result of coronary heart disease (CHD) or related diseases, disorders, or conditions, including coronary artery disease, coronary artery disease, atherosclerosis, angina pectoris, ventricular arrhythmias, and/or ventricular fibrillation. CAD is the result of a gradual buildup of cholesterol in the coronary arteries, which can lead to myocardial infarction (MI), a potentially fatal destruction of the heart muscle.

The term "acute coronary syndrome (ACS)" refers to the spectrum of clinical manifestations, from those occurring in ST elevation myocardial infarction (STEMI) to those occurring in non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (NS). It is almost always associated with rupture or erosion of atherosclerotic plaque and partial or complete thrombosis of the infarct-associated artery.

As used herein, the term "serious adverse cardiovascular event" or "AESD" includes death from cardiovascular disease, fatal or non-fatal myocardial infarction, UA, fatal or non-fatal stroke, need for a revascularization procedure, heart failure, resuscitation from cardiac arrest and/or new objective evidence of ischemia, and any and all subcategories of events that fall within the scope of each of these events (e.g., STEMI and NSTEMI, documented HC requiring urgent hospitalization). In specific embodiments, AESD is death from cardiovascular disease, fatal or non-fatal MI, UA (including UA requiring urgent hospitalization), fatal or non-fatal stroke, and/or risk or danger due to revascularization. In specific embodiments, the implementation of SNOS represents death from cardiovascular disease, fatal or non-fatal MI and ischemic stroke. In specific embodiments, the implementation of SNOS represents death from cardiovascular disease, fatal or non-fatal MI, for example, MI. In specific embodiments, treating or preventing coronary heart disease (or reducing the risk of coronary heart disease, or treating patients at risk of SNOS, including patients who have experienced acute MI, or patients who have not experienced acute MI, or who have not experienced MI within seven days prior to treatment) with a formulation such as vHDL results in a reduction in the likelihood of developing ESOS, delaying the development of ESOS, and/or reducing the severity of ESOS. In each of these cases, an effect on SNOS may mean an effect on the SNOS in general (eg, a reduction in the likelihood of developing all types of SNOS), an effect on one or more specific types of SNOS, for example, a reduction in the likelihood of death, non-fatal MI, NS with the need for urgent hospitalization, non-fatal stroke, or the need for a revascularization procedure or the risk associated with it, or a combination of both.

In certain aspects described herein, a vHDL formulation is intended to be used to either (i) reduce the risk of subsequent ESDS in a patient who has had a recent MI (i.e., who had had an MI within seven days prior to starting treatment) or (ii) ) reducing the risk of SIDS in a patient who has not had a MI, or who has not had a recent MI (i.e., who did not have a MI within seven days of starting treatment). In these contexts, reducing the risk of SNOS may mean reducing the likelihood of developing SNSS, delaying the development of SNSS, and/or reducing the severity of SNSS. This may be due to an increase in RCT; thus, in preferred embodiments, the reduction in the risk of SRSS (or the risk of subsequent SRSS) is accompanied by an increase in RCT, more preferably an increase in ABCA1-dependent RCT.

Patients at risk of SIOS include patients who have had a myocardial infarction and patients with coronary heart disease or related diseases as noted above. Such patients are especially contemplated as subjects of the present invention.

The term "myocardial infarction" (other names "acute myocardial infarction", "acute myocardial infarction" or "AMI") is well known in the art and is synonymous with the more commonly used term "heart attack". Acute MI occurs when blood flow to part of the heart is stopped, causing damage to the heart muscle. Acute MI can cause heart failure, irregular heartbeat (including severe cases), cardiogenic shock, or cardiac arrest.

The predominant cause of acute MI is coronary artery disease, and acute MI often results from coronary artery blockage caused by atherosclerotic plaque rupture. Risk factors include high blood pressure, smoking, diabetes, lack of physical activity, obesity, high blood cholesterol, unhealthy diet, and excessive alcohol consumption.

Acute MI is often diagnosed based on an electrocardiogram (an ECG that determines whether an acute MI is ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI)), blood tests (for example, to determine troponin), and results coronary angiography. A patient with acute MI, therefore, may have STEMI or NSTEMI. Recognized criteria for defining acute MI are given, for example, in Thygesen et al . ^thirty

Without wishing to be bound by a particular theory, it is believed that the increase in RTC due to the administration of vHDL (as shown in the examples) is associated with the reverse transport of cholesterol from atherosclerotic plaques and, as a result, a decrease in the likelihood of SNSS.

As used herein, the terms "treatment" or "treat" or "therapy" means a therapeutic intervention that at least partially eliminates, or reduces, one or more existing, or previously identified, pathologies, or symptoms, diseases, or conditions. . In some embodiments, treatment after an acute MI may, at least partially or temporarily, prevent or suppress or reduce the likelihood of subsequent MI.

It should be understood that treatment may be considered completed even if some symptoms of the disease, or condition, appear or persist, and complete or absolute elimination, reduction, prevention, or suppression of the disease, condition, or symptom is not necessary.

As used herein, a "decrease" or "increase" in any parameter is generally by any amount, but preferably by a statistically significant amount, and is relative to the same parameter in the absence of said treatment. For example, a reduction in the risk of ESOS (eg, a decrease in the likelihood of developing or a decrease in the severity of ESOS) is a reduction in the risk of ESOS compared with the risk of ESOS (eg, the likelihood of developing or severity of ESOS) in the absence of the treatment described herein. This reduction, or reduction, may be by any amount (eg, 5%, 10%, 15%, 20%, 25%, 50% or more). Similarly, if the reduction in risk is manifested in the delay in the development of SNOS, this delay is relative to the time of development of SNOS in the absence of treatment described herein, and can occur for any amount of time (for example, a delay of 1, 2, 3, 4, 5 or 6 months or more, or 1, 2, 5 or 10 years or more, such as 1 month to 10 years), but preferably there is a statistically significant delay.

In specific aspects of the invention, the human patient is treated within 7 days of an acute MI. In other aspects, the human patient has not had a MI, or has not recently had a MI, that is, has not had a MI within seven days prior to the start of treatment (i.e., more than seven days have passed since the patient had a MI by the time treatment was started) . As described above, diagnosing MI is a routine procedure. In specific embodiments, the human patient did not experience an MI within 8, 9, or 10 days or more prior to treatment, or 2, 3, or 4 weeks prior to treatment, or more, or within 1, 2, 3, 4 , 5, 6, 7, 8, 9, 10, 11, or 12 months prior to treatment, or more, or within 1, 2, 5, 10, 15, 20, 30, 40, 50, 60, 70, 80 , 90 years prior to treatment. Alternatively, the human patient was not diagnosed with MI that occurred in one of the time periods indicated above.

The patient may be at risk of developing SIDS from any cause, such as coronary heart disease, coronary artery disease, atherosclerosis, angina pectoris, ventricular arrhythmias, and/or ventricular fibrillation, or the patient may have had an acute MI (including having had an acute MI in within the last 7 days). Alternatively or additionally, the patient may have one or more other risk factors for SNOS, for example they may:

- be 45 years of age or older (for example, at least 50, 55, 60, 65, 70, 75, 80 or 85 years old);

- smoking;

- have high blood pressure (140/90 mmHg or higher);

- have high blood levels of cholesterol or triglycerides, such as high levels of low-density lipoprotein (LDL) cholesterol (fasting LDL-cholesterol levels of 160-199 mg/dL or 4.1-4.9 mmol/L) or high levels of triglycerides;

- have diabetes;

- have a family history of MI;

- be physically inactive;

- be obese (for example, a BMI of 30 or more).

The human patients to be treated may have any condition of their renal function. Preferred examples include patients with normal renal function, mild renal impairment and moderate renal impairment. Renal failure is a common comorbid condition in acute coronary syndrome, with approximately 30% of subjects having stage 3 chronic renal failure. Kidney function is usually determined using a formula developed by the Collaboration for the Epidemiology of Chronic Kidney Disease (see e.g. Levey, 2009 Ann Intern Med May 5; 150(9): 604-612) to determine the value of the estimated glomerular filtration rate (eGFR), which correlates with the state of kidney function (see, for example, Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney inter., Suppl. 2013 ; 3: 1-150). The glomerular filtration rate (GFR) is considered the best overall indicator of kidney function in healthy and diseased states. Normal kidney function (stage 1 kidney function) is generally defined as eGFR ≥90 ml/min/1.73 m ² . Patients with mild renal impairment (stage 2 renal function) have an eGFR ≥60 to <90 mL/min/1.73 m ² , and patients with moderate renal impairment have an eGFR ≥30 to <60 mL/min/1.73 m ² . Patients with moderate renal insufficiency can be further subdivided into patients with eGFR ≥45 to <60 ml/min/1.73 m ² (stage 3a renal function) and patients with eGFR ≥30 to <45 ml/min/ 1.73 m ² (stage 3b kidney function). Patients with severe renal insufficiency have eGFR ≥15 to <30 ml/min/1.73 ^m2 (stage 4 renal function), while patients with eGFR <15 ml/min/1.73 ^m2 are considered ( stage 5 kidney function), suffer from kidney failure.

As noted elsewhere, in preferred embodiments, treatment with vHDL does not cause a significant change in kidney function, however, patients suffering from renal insufficiency, for example, mild or moderate renal insufficiency, prior to treatment with vHDL, may receive treatment in accordance with the invention.

In some embodiments, the human patient receiving treatment within 7 days of an acute myocardial infarction has normal renal function, mild renal impairment, or moderate renal impairment.

In some embodiments, a human patient who has not had a previous MI, or who has not recently had an MI (ie, did not have an MI within seven days prior to treatment), has moderate renal insufficiency. In other embodiments, such a patient has mild renal insufficiency. In other embodiments, such patients have normal renal function. In specific embodiments, patients with moderate renal insufficiency are treated, as illustrated in Example 2 and Example 3.

In the context of the present invention, the term “reduced HDL (vHDL) composition” means a composition or composition of any artificially produced lipoprotein that is functionally similar, similar, corresponding to or mimics the high density lipoprotein (HDL) normally found in blood plasma. Compounds in HDL include "HDL mimics" and "synthetic HDL particles". The vHDL formulation preferably contains an apolipoprotein, a lipid, a stabilizer, and optionally a detergent. Specific embodiments of vHDL formulations will be described in more detail below. A particularly preferred embodiment of the vHDL formulation is referred to herein as "CSL112". See international patent publications WO2012/000048, WO2013/090978 and WO2014/066943 for specific examples of CSL112 formulations.

Preferably, the methods of treatment of the above aspects (e.g., wherein the patient is treated within about 7 days of the acute myocardial infarction) comprise administering an initial dose of the vHDL formulation to the human patient within about seven (7) days of the acute MI. This may include administration several hours (eg, 4, 6, 12, or 18 hours) after an acute MI, or 1, 2, 3, 4, 5, 6, or 7 days (or any hourly intervals in between) after an acute MI. THEM. Preferably, treatment comprises administering an initial dose of the vHDL formulation to a human patient within about five (5) days of acute MI.

If the patient does not receive treatment within 7 days of an acute MI (eg, because the patient has not had an MI or has recently had a MI), the initial dose may be administered at any appropriate time.

In a specific embodiment, an angiographic contrast agent may be administered to a human patient. In such an embodiment, the initial dose of the vHDL formulation is administered no earlier than 12 hours after the administration of the contrast agent.

The same or different dose of the vHDL formulation may subsequently be administered to the human patient one or more times per week for about 2, 3, 4, 5, 6, 7, 8, 9, or 10 weeks. Preferably, the same dose of the vHDL formulation is subsequently administered to the human patient once a week for about 4 weeks. The treatment period can be defined as the time from the initial dose of vHDL to one week after the last infusion. If a patient does not receive treatment within 7 days of an acute MI (eg, because the patient did not have a MI, or has recently had a MI), this may continue, for example, for up to, or at least, 1 , 2, 3, 4, 5, 6 months or up to, or at least 1, 2, 3, 4, 5 years.

Preferably, the vHDL formulation is administered by intravenous (IV) infusion. The IV infusion can be performed over a period of approximately 0.5, 1, 1.5, 2, 2.5, 3, 3.5, or 4 hours. In a specific embodiment, the IV infusion is performed over approximately 2 hours. In some embodiments, the amount of an apolipoprotein, such as apoA-I, in a vHDL formulation may be 2 g (such a dose is referred to as a "low dose") or 6 g (such a dose is referred to as a "high dose"). Thus, preferred infusion rates in these embodiments are from about 1 g to about 3 g of apoA-I per hour.

Preferably, the vHDL formulation is administered weekly as a 2-hour intravenous infusion for 4 consecutive weeks. The treatment period can be defined as the time from the initial dose of vHDL to one week after the last infusion. If a patient does not receive treatment within 7 days of an MI (for example, because the patient did not have a MI, or did not have a recent MI), this may continue, for example, for up to, or at least 1, 2, 3, 4, 5, 6 months or up to or at least 1, 2, 3, 4, 5 years.

It is a feature of the present invention that the methods of the above aspects result in an increase in reverse cholesterol transport (RTC) in a human patient, eg following an acute MI. Reverse cholesterol transport (RTC), an ex-vivo measure of HDL function, measures the ability of HDL to cause excess cholesterol to be removed from atherosclerotic plaques for transport to the liver. RCT is a factor correlated with SNSS that is independent of HDL-C, however vHDL formulations that increase or improve RCT may thereby lead to plaque reduction and stabilization of unstable plaques, which may be more valuable than just increase in HDL levels.

Preferably, RTX is total reverse cholesterol transport, preferably measured or expressed as %/4 hours. In one embodiment, RCT is measured with an arithmetic mean of at least about 12. Preferably, RCT includes ABCA1-dependent reverse cholesterol transport (preferably measured or expressed as %/4 hours) with an arithmetic mean of at least about 5. Assays for reverse cholesterol transport can be performed in apoB-depleted serum samples using J774 macrophages, for example, as described in de le Llera-Moya et al., Arterioscler. Thromb. Vasc. Biol. 2010; 30-796-801.

Preferably, the methods disclosed herein result in an increase in total cholesterol reverse transport of at least about 1.5-fold, up to about 2.5-fold. ABCA1-dependent reverse cholesterol transport can be increased by at least about 3-fold and up to about 5-fold. This large increase in ABCA1-dependent reverse cholesterol transport (also compared to circulating levels of apoA-I) suggests that CSL112 may lead not only to an increase in circulating apoA-I, but also to an increase in ABCA1-dependent reverse transport in terms of on the amount of apoA-I. The "specific activity" of the circulating pool of apoA-I for ABCA1-dependent reverse cholesterol transport can be calculated as the ratio of ABCA1-dependent reverse cholesterol transport/apoA-I at the end of the infusion. As an example, CSL112 infusion resulted in a 2.51-fold increase in the ratio in the 2 g dose group (0.05) and a 1.78-fold increase in the ratio in the 6 g dose group (0.035) compared to the placebo group (0.05). 02). The increase in ABCA1-dependent reverse transport was greater than the increase in apoA-I. Without wishing to be bound by a particular theory, it is believed that CSL112 infusion leads to an increase in not only the amount but also the functionality of the apoA-I pool. The ratios of ABCA1-dependent reverse cholesterol transport/apoA-I were increased for both doses, 2 g and 6 g, of CSL112 compared to the placebo group.

Preferably, the increase in RCT is not associated with, or does not cause a significant change in liver or kidney function in the human patient.

Non-limiting examples of measures of liver function(s) include alanine aminotransferase (ALT), aspartate aminotransferase (AST) activity and/or bilirubin levels. The measurement of these parameters is well known in the art (see e.g. Fischbach FT, Dunning MB III, eds. (2009). Manual of Laboratory and Diagnostic Tests, 8th ed. Philadelphia: Lippincott Williams and Wilkins) and is a routine analysis in medical laboratories. . Kits for measuring these indicators are commercially available. Typically, liver and/or kidney function is measured following administration of the vHDL formulation. Scores obtained can be compared with liver and/or kidney function scores prior to administration of the vHDL formulation, for example, to determine if a change in function has occurred. Avoiding a significant change in liver and/or kidney function is an advantage. It is preferable to maintain the level of liver and/or kidney function that occurred before treatment, for example, it is preferable if treatment with vHDL does not cause any change in liver and/or kidney function. In specific embodiments, the level of liver and/or kidney function may improve (i.e., indicators of stronger liver and/or kidney function will be obtained than in the absence of treatment), however, in any case, it is preferable to avoid a significant decrease in liver and/or kidney function.

In specific embodiments, the methods may further comprise the step of assessing liver and/or kidney function (i) after administration of the vHDL formulation, and optionally also (ii) prior to administration of the vHDL formulation. Parameters of kidney and/or liver function before and after administration of the vHDL formulation can be compared to determine if a change in liver and/or kidney function has occurred. In specific embodiments, such methods may further include the step of obtaining an appropriate sample (eg, blood, serum, plasma) from a human patient.

In some embodiments, an indication of a significant change in liver function is an ALT value greater than about 2 or 3 times the upper limit of normal (ULN); or an increase in the level of total bilirubin to a value of at least 1.5-2 times the ULN. As a result, it is preferred that the human patient not have an ALT value greater than about 2 or 3 times the upper limit of normal (ULN), both before treatment with vHDL and after treatment with vHDL. Also preferably, the human patient will not have a total bilirubin greater than at least 1.5-2 times the ULN, both before treatment with vHDL and after treatment with vHDL. In specific preferred embodiments, the ALT value remains substantially constant before and after treatment (eg, remains within 10% or 20% of pre-treatment value).

Renal toxicity can be determined based on serum creatinine levels. In some embodiments, a significant change in kidney function is indicated by a serum creatinine level greater than, or approximately, 1.2 to 1.5 times baseline. Therefore, it is preferable if the human patient does not have a serum creatinine level greater than, or approximately, 1.2-1.5 times baseline, both before treatment with vHDL and after treatment with vHDL. In some preferred embodiments, the serum creatinine level remains substantially constant before and after treatment (eg, remains within 10% or 20% of the pre-treatment value).

Additionally or alternatively, renal toxicity can be determined based on a decrease in glomerular filtration rate (eGFR). The normal glomerular filtration rate (eGFR) in humans is at least about 90 ml/min/m ² (eg, at least about 90 ml/min/1.73 m ² ). It can be calculated using the CKD-EPI formula (see, for example, Levey, 2009 Ann Intern Med May 5; 150(9): 604-612). The correlation between eGFR and kidney disease is well known and standardized in the field (see e.g. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney inter., Suppl. 2013; 3: 1-150). Thus, a sign of a significant change in kidney function is an eGFR significantly less than 90 ml/min/m ² (eg, significantly less than 90 ml/min/1.73 m ² ). Mild renal failure is typically associated with an eGFR of at least about 60 ml/min/m ² (eg, at least about 60 ml/min/1.73 m ² ).

As noted above, the invention relates to patients with normal renal function, mild renal insufficiency and moderate renal insufficiency. Thus, it should be understood that patients with an eGFR of less than 90 ml/min/1.73 m ² prior to treatment with vHDL (eg, patients with mild to moderate renal impairment) may have an eGFR of less than 90 ml/min. min/1.73 m ² , after treatment with vHDL, while this level of eGFR is not caused by treatment. Therefore, in these cases, treatment with vHDL is not considered to cause "changes in kidney function" as described herein, solely on the basis that eGFR is less than 90 ml/min/1.73 m ² . Thus, it may be useful to ascertain the status of a patient's kidney function prior to treatment in order to determine if the treatment is causing a change in kidney function.

So, for example, if a human patient does not have an eGFR significantly less than 90 ml/min/1.73 m ² prior to treatment with vHDL, then said patient will preferably not have an eGFR significantly less than 90 ml/min. /1.73 m ² after treatment vHDL. In addition, if a human patient does not have an eGFR significantly less than 60 ml/min/1.73 m ² prior to treatment with vHDL, then said patient will preferably not have an eGFR significantly less than 60 ml/min/ 1.73 m ² after vHDL treatment. Similarly, if a human patient does not have an eGFR significantly less than 30 ml/min/1.73 m ² prior to treatment with vHDL, then said patient will preferably not have an eGFR significantly less than 30 ml/min/1. .73 m ² , after treatment with HDL. In other words, in preferred embodiments, treatment with vHDL does not cause a change in the patient's kidney status according to the standard definitions used in the CKD Work Group's Kidney Disease: Improving Global Outcomes (KDIGO) publication. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney inter., Suppl. 2013; 3: 1-150, and used elsewhere in this document.

Given that the above patient groups are classified into certain discrete categories according to the kidney disease model, while eGFR changes gradually, it may be useful to determine a significant change in kidney function based on a change (for example, a decrease) in eGFR after treatment with vHDL by 10 or 20 or 30 ml/min/1.73 m ² or more compared to eGFR before vHDL treatment. By way of example, the patient preferably has a post-treatment eGFR within 10, 20, or 30 ml/min/1.73 m ² of pre-treatment eGFR with vHDL. For example, a patient is considered to have no significant change in kidney function if the eGFR after treatment with vHDL is within 30, 20, or 10 ml/min/1.73 m ² of the eGFR before treatment.

Alternatively, renal toxicity may be determined based on the need for renal replacement therapy.

Preferably, the HDL formulation contains an apolipoprotein or fragment thereof. The apolipoprotein can be any apolipoprotein that is a functional, biologically active component of natural HDL or reduced high density lipoprotein/vHDL. Typically, the apolipoprotein is either a plasma derived or recombinant apolipoprotein such as apoA-I, apoA-II, apoA-V, pro-apoA-I, or a variant such as apoA-I Milano. Preferably, the apolipoprotein is apoA-I. More preferably, apoA-I is either recombinantly produced containing the wild-type or Milano sequence, or alternatively, it has been purified from human plasma. The apolipoprotein may be in the form of a biologically active fragment of an apolipoprotein. Such fragments may be natural, chemically synthesized or recombinant. By way of example only, a biologically active fragment of apoA-I preferably has at least 50%, 60%, 70%, 80%, 90% or 95% to 100% or more than 100% lecithin-cholesterol acyltransferase (LCAT) stimulatory apoA-I activity.

In some general embodiments, the apolipoprotein is present at a concentration of about 5 to about 50 mg/mL. This includes concentrations of 5, 8, 10, 15, 20, 25, 30, 35, 40, 45, and 50 mg/mL, and any range in between. The apolipoprotein is preferably present at a concentration of about 25-45 mg/ml. In specific embodiments, the apolipoprotein is apoA-I, preferably at a concentration of about 25-45 mg/mL. In other embodiments, the apolipoprotein may be present at a concentration of about 5-20 mg/ml, such as about 8-12 mg/ml. In some embodiments, the apolipoprotein is apoA-I, and its content in the composition of vHDL is approximately 25-45 mg/ml. In other embodiments, the vHDL is reconstituted after lyophilization such that the apoA-I content of the reconstituted vHDL formulation is approximately 5-50 mg/mL. ApoA-I, after reconstitution of the lyophilized formulation into HDL, preferably has a concentration of approximately 25-45 mg/mL. In specific embodiments, apoA-I, after reconstitution of the lyophilized formulation, has a concentration of about 30-40 mg/mL in vHDL. In one embodiment, apoA-I, after reconstitution of the lyophilized formulation, has a concentration of about 30 mg/mL in vHDL.

Typically, the administered dose of a vHDL formulation may be in the range of about 1 to about 120 mg/kg body weight. Preferably, the dose is in the range of about 5 to about 80 mg/kg, including doses of 8 mg/kg, 10 mg/kg, 12 mg/kg, 20 mg/kg, 30 mg/kg, 40 mg/kg, 50 mg /kg, 60 mg/kg and 70 mg/kg.

In alternative embodiments, the implementation of the vHDL formulation may be in the form of a "fixed dose" formulation. Preferably, the apolipoprotein fixed dose formulation is at a dose that is therapeutically effective when administered to human patients of any body weight, or any body weight within a defined body weight range. Accordingly, the dose of the vHDL formulation is not calculated, determined, or selected based on the individual's specific body weight, as is typically the case with "weight-adjusted dose".

Rather, a fixed-dose apolipoprotein formulation is defined as a formulation that, when administered to human patients of any body weight, or any body weight within a given body weight range, will result in relatively lower inter-patient variability in exposure to the apolipoprotein components of the formulation. apolipoprotein. The inter-patient variability is relatively lower than that observed or associated with administration of the patient population at body weight-adjusted doses.

Exposure variability can be expressed or measured as patient variation in apolipoprotein exposure following administration of a fixed dose formulation of apolipoprotein. Preferably, the variability is that which would occur when the fixed dose formulation of apolipoprotein is administered to human patients having body weights in a certain range, as compared to the variability that would occur if weight-adjusted doses were administered to human patients. having a body weight in the same range as patients receiving a fixed dose. In some embodiments, apolipoprotein exposure can be measured as an average exposure (eg, mean or median exposure), total exposure (eg, cumulative amount over time of exposure), or maximum exposure level (eg, C _max ). Typically, the weight, or weight range, of a body is 20, 30, 40, 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190 or 200 kg, or any range between these values. Preferably, the weight, or weight range, of the body is 20-200 kg, 20-60 kg, 40-160 kg, 50-80 kg, 60-140 kg, 70-80 kg, 80-120 kg, 100-180 kg, or 120-200 kg.

Preferably, the variability is less than 100% or preferably 99%, 98%, 97%, 96% 95%, 94%, 93%, 92%, 91%, or less than 90%, 85% or 80% of the variability, occurring in the case of administration of weight-adjusted doses. Variability can be calculated and expressed using any statistical measure known in the art, including but not limited to coefficient of variation (eg, % CV), standard deviation, standard error, or the like.

Despite administration of a fixed dose formulation of apolipoprotein to patients with significant body weight variation, apolipoprotein exposure in patients is surprisingly uniform. Accordingly, it is expected that the therapeutic efficacy of a fixed dose formulation of apolipoprotein will not be significantly impaired or reduced compared to a body weight adjusted dose formulation.

By way of example only, it has been shown that there is no difference in total apolipoprotein exposure when a fixed dose formulation of apolipoprotein is administered to patients weighing in the range of 60-120 kg. In addition, the C _max value for apolipoprotein decreased by an average of 16% in the body weight range of 60-120 kg.

In comparison, in weight-adjusted dose regimens using the same apolipoprotein formulation, doubling body weight from 60 kg to 120 kg requires doubling the dose of apolipoprotein and increasing the exposure to apoA-I.

Apolipoprotein fixed dose formulations may be administered in multiple doses at any suitable frequency, including daily, biweekly, weekly, biweekly, or monthly. Apolipoprotein fixed dose formulations can be administered by any route of administration known in the art, such as intravenous (e.g., as a bolus or continuous infusion over a period of time, e.g., 60, 90, 120, or 180 minutes), intramuscular, intraperitoneal, intra-arterial, including directly into the coronary arteries, into the cerebrospinal fluid, subcutaneous, intra-articular, intra-synovial, intrathecal, oral, topical or inhalation routes of administration. Typically, fixed dose formulations of apolipoprotein are administered parenterally, eg, by intravenous infusion or injection.

Preferred fixed doses include 0.1-15 g, 0.5-12 g, 1-10 g, 2-9 g, 3-8 g, 4-7 g or 5-6 g of apolipoprotein. Particularly preferred fixed doses include 1-2 g, 3-4 g, 5-6 g or 6-7 g of apolipoprotein. Non-limiting examples of specific fixed doses include 0.25 g, 0.5 g, 1 g, 1.7 g, 2 g, 3.4 g, 4 g, 5.1 g, 6 g, 6.8 g, and 8 g apolipoprotein. Accordingly, the vial of the fixed dose vHDL formulation preferably contains a lyophilized vHDL formulation with an apolipoprotein content of 0.25 g, 0.5 g, 1, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 8 or 10 g per ampoule. More preferably, the content of apolipoprotein is either 2, 4, 6, 8, or 10 g per ampoule. Particularly preferably, the ampoule contains 6 g or more of the vHDL formulation.

A non-limiting example of fixed dose formulations of CSL112 in HDL can be found in International Patent Publication WO2013/090978.

The lipid in vHDL can be any lipid that is a functional, biologically active component of natural HDL or reduced high density lipoprotein (vHDL). Such lipids include phospholipids, cholesterol, cholesterol esters, fatty acids and/or triglycerides. Preferably, the lipid is at least one charged or uncharged phospholipid, or a mixture thereof.

In a preferred embodiment, the vHDL formulation of the present invention contains a combination of a detergent and an uncharged phospholipid. In an alternative preferred embodiment, the vHDL formulation contains a charged phospholipid but no detergent at all. In a further preferred embodiment, the vHDL formulation contains charged and uncharged lipids as well as a detergent.

The "uncharged phospholipids" described herein, also referred to as neutral phospholipids, are phospholipids having a net charge of approximately zero at physiological pH. The uncharged phospholipids may be zwitterions, although other types of total neutral phospholipids are known and may be used. "Charged phospholipids" are phospholipids that have a net charge at physiological pH. The charged phospholipid may include a single species of charged phospholipid, or a mixture of two or more different, generally equally charged, phospholipids. In some examples, the charged phospholipids are negatively charged glycophospholipids.

The vHDL formulation may also contain a mixture of different lipids, for example a mixture of several uncharged lipids, or an uncharged lipid and a charged lipid. Examples of phospholipids include phosphatidylcholine (lecithin), phosphatidic acid, phosphatidylethanolamine (cephalin), phosphatidylglycerol (PG), phosphatidylserine (PS), phosphatidylinositol (PI), and sphingomyelin (SM), or natural or synthetic derivatives thereof. Natural derivatives include egg phosphatidylcholine, egg phosphatidylglycerin, soy phosphatidylcholine, hydrogenated soy phosphatidylcholine, soy phosphatidylglycerin, brain phosphatidylserine, sphingolipids, brain sphingomyelin, egg sphingomyelin, galactocerebroside, gangliosides, cerebrosides, cephalin, cardiolipin, and dice tyl phosphate. Synthetic derivatives include dipalmitoylphosphatidylcholine (DPPC), didecanoylphosphatidylcholine (DDPC), dierucoylphosphatidylcholine (DEPC), dimyristoylphosphatidylcholine (DLPC), palmitoyloleoylphosphatidylcholine (PMPC), palmitoylstearoylphosphatidylcholine (PSPC), dioleoylphosphatidylethanolamine (DOPE), dilauroylphosphatidylglycerol (DLPG ), distearoylphosphatidylglycerol (DSPG), dioleoylphosphatidylglycerol ( DOPG), palmitoyloleoylphosphatidylglycerol (POPG), dimyristoylphosphatidic acid (DMPA), dipalmitoylphosphatidic acid (DPPA), distearoylphosphatidic acid (DSPA), dipalmitoylphosphatidylserine (DPPS), distearoylphosphatidylethanolamine (DSPE), dioleoylphosphatidylethanolamine (DOPE), dioleoylphosphatidylserine (DOPS), dipalmito ylsphingomyelin (DPSM) and distearoilsphingomyelin (DSSM).

The phospholipid may also be a derivative or analogue of any of the above phospholipids. The best results can be obtained with phosphatidylcholine. In another embodiment, the lipids in the formulation of the present invention are sphingomyelin and a negatively charged phospholipid such as phosphatidylglycerol (eg, DPPG).

A vHDL formulation may contain a mixture of sphingomyelin and phosphatidylglycerol (particularly DPPG). In these embodiments, sphingomyelin and phosphatidylglycerol may be present in an appropriate ratio, eg, 90:10 to 99:1 (by weight), typically 95:5 to 98:2, and most commonly 97:3. In other embodiments, the implementation of the composition vHDL does not contain a mixture of sphingomyelin and phosphatidylglycerol (in particular, DPPG).

Preferably, the molar ratio of apolipoprotein:lipid is generally from about 1:20 to about 1:120, and preferably from about 1:20 to about 1:100, more preferably from about 1:20 to about 1:75 (mol :mol), and in particular from 1:45 to 1:65. This range includes such molar ratios as, for example, 1:25, 1:30, 1:35, 1:40, 1:45, 1:50, 1:55, 1:60, 1:65, 1:70, 1:75, 1:80, 1:85, 1:90, 1:95 and 1:100. A particularly preferred ratio of apolipoprotein:lipid is from 1:40 to 1:65 (mol:mol). This ensures that the vHDL formulation of the present invention contains lipid at a level that does not cause liver toxicity.

In other embodiments, the molar ratio of apolipoprotein:lipid may range from about 1:80 to about 1:120. For example, the ratio may be from 1:100 to 1:115, or from 1:105 to 1:110. In such embodiments, the molar ratio may be, for example, 1:80 to 1:90, 1:90 to 1:100, or 1:100 to 1:110. In alternative embodiments, the apolipoprotein:lipid molar ratio is not in the range of about 1:80 to about 1:120.

Preferably, the HDL formulation contains a stabilizer. Typically, the stabilizer is present at a concentration of from about 1.0% to about 6.0%, for example, from 1.0, 1.1, 1.2 or 1.3% to 5.5, 5.6, 5, 7, 5.8, 5.9, or 6.0%, preferably from about 1.0% to less than 6.0%, for example, from about 1.0% to 5.9% (based on the weight of the composition vHDL). Preferably from about 3.0% to less than 6.0%, for example, from about 3.0% to 5.9%, preferably from about 4.0% to 5.9%, preferably from about 4.0% to 5 .5%, preferably from 4.3% to 5.3%, preferably from 4.3% to 5.0%, and most preferably from 4.6% to 4.8% (by weight), and in the specified composition the ratio between apolipoprotein and lipid is preferably from about 1:20 to about 1:75, more preferably from about 1:45 to about 1:65 (mol:mol). The lyophilization stabilizer is preferably a sugar (eg a disaccharide such as sucrose).

This relatively low amount of stabilizer may reduce the risk of renal toxicity. It is also particularly suitable for patients receiving contrast agents for acute coronary syndrome (ACS) therapy, as these agents may compete with the stabilizer for renal clearance.

Preferably, the stabilizer is a "lyophilization stabilizer", which is a substance that stabilizes a protein during lyophilization. The preferred lyophilization stabilizer is sugar. For example, disaccharides such as sucrose are particularly suitable sugars for use as a lyophilization stabilizer. Other disaccharides that can be used include fructose, trehalose, maltose and lactose. In addition to disaccharides, trisaccharides such as raffinose and maltotriose can be used. Larger oligosaccharides may also be suitable, such as maltopentose, maltohexose and maltoheptose. Alternatively, monosaccharides such as glucose, mannose and galactose can be used. These mono-, di-, tri- and larger oligosaccharides can be used either alone or in combination with each other.

In some other embodiments, the lyophilization stabilizer is a sugar alcohol, an amino acid, or a mixture of sugar and a sugar alcohol and/or an amino acid.

A particular sugar alcohol is mannitol. Other sugar alcohols that can be used include inositol, xylitol, galactitol, and sorbitol. Polyols such as glycerol may also be suitable.

You can use a mixture of sucrose and mannitol. Sugar and sugar alcohol can be mixed in any suitable ratio, for example, from about 1:1 (by weight) to about 3:1 (by weight) and, in particular, about 2:1 (by weight). Particularly contemplated are ratios of less than 2:1, for example less than 3:2. Typically, the ratio is greater than 1:5, eg greater than 1:2 (by weight). In some embodiments, the formulation contains less than 4% sucrose and 2% mannitol (based on the weight of the vHDL formulation), such as 3% sucrose and 2% mannitol. In some embodiments, the composition contains 4% sucrose and less than 2% mannitol. In some embodiments, the formulation contains less than 4% sucrose and less than 2% mannitol, such as about 1.0% to 3.9% sucrose and about 1.0% to 1.9% (by weight) mannitol.

Amino acids that can be used as freeze-drying stabilizers include proline, glycine, serine, alanine, and lysine. Modified amino acids can also be used, for example 4-hydroxyproline, L-serine, monosodium glutamate, sarcosine and γ-aminobutyric acid. Proline is a particularly suitable amino acid for use as a lyophilization stabilizer. In some embodiments, the lyophilization stabilizer is a mixture of sugar and amino acid. For example, a mixture of sucrose and proline can be used. Sugar and amino acid can be mixed in any suitable ratio, for example, from about 1:1 to about 3:1 (by weight) and, in particular, about 2:1 (by weight). Particularly contemplated are ratios of less than 2:1, for example less than 3:2 (by weight). Typically, the ratio is greater than 1:5, eg greater than 1:2 (by weight). Preferably, the amino acid is present at a concentration of from about 1.0 to about 2.5%, such as 1.0, 1.2 or 1.3 to 2.0, 2.1, 2.2, 2.3, 2, 4 or 2.5% (based on the weight of the vHDL composition). In some embodiments, the formulation contains 1.0% sucrose and 2.2% proline, or 3.0% sucrose and 1.5% proline, or 4% sucrose and 1.2% proline. The amino acid can be added to the sugar to keep the solution isotonic. Solutions with osmolality greater than 350 mosmol/kg are typically hypertonic, while solutions with osmolality less than 250 mosmol/kg are typically hypotonic. Solutions with osmolality from 250 mosmol/kg to 350 mosmol/kg are generally isotonic.

The ratio between apolipoprotein and lyophilization stabilizer is generally adjusted such that the ratio is from about 1:1 to about 1:7 (by weight). More preferably, the ratio is from about 1:1 to about 1:3, in particular from about 1:1.1 to about 1:2. Thus, in specific embodiments, the vHDL formulations have a ratio of 1:1.1, 1:1.2, 1:1.3, 1:1.4, 1:1.5, 1:1.6, 1:1 .7, 1:1.8, 1:1.9 or 1:2 (by weight). However, it is contemplated that in specific embodiments where amounts of protein are low (e.g., <20 mg/mL), the ratio between apolipoprotein and freeze-drying stabilizer can be widened, e.g., about 1:7 (by weight), e.g., about 1:4.5 (by weight).

See International Patent Publication WO2014/066943 for non-limiting specific examples and descriptions of lyophilization stabilizers in the context of the CSL112 vHDL formulation.

In some optional embodiments, the implementation of the composition vHDL contains a detergent. The detergent can be any ionic (eg, cationic, anionic, zwitterionic) detergent or non-ionic detergent, including bile acids and their salts suitable for use in vHDL formulations. Ionic detergents may include bile acids and their salts, polysorbates (e.g. PS80), 3-[(3-cholamidopropyl)dimethylammonio]-1-propanesulfonate (CHAPS), 3-[(3-cholamidopropyl)dimethylammonio]-2-hydroxy- 1-propanesulfonate (CHAPSO), cetyltrimethylammonium bromide, lauroylsarcosine, t-octylphenylpropanesulfonic acid and 4'-amino-7-benzamidotaurocholic acid.

Bile acids are typically dihydroxylated or trihydroxylated 24 carbon steroids, including cholic acid, deoxycholic acid, chenodeoxycholic acid, or ursodeoxycholic acid. Preferably, the detergent is a bile salt such as cholate, deoxycholate, chenodeoxycholate or ursodeoxycholate. A particularly preferred detergent is sodium cholate. The concentration of the detergent, in particular sodium cholate, is preferably 0.3-1.5 mg/ml. In some embodiments, the vHDL formulation contains cholate at levels of about 0.015-0.030 g/g apolipoprotein. Bile acid concentration can be determined by various methods, including colorimetric analysis (for example, see Lerch et. al., 1996, Vox Sang. 71:155-164; Sharma, 2012, Int. J. Pharm Biomed. 3(2), 28- 34; and the Gallsäuren and Gallsäuren-Stoppreagens assay kit (Trinity Biotech)). In some embodiments, the vHDL formulation contains cholate at levels of 0.5-1.5 mg/mL, as determined in a colorimetric assay.

In a preferred embodiment, the vHDL formulation disclosed herein has a pH in the range of 6 to 8, preferably in the range of 7 to 8. Even more preferably, the pH is in the range of 7.3 to 7.7.

In a preferred embodiment, the vHDL formulation is lyophilized. Due to the presence of the freeze-drying stabilizer described earlier herein, preferably sucrose, in combination with the apolipoprotein:lipid combination, freeze-drying produces a stable powder having a long shelf life. This powder can be stored, used immediately or after storage as a powder, or used after rehydration used to prepare a reconstituted high density lipoprotein formulation.

The invention can be applied to vHDL made in a large scale manufacturing process using human plasma derived apoA-I. The lyophilized product may be prepared from bulk formulations or, alternatively, the protein/lipid mixed solution may be dispensed into small containers (eg, single dose containers) prior to lyophilization, and such small containers may be used as sterile unit dosage forms. The lyophilized formulation can be reconstituted to provide a solution or suspension of a protein-lipid complex, which is a reconstituted high density lipoprotein. The lyophilized powder is rehydrated with an aqueous solution to an appropriate volume. Preferred aqueous solutions are water for injection (WFI), phosphate buffered saline or physiological saline. The mixture can be stirred to facilitate rehydration. Preferably, the reduction step is carried out at room temperature.

The person skilled in the art is well aware of how a solution containing lipid and apolipoprotein, such as described in WO 2012/000048, can be obtained.

The lyophilized vHDL formulation of the present invention can be prepared using any lyophilization method known in the art, including, but not limited to, freeze drying, i.e., a solution containing an apolipoprotein/lipid mixture is subjected to freezing followed by dehydration under reduced pressure.

The present lyophilized vHDL formulations can retain substantially their original stability characteristics for at least 2, 4, 6, 8, 10, 12, 18, 24, 36 or more months. For example, lyophilized vHDL formulations stored at 2-8°C or 25°C can generally retain HPLC-SEC molecular size distribution substantially unchanged after storage for 6 months or longer. Specific embodiments of a vHDL formulation may be stable and suitable for commercial pharmaceutical use for at least 6 months, 12 months, 18 months, 24 months, 36 months, or even longer when stored at 2-8°C and/ or at room temperature.

It should also be understood that the method and/or formulation of vHDL disclosed herein may include one or more additional therapeutic agents. Similarly, the reduced high density lipoprotein (vHDL) formulation disclosed herein, used in the specific methods disclosed herein, may be used with one or more additional therapeutic agents. Preferably, one or more additional therapeutic agents can help or contribute to the treatment, prevention or reduction of the risk of acute myocardial infarction (MI) and/or SRSS, and/or increase reverse cholesterol transport (RCT) in a human patient, but without limitation.

One or more additional therapeutic agents may include: one or more lipid-modifying agents; one or more cholesterol absorption inhibitors; one or more anticoagulants; one or more antihypertensive agents; and one or more bile acid binding molecules.

Lipid-modifying agents can cause a decrease or decrease in LDL and/or triglyceride levels, and/or an increase in HDL levels. Non-limiting examples include HMG-CoA reductase inhibitors, fibrates (eg, fenofibrate, gemfibrozil), subtilisin-kexin type 9 proprotein convertase 9 (PCSK9) inhibitors, and niacin.

Non-limiting examples of HMG-CoA reductase inhibitors include, but are not limited to, "statins" such as lovastatin, rosuvastatin, atorvastatin, pitavastatin, and simvastatin.

A non-limiting example of a cholesterol uptake inhibitor is ezetimibe, which can be administered alone or together with a statin, as described earlier herein.

Non-limiting examples of anticoagulants include, but are not limited to, warfarin, vitamin K antagonists, heparin or derivatives thereof, factor Xa inhibitors, and thrombin inhibitors.

Non-limiting examples of antihypertensive agents include angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, ramipril, captopril, etc.), angiotensin II receptor antagonists (eg, irbesartan), renin inhibitors, adrenergic receptor antagonists, calcium channel blockers, vasodilators, benzodiazepines, and diuretics (for example, thiazides), but without limitation.

Non-limiting examples of bile acid binding molecules, or "sequestrants", include, but are not limited to, cholestyramine, colestipol, and colesevilam.

Appropriate doses of one or more additional therapeutic agents can be readily determined based on existing, proven safe dose regimens for those agents, which can be easily changed or modified by practitioners of the art.

It should be understood that one or more additional therapeutic agents may be included in the vHDL formulation disclosed herein, or may be administered separately in accordance with the method of treatment or therapeutic use disclosed herein. This may include administration before or after administration of the vHDL formulation disclosed herein, at least within 24, 18, 12, 6, 3, 2, or 1 hours of administration of the vHDL formulation.

For easier understanding and practical application of specific embodiments of the invention, the following non-limiting examples are given.

EXAMPLES

Abbreviations

ACS: Acute coronary syndrome

AE: Adverse event

AKI: Acute Kidney Injury

AMI: Acute myocardial infarction

ApoA-I: Apolipoprotein A-I

AST: Aspartate aminotransferase

AUC: Area under the curve

BARC: Academic Research Consortium on Bleeding

CCA: Coronary Artery Disease

RTX: Reverse Cholesterol Transport

CKD-EPI: Collaboration in the Epidemiology of Chronic Kidney Disease

SC: System clearance

C _max : Maximum plasma concentration

SS: Cardiovascular disease

DSMB: Independent Data Monitoring Committee

eGFR: Estimated glomerular filtration rate

HAV: Hepatitis A virus

HBV: Hepatitis B virus

HCV: Hepatitis C virus

HDL: High Density Lipoprotein

HIV: Human Immunodeficiency Virus

ITT: Population of all patients originally selected for study

LVEF: Left ventricular ejection fraction

SNOS: Serious adverse cardiovascular events

MI: Myocardial Infarction

Mind. PN: Moderate renal failure

TNK: Nucleic acid testing

NFP: Normal kidney function

NYHA: New York Heart Association

PC: Phosphatidylcholine

PCI: Percutaneous coronary intervention

PK/PD: Pharmacokinetics/Pharmacodynamics

PN: renal failure

SAE: Serious Adverse Event

t _1/2 : Half-life

AELV: Adverse event occurring during treatment

T _max : Time to reach maximum plasma concentration

HPN: Upper limit of normal

V _ss : Volume of distribution at steady state

EXAMPLE 1

CSL112 is a plasma-derived apoA-I, the main functional component of HDL, reduced to disc-shaped lipoproteins with phosphatidylcholine and stabilized with sucrose24. Initial studies with CSL112 administration demonstrated a significant dose-dependent increase in plasma levels of apoA-I and a dose-dependent increase in total and ABCA1-dependent reverse cholesterol transport ^25-27 . To date, a favorable safety profile has been demonstrated in clinical studies, including in patients with stable atherosclerotic heart disease, although it has not been characterized in patients with acute MI ²⁷ . Development of a prototype formulation of CSL112 was discontinued due to a transient increase in liver enzymes, presumably related to the content of the phosphatidylcholine excipient ^28,29 . With intravenous administration of high doses of sucrose, a risk of renal toxicity has been noted. Therefore, the inventors evaluated both liver function and kidney function after infusion of this formulation of CSL112, having a lower phosphatidylcholine content and a lower sucrose content, in MI patients.

The Apo-I Event reductinG in Ischemic Syndromes I (AEGIS-I) study was a phase 2b, multicenter, randomized, placebo-controlled, dose-titrated clinical trial whose primary objective was to assess safety and tolerability, with secondary and exploratory objectives including determination of time to first ESOS, and to determine pharmacokinetics and pharmacodynamics for 4 weekly two doses of CSL112 versus placebo in acute MI patients with either normal renal function or mild renal impairment (ClinicalTrials.gov: NCT02108262).

Methods

Study control

The AEGIS-I study was a randomized, double-blind, placebo-controlled dose-titrated phase 2b clinical trial co-designed by the study sponsor (CSL Behring) and executive and steering committee members. Statistical analysis was performed independently by the PERFUSE research team using SDTM databases. The Executive Committee drafted all draft versions of the manuscript and approved the contents of the final version. The sponsor had the opportunity to review and comment on the final version of the manuscript, but had no editorial authority. The design of the study was in accordance with the 1964 Declaration of Helsinki and its later revisions, and was approved by the relevant national and institutional regulatory authorities and ethics committees. An independent data monitoring committee (DSMB) oversaw the study and reviewed the data after the randomization code was released.

The population included in the study

The study included men and women aged at least 18 years with clinical manifestations consistent with type I MI (spontaneous) within the last 7 days who had either normal renal function or mild renal insufficiency. The criteria for defining MI were based on the third universal definition of MI ³⁰ . Normal kidney function was defined as eGFR ≥90 ml/minute/1.73 m ² and mild renal failure was defined as eGFR <90 ml/minute/1.73 m ² and ≥60 ml/minute/1.73 m ² .

The main exclusion criteria included the presence of evidence of current hepatobiliary disease, the presence of an initial moderate or severe chronic renal failure, a history of acute kidney injury caused by a contrast agent, or the presence of ongoing hemodynamic instability. Among subjects undergoing angiography who were injected with contrast, stable renal function at least 12 hours after contrast injection (i.e., no increase in serum creatinine by ≥0.3 mg/dL from pre-contrast levels) was required. condition for inclusion in the study. The study was approved by an institutional review committee and all subjects provided written informed consent prior to enrollment in the study.

Study protocol

The US Food and Drug Administration instructed the DSMB to review the study's kidney and liver safety issues after the first 9 patients were enrolled in the study, and enrollment into the main study was initiated following DSMB's approval. Eligible patients were first stratified by state of renal function (either normal renal function or mild renal impairment) and then randomized in a 1:1:1 ratio to one of three treatment groups: low-dose CSL112 (2 g apoA-I /dose), the high dose CSL112 group (6 g apoA-I/dose) or the placebo group. Study formulation was administered as a weekly 2 hour intravenous infusion for 4 consecutive weeks (on study days 1, 8, 15 and 22). The active treatment period was defined as the time from the first dose of study formulation (study day 1) to one week after the last infusion (study day 29).

Patients were assessed regularly at predetermined time intervals from screening to the last follow-up visit. Health assessment included physical examination, tests for serum creatinine, total bilirubin, alkaline phosphatase, ALT, AST, BUN, Cr, glucose, metabolic, cardiovascular and lipid biomarkers, markers of immunogenicity, as well as an assessment of the area of infusion, bleeding and adverse events . The occurrence of serious adverse cardiovascular events (SAEs) was also monitored in all subjects for up to one year after randomization, or until the time the last randomized subject completed the study day 112 visit.

Plasma concentrations of apoA-I and ex vivo reverse cholesterol transport were measured at several time points. In addition, a pharmacokinetic/pharmacodynamic (PK/PD) substudy was performed for 63 patients. Subjects included in the substudy were equally stratified for renal function status and were randomized 2:3:3 to placebo, low-dose CSL112 (2 g apoA-I/dose), or high-dose CSL112 (6 g apoA-I). I/dose), respectively. The ability of plasma to mediate reverse cholesterol transport from cultured J774 cells was determined as previously described ²⁶ . These assays measured both total reverse cholesterol transport and reverse transport that could be associated with the ABCA1 transporter. Both measures of reverse transport were expressed as a percentage of cellular cholesterol content. Additional details of the design of the AEGIS-I study have been published previously ³¹ .

Combined primary safety endpoints

The combined primary safety endpoints were hepatotoxicity and renal toxicity. Hepatotoxicity was defined as either ALT >3x upper limit of normal (ULN) or total bilirubin >2x ULN confirmed on remeasurement. Renal toxicity was defined based on either serum creatinine ≥1.5x baseline confirmed by repeat measurement or need for renal replacement therapy. Safety endpoints for both the liver and the kidneys were assessed from the start of the study (before the first infusion) until the end of the active treatment period (day 29 of the study). All combined primary safety endpoints were based on results from the central laboratory.

Secondary and exploratory endpoints

Secondary and exploratory efficacy endpoints were assessed in the All Initially Selected (ITT) Patient Population (all randomized patients, including those not receiving study formulation), and these criteria included time to first ESOS, which was defined as , as the sum of deaths from cardiovascular disease, cases of non-fatal MI, ischemic stroke, or hospitalization for unstable angina, from the time of randomization up to the time the last treated subject completed the study day 112 visit. All SIOS were reviewed by an independent clinical event control committee, whose members were not aware of the randomization codes.

Bleeding was assessed as a secondary safety endpoint as most subjects were expected to receive dual antiplatelet therapy after MI. Measured and baseline-corrected plasma concentrations of apoA-I were evaluated, pharmacodynamic characteristics of CSL112 were analyzed, including changes in total and ABCA1-dependent reverse cholesterol transport ( ex vivo ), and lipid, metabolic, and cardiovascular biomarkers were analyzed. Additional preset endpoints are described earlier ³¹ .

Statistical analysis

Statistical analysis was performed using SAS ^® version 9.4. All safety endpoints were analyzed in a safety population that consisted of randomized subjects who received at least one partial dose of study formulation. In the safety population, subjects were classified according to the actual treatment they received and their true typical group for renal function status. Endpoints for evaluating efficacy were analyzed in the ITT population, which consisted of all randomized subjects. In the ITT population, subjects were classified according to the treatment for which they were randomized and according to the typical renal function group from which they were randomized, regardless of the actual treatment or true typical group for kidney function. Additional populations, such as the PK analysis population, the PK/PD analysis population, and the biomarker analysis population, were predefined in the study protocol.

The Newcomb-Wilson method was used to calculate two-sided 95% confidence intervals for the difference in scores (CSL112 minus placebo) for the combined primary safety endpoints. The upper limit of the two-tailed 95% confidence interval was established for the combined primary endpoints compared to the established endpoint cut-offs to assess hepatic and renal safety to assess non-inferiority. This gives a one-sided 2.5% Type I error for each of the endpoints for assessing hepatic and renal safety, and was based on the use of the Bonferroni method to control for a total Type I error of 5%. It was predetermined that the results would meet the no less effective criteria for difference in scores if the upper limit of the 95% confidence interval was ≤4% in liver function results and ≤5% in renal function results in a pairwise comparison of treatment groups. Bleeding results were compared for the three groups.

Although not powerful enough to detect a difference in SNOS, secondary and exploratory outcomes for SNSS were assessed by calculating the difference in time to the first occurrence of SNSS between treatment groups using a Cox proportional hazards model using allocation to treatment group and typical group by baseline function. kidneys as covariates. A two-sided log-rank p-value was calculated for each dose of CSL112 versus placebo, stratified by renal function. No formal hypothesis testing for the SNCL was intended.

results

From January 2015 to November 2015, a total of 1258 patients in 16 countries were randomized, of whom 1244 (99.6%) received at least one dose of study formulation and 1147 (91.2%) received all 4 infusions . A total of 680 (54.1%) patients were stratified into the typical normal renal function group and 578 (45.9%) were stratified into the typical mild renal impairment group (Figure 1). As an index event, 61.6% of patients underwent STEMI and 38.4% underwent NSTEMI. The median time from index event to randomization was 4 days, and although for 24-34 patients per treatment group, the follow-up period was one year, the median follow-up period was 7.5 (IR 5.8, 9.7) months . Baseline characteristics were well balanced between the 3 treatment groups (Table 1).

Results for combined primary endpoints

During the active treatment period, the development of liver failure, as a combined primary safety endpoint, occurred in 0 (0.0%) patients in the placebo group, 4/415 (1.0%) patients in the 2 g dose group ( p=0.12 vs. placebo), 2/416 (0.5%) patients in the 6 g dose group (p=0.50 vs. placebo). The results for both dose groups compared to the placebo group were not significantly different and were within the predetermined limits of ≤4% (Table 2). There were no cases in the study consistent with High's law (i.e., simultaneous elevations in ALT/AST and bilirubin without any other explanation for the combination). The results of two predefined sensitivity analyzes, including patients with elevated baseline bilirubin levels and all elevated values, regardless of the confirmed values, were in line with the results of the primary safety analysis (Table 7).

The development of renal failure, as a combined primary safety endpoint, occurred in 1/413 (0.2%) patients in the placebo group, 0/415 (0.0%) patients in the 2 g dose group (p=0 .50 vs. placebo) and 3/416 (0.7%) patients in the 6 g dose group (p=0.62 vs. placebo). The results for both dose groups compared to the placebo group were not significantly different and were within the predetermined limits of ≤5% (Table 2). The results of additional predefined exploratory safety analyzes and post hoc analyzes are shown in Tables 8 and 9.

Results for secondary and exploratory endpoints

At 12 months of follow-up, the risks of developing a combined ESOS as a secondary endpoint (CV death, non-fatal MI, ischemic stroke, and hospitalization for unstable angina) with CSL112 treatment compared with placebo were similar (low dose [ 2 g] (27/419, 6.4%) vs. placebo (23/418, 5.5%): relative risk, 1.18; 95% CI, 0.67-2.05; p=0.72 ) and high dose [6 g]: (24/421, 5.7%, relative risk, 1.02; 95% CI, 0.57-1.80; p=0.52) (Figure 2). Similar risks were observed for treatment groups with respect to combined ESOS as an exploratory endpoint, including the traditional phase 3 endpoint of death from cardiovascular disease, non-fatal MI, and stroke (Figure 3). As with the combined SIOS as a secondary endpoint, the results for most of the SIOS as additional study endpoints were similar across treatment groups. There was a difference in the number of deaths associated with cardiovascular diseases when comparing CSL112 with 6 g apoA-I (n=4, 1.0%; p=0.0477) and placebo (n=0, 0.0% ), however, this difference was absent when comparing CSL112 with 2 g apoA-I (n=2, 0.5%; p=0.32) and placebo. However, the number of patients who died from cardiovascular disease was low (Table 3). Similarly, there was a difference in the incidence of heart failure when CSL112 was compared with 6 g apoA-I (n=4, 1.0%; p=0.2525) and placebo (n=1, 0.2%), and CSL112 with 2 g apoA-I (n=5, 1.2%; p=0.1205) and placebo. The number of patients experiencing heart failure was low (Table 3).

Bleeding rates for all BARC categories were low and comparable across all 3 groups (Table 4). Hypersensitivity reactions to the drug and reactions in the infusion zone were approximately the same for all groups. In general, the rates of serious and life-threatening adverse events, as well as serious adverse events leading to discontinuation of the drug, were relatively low and comparable in all groups (Tables 10 and 11).

Baseline plasma concentrations of apoA-I, reverse cholesterol transport, and lipid and cardiovascular biomarkers were similar across the three treatment groups (Table 5). CSL112 infusion resulted in a dose-dependent increase in both apoA-I levels and reverse cholesterol transport (Table 6). A dose of 2 g resulted in a 1.29-fold increase in apoA-I levels and a 1.87-fold increase in total reverse cholesterol transport, while a 6 g dose resulted in a 2.06-fold increase in apoA-I levels and total reverse cholesterol transport. 2.45 times. Consistent with previous results, the increase in ABCA1-dependent reverse cholesterol transport (3.67-fold for the 2 g dose, 4.30-fold for the 6 g dose) was significantly greater than the increase in apoA-I or total reverse cholesterol transport. cholesterol transport, indicating that CSL112 may not only cause an increase in circulating apoA-I, but may also cause an increase in activity for ABCA1-dependent reverse transport per apoA-I ²⁶ . The inventors estimated this "specific activity" of the apoA-I circulating pool for ABCA1-dependent reverse cholesterol transport by calculating the ABCA1-dependent reverse cholesterol transport/apoA-I ratio at the end of the infusion. CSL112 infusion resulted in a 2.51-fold increase in the ratio in the 2 g dose group (0.05) and a 1.78-fold increase in the ratio in the 6 g dose group (0.035) compared to the placebo group (0.02) ²⁶ . The increase in ABCA1-dependent reverse transport was greater than the increase in apoA-I. Although this ratio is not a recognized indicator, it can be assumed that the infusion leads to an increase not only in the number, but also in the functionality of the apoA-I pool. Indeed, ratios of ABCA1-dependent reverse cholesterol transport/apoA-I were increased with both doses of CSL112 compared to placebo (Table 9).

Discussion

Infusions of both low [2 g] and high [6 g] doses of CSL112, reconstituted plasma-derived apoA-I, given as 4 weekly infusions starting within 7 days of acute MI, were not associated with a change in the functions of both the liver and kidneys. This study was the first in which CSL112 was administered to patients with acute MI and the first time this procedure was added to the standard of care for acute MI. Establishing the safety and feasibility of the procedure in acute MI was an important step before starting a large-scale phase 3 study to evaluate treatment outcomes. The results of the AEGIS-I study indicate that the present formulation of CSL112, in comparison with the prototype formulation, is not problematic in terms of liver safety. In addition, CSL112 infusion shortly after contrast medium administration to MI patients was not associated with renal toxicity, suggesting that CSL112 should be administered to an MI patient with normal renal function or mild renal failure shortly after angiography. A study in MI patients with moderate renal impairment is currently ongoing.

The number of SSES was generally low (n=74), as was the number of subjects for whom the follow-up period was completed within one year (89/1258). The study power for assessing SNOS as a secondary endpoint was very low, approximately 8.4% (Table 13). SIRS rates were generally comparable across all groups, although cardiovascular mortality was higher in the 6 g dose group compared to the placebo group (4 vs. 0 deaths, p=0.0477). The calculated p-value was not adjusted for a multiplicity of 32 efficacy comparisons. There was no clustering of death events in close proximity in time with CSL112 infusion (Table 12 and Figure 4). It should be noted that deaths of undetermined cause were considered deaths from cardiovascular disease. A single difference in mortality was not consistent with the overall similar indicators for SNSS.

Compared to placebo, the CSL112 formulation also resulted in improvements in reverse cholesterol transport. It has been suggested that improving HDL function, rather than HDL concentration, may be more important in stabilizing atherosclerotic plaques and reducing CV complications. In the Dallas Heart Study, high reverse cholesterol transport, a measure of the effectiveness of reverse cholesterol transport, was associated with a 67% reduction in the risk of rash compared to low reverse cholesterol transport ¹⁸ , an association independent of HDL concentration. Currently, while treatments that increase HDL levels do increase HDL levels, they have little or no effect on reverse cholesterol transport, an observation that may explain, at least in part, why therapies aimed at increasing HDL levels have not been able to reduce the incidence of SRSS in the past ^32-38 . In contrast, reverse cholesterol transport was markedly increased immediately after CSL112 infusion. In particular, ABCA1-dependent reverse transport, a pathway especially associated with cholesterol-loaded cells in plaques, was more than threefold increased after CSL112 infusion. It is worth noting that the increase in ABCA1-dependent reverse transport occurred to a greater extent than the increase in the level of apoA-I, thus indicating that the infusion leads to an increase not only in the number, but also in the functionality of the apoA-I pool. Indeed, the ratios of ABCA1-dependent reverse cholesterol transport/apoA-I were increased in both CSL112 dose groups compared to the placebo group (Table 6). Previous mechanistic studies ³⁹ showed comparable functional changes and determined that CSL112 leads to an increase in ABCA1-dependent reverse transport by restructuring endogenous HDL to smaller, more functional HDL species with a high ability to interact with ABCA1.

The increase in reverse cholesterol transport induced by CSL112 has been shown to be transient and returns to baseline after clearance of apoA-I ²⁶ . It is not known how a transient increase in reverse cholesterol transport immediately after an acute MI would affect clinical outcomes compared with permanent or long-term reverse cholesterol transport rates assessed in the Dallas Heart Disease Study ¹⁸ . Although the number of SNSS was not reduced in the AEGIS-I study, this Phase 2b study was designed as a safety study and was not powered to evaluate efficacy (Table 13). As with other phase 2 safety studies, serious adverse cardiovascular events (SAEs) were studied in AEGIS-I to estimate the timing and frequency of these events and to identify subgroups of patients at high risk for these events so that so that a phase 3 study can be designed with adequate power to reliably assess efficacy. Although these analyzes are exploratory, they were predefined to focus on analyzes when planning the Phase 3 study.

The events serving as the combined primary safety endpoints were less frequent than expected in the no-less-benefit analysis, but the very low frequency of these events suggested that there were no clinically significant problems associated with liver or kidney safety. Although several lipid and lipoprotein analyzes were performed, Lp(a) and apoE levels were not assessed after infusion.

This study was a Phase 2 safety study that did not have sufficient power to evaluate efficacy and was not intended to obtain regulatory approval for efficacy. For the number of SNES as a secondary endpoint, the power of the study was 8.4% to determine a clinically significant risk reduction of 15%, based on an event rate in the placebo group of 5.5% (Table 13). Like many phase 2 studies, this study was undertaken primarily to assess safety, but also to estimate the frequency and timing of ESOS and to identify patients at risk of such events so that a definitive phase 3 study could be carried out with adequate power to evaluate efficiency.

Finally, 4 weekly infusions of CSL112, reconstituted plasma-derived apoA-I, at both low [2 g] and high [6 g] doses, given starting within 7 days of acute MI and close in time from contrast medium administration were reasonable, were not associated with changes in both liver and kidney function or other major safety concerns, and were associated with dramatic improvements in reverse cholesterol transport. Further evaluation of the clinical efficacy of CSL112 in reducing the number of early recurrences of cardiovascular events after acute MI should be done in a well-powered, multicenter, randomized phase 3 trial.

EXAMPLE 2

Introduction

This example describes data from a clinical study of CSL112 and its ability to induce reverse transport of cholesterol from macrophages in patients with moderate renal insufficiency.

Previous clinical studies of CSL112 have demonstrated a favorable safety profile, favorable pharmacokinetic (PK) and pharmacodynamic results in healthy subjects, patients with stable atherosclerotic disease, and patients with acute MI with normal renal function (NRF) or mild renal insufficiency ^26,27 . Renal failure is a common condition in acute coronary syndrome, with approximately 30% of subjects developing stage 3 chronic renal failure (CRF). The aim of this study was to evaluate the effect of CSL112 infusion on RCT and lipoprotein biomarkers in subjects with moderate renal impairment (Mr RI).

reverse cholesterol transport

In reverse cholesterol transport, free cholesterol (CX) is transferred from cells to pre-β1-HDL by the ABCA1 transporter, which is highly expressed on macrophages in atherosclerotic plaques. The SC in the HDL particle is then esterified by lecithin-cholesterol acyltransferase (LCAT) to form larger HDL particles (HDL3 and HDL2). CX is also transported to HDL3 via the ABCG1 and SR-B1 transporters. The esterified HDL cholesterol is then transported to the liver for excretion or recycling.

Infusion of CSL112 leads to an increase in the production of pre-β1-HDL, which, in turn, causes an increase in RCT, mainly due to the ABCA1 transporter, and, as a result, an increase in LCAT activity and esterification of CX.

Methods

Study design

A phase 1, double-blind, single incremental dose study (NCT02427035) was conducted to evaluate the PK, safety, and biomarkers of CSL112 in adults with UM. Mon. Kidney failure was classified as moderate if eGFR was ≥30 and <60 ml/min/1.73 m ² . A comparison was made with NFP, in which the eGFR is ≥90 ml/min/1.73 m ² .

A total of 32 subjects participated in the study, including 16 with NPD and 16 with Um. Mon. Subjects were randomized into groups based on renal function status to receive 2 g (n=6 per group) or 6 g (n=6 per group) of CSL112, or placebo (n=4 [n=2 per CSL112 dose group]) .

The study consisted of a 28-day screening period, followed by a 16-day active treatment period, including a mandatory hospital stay during which CSL112 was administered by one 2-hour intravenous (IV) infusion, multiple outpatient visits, and a 76-day follow-up period. observations for safety assessment.

Determination of biomarkers

Thirteen different baseline cholesterol and lipoprotein reverse transport parameters were measured in each group based on the state of kidney function. Plasma apoA-I, apolipoprotein B (apoB), and highly sensitive C-reactive protein (hsCRP) were measured by immunoturbidimetric method. RCT, total and ABCA1-independent, was measured after serum incubation in vitro with macrophages preloaded with radiolabelled cholesterol, not expressing ABCA1, or with cyclic AMP-induced expression of ABCA1 (see, e.g., de le Llera-Moya et al., Arterioscler Thromb Vasc Biol 2010; 30-796-801). ABCA1-dependent RTC was calculated by subtracting ABCA1-independent RTC from total RTC. Pre-β1-HDL was measured by sandwich ELISA using conformation-specific anti-apoA-I antibody in pre-β1-HDL. Other lipid parameters were assessed by standard enzymatic methods.

Statistical analysis

A parallel Student's t-test was used to compare baseline parameters of cholesterol and lipoprotein reverse transport in patients with Um. PN and NFP. The effect on biomarkers of CSL112 dose was compared for groups based on the state of kidney function using ANOVA.

results

Initial characteristics

A total of 32 subjects (n=16 NPP and n=16 WM) received a single IV infusion of CSL112 or placebo. Baseline characteristics for each of these patient groups are shown in Table 14.

At baseline, the indicators of total and ABCA1-dependent RTC were 1.3 times and 1.8 times higher, respectively, in subjects with Um. PN compared with subjects with NFP, but there was no significant difference in ABCA1-independent RCT. Consistent with this result, there was a significant 1.4-fold increase in baseline pre-β1-HDL in the Um group. PN in comparison with the NFP group. The levels of all other lipids and lipoproteins, as well as hsCRP, at baseline were similar in groups of subjects with different renal function status (Table 15). (Meier et al., Life Sci 2015; 136:1-6, previously observed higher RCT with lower eGFR in adults with CKD).

The levels of all other lipids and lipoproteins, as well as hsCRP, at baseline were similar in groups of subjects with different renal function status (Table 15). CSL112 infusion did not significantly change levels of pro-atherogenic apoB lipids, non-HDL cholesterol, or triglycerides from baseline in any renal function group (data not shown).

Parameters of cholesterol and lipoprotein reverse transport after CSL112 infusion

Following CSL112 infusion, the apoA-I level increased rapidly in a dose dependent manner, peaking at the end of the infusion period (2 h) and remained elevated from baseline levels 72 h post infusion. Plasma concentrations of apoA-I over time were similar across groups of patients with different renal function, in each CSL112 dose group (Figure 5).

A rapid dose-dependent increase in total, ABCA1-dependent and ABCA1-independent RCT was observed after CSL112 infusion. The effect of CSL112 infusion on total and ABCA1-independent RCT was similar across groups of patients with different renal function. In both groups of patients with different renal function, the composition of CSL112 resulted in a dose-dependent increase in pre-β1-HDL levels (Figure 6A-B).

In both groups of patients with different renal function, CSL112 formulation resulted in a dose-dependent increase in total RCT, ABCA1-independent RTC, ABCA1-dependent RTC, and pre-β1-HDL levels. In the case of pre-β1-HDL, this dose-dependent increase was more pronounced in subjects with Um. PN than in subjects with DFP (Figure 7 A-B).

Without being bound by a particular theory, a possible explanation for this result is that downregulation of ABCA1 expression on peripheral cells in subjects with Um. PN leads to an increase in the levels of pre-β1-HDL due to a decrease in the ability to metabolically convert pre-β1-HDL to HDL3. In this case, infusion of CSL112 would result in a stronger increase in pre-β1-HDL levels in subjects with Um. PN than in subjects with NFP. This is consistent with the difference in baseline pre-β1-HDL levels (Table 14).

Following CSL112 infusion, there was a transient dose-dependent increase in HDL-non-esterified cholesterol (HDL-NC) levels that peaked at the end of the infusion period (2 hours) and then declined (Figure 8). This was followed by an increase in HDL-esterified cholesterol (HDL-EC) levels, peaking 24 hours after infusion and exceeding HDL-NC levels. Both HDL-NC and HDL-EC levels remained above baseline 144 hours post-infusion. Similar results were obtained for CSL112 at a dose of 2 g. This result is consistent with the constant movement of non-esterified cholesterol to HDL and rapid esterification by LCAT. LCAT activity was not directly measured in this study, however, a strong increase in esterification was previously observed in the plasma of rabbits injected with CSL112 by infusion. In dosing groups, CSL112 had a similar effect on HDL-NC and HDL-EC levels in both groups of patients with different renal function (Figure 8).

CSL112 infusion did not significantly change the levels of pro-atherogenic apoB lipids, non-HDL cholesterol or triglycerides from baseline in any of the groups of patients with different renal function.

conclusions

Infusion of CSL112 in subjects with M. PN and NFP resulted in a similar rapid, strong, dose-dependent increase in apoA-I and RCT levels. In subjects with Mind. PN showed a greater increase in pre-β1-HDL levels (p=0.003), which may reflect a reduced ability to metabolize pre-β1-HDL to HDL3. LCAT activity, manifested as a change in the ratio of free cholesterol to esterified cholesterol over time, appeared to be similar in Um subjects. PN and NFP. Neither group saw any CSL112-related changes from baseline in apoB, non-HDL cholesterol or triglyceride concentrations.

The results of this study show that CSL112 leads to an increase in the levels of reverse cholesterol transport biomarkers in a similar manner in subjects with UM. PN and NFP. This suggests that CSL112 may represent a novel therapeutic formulation to rapidly reduce atherosclerotic burden and reduce the risk of recurrent CV events in patients with UM. PN, or without it, after acute myocardial infarction.

These results were obtained for subjects with Mind. PN who did not have a MI within seven days before the start of treatment.

EXAMPLE 3

Introduction

For patients with ACS and FR, the prognosis, both short-term and long-term, is less favorable than for patients with normal renal function, since the risk of CV events and mortality are inversely proportional to the estimated glomerular filtration rate (eGFR) [Nabais et al., 2008 ; Bhandari and Jain, 2012]. Because subjects with moderate PI represent a significant proportion (i.e., up to 30% [Gibson et al., 2004; Fox et al., 2010]) of the ACS patient population, it is important to include this subpopulation in the phase 3 CSL112 study program.

The CSL112_2001 study, a multicentre, double-blind, randomized, placebo-controlled, parallel-group, Phase 2 study, was undertaken to evaluate renal and other safety with multiple doses of 6 g CSL112 in subjects with AMI and moderate HF.

Study design

The CSL112_2001 study included subjects with moderate PI who were screened within 5-7 days of AMI. Approximately 81 subjects were enrolled and randomized to receive 4 weekly infusions of a 6 g dose of CSL112 (~54 subjects) versus placebo (~27 subjects) to evaluate renal and other safety parameters. To ensure that at least one third of the patient population included in the study had an eGFR in the range of chronic renal failure (CRF) stage 3b (eGFR 30 to <45 mL/min/1.73 ^m2 ), no more than two-thirds of the patient population included in the study (ie, 54 subjects) were required to have an eGFR in the range corresponding to stage 3a CKD (45 to <60 ml/min/1.73 m ² ). During randomization, eGFR was stratified (from 30 to <45 ml/min/1.73 m ² or from 45 to <60 ml/min/1.73 m ² ), performing calculations in accordance with the formula developed by the Epidemiology of Chronic Kidney Disease (CKD-EPI) [Levey et al., 2009; Stevens et al., 2010], and the presence of a history of diabetes controlled by modern methods of pharmacotherapy. Subjects were to be observed for approximately 60 days.

Study Goals and Endpoints

The primary objective of the CSL112_2001 study was to evaluate the renal safety of CSL112 in subjects with moderate HF and AMI. The combined primary endpoints were renal SAEs and AKI events. Event frequency rates were based on the number of subjects who experienced at least 1 event of interest.

- Renal SAEs were defined according to the Medical Regulatory Activity Dictionary (MedDRA) preferred term (PT) included in the Acute Renal Failure narrow Standard MedDRA Query (SMQ) or PT for renal tubular necrosis, renal cortical necrosis, renal necrosis, or renal papillary necrosis.

- Acute kidney injury was defined as an absolute increase in serum creatinine from baseline of ≥0.3 mg/dL (26.5 µmol/L) during the active treatment period, which persisted when measured again at the central laboratory for at least than 24 hours after measuring the elevated value. If a value was not re-obtained (due to lack of follow-up or protocol violation, for example), one serum creatinine value that was ≥0.3 mg/dL (26.5 µmol/L) higher than baseline during the active treatment period, should have been sufficient to determine AKI. The baseline for determining AKI was the level of serum creatinine determined in the central laboratory before the infusion on day 1 of the study.

The secondary objectives of the study were 1) to further determine the safety and tolerability of CSL112 in subjects with moderate PN and AMI, and 2) to determine the FA of CSL112 after multiple doses in subjects with moderate PN and AMI.

Relevant endpoints for these goals included:

- Incidence of AELVs and adverse drug reactions (ARRS) or suspected SRRS

- Incidence of bleeding events during treatment

- Change from baseline in renal function (serum creatinine, eGFR) and liver function (alanine aminotransferase [ALT], total bilirubin) as measured

- Clinically significant changes in clinical laboratory test results (serum biochemistry, blood test and urinalysis), physical examination results, body weight, electrocardiogram (ECG), and vital signs

- Presence of antibodies to CSL112 or apoA-I

- Plasma concentration at the beginning of the study and after the end of the infusion of apoA-I and PC

- Accumulation ratio (R) for apoA-I and PC.

The research objectives of the study were 1) to determine the pharmacodynamic features of CSL112 by assessing the reverse transport of cholesterol, as well as other lipid and CC biomarkers of CSL112 activity, and 2) to assess the effect of CSL112 on renal safety biomarkers.

results

Distribution of participants in a clinical trial

A total of 102 subjects provided written informed consent to participate in the study and were screened for inclusion in the CSL112_2001 study (Figure 9). Of these subjects, 19 failed screening and the remaining 83 (81.4%) eligible subjects were randomized 2:1 to active formulation and placebo to receive 6 g CSL112 (55 subjects, 53.9%) or placebo. (28 subjects, 27.5%), respectively. Three subjects randomized to the CSL112 group did not receive the formulation. Sixty-nine (83.1%) randomized subjects completed the study, with 46 (83.6%) subjects completing the study in the CSL112 group and 23 (82.1%) subjects completing the study in the placebo group.

Fourteen (16.9%) subjects did not complete the study, 9/55 (16.4%) and 5/28 (17.9%) in the CSL112 and placebo groups, respectively. Reasons for subjects not completing the study included AE (1.8% CSL112; 0 placebo), death (3.6% CSL112; 7.1% placebo), protocol deviation (1.8% CSL112; 0 placebo) , subject's solution (9.1% CSL112; 7.1% placebo) and other (0 CSL112; 3.6% placebo).

Initial characteristics

The mean age of the subjects was 71.1 years, with 81.9% of the subjects being at least 65 years of age, and the mean BMI was 29.5 kg/m ² . The treatment groups were well balanced in terms of age and gender of participants (Table 16).

The mean eGFR in subjects at screening was 46.32 ml/min/1.73 m ² , determined by the central laboratory. Median laboratory eGFR approximated the end point for chronic renal failure (CRF) stage 3a/3b (ie, 45 ml/min/1.73 m ² ). At randomization, 47.0% and 53.0% of subjects were classified based on local laboratory evaluation as having stage 3b (30 to <45 ml/min/1.73 m ² ) or stage 3a (45 to < 60 ml/min/1.73 m ² ), respectively, with data from the central laboratory identifying 39.8% of subjects as having stage 3b CKD and 44.6% of subjects as having stage 3a CKD. Differences in test results from the central and local laboratories may have led to a re-categorization of subjects based on the results from the central laboratory compared to the results from the local laboratory that were used for randomization.

Subjects received aspirin (95.2%), other antiplatelet therapies (91.6%), statins (89.2% total; 59.0% high intensity), other lipid-modifying agents (6.0%), beta -blockers (79.5%), angiotensin I-converting enzyme inhibitors or angiotensin receptor blockers (74.7%) and oral antithrombotics (26.5%).

Overall, the treatment groups were well balanced in terms of demographic and baseline characteristics.

Security Analysis

Exposure of the studied composition

All 80 (100%) subjects in the safety population received at least 1 infusion of study formulation; the majority of subjects (81.3%) received, and completed, a course of 3 or 4 infusions of study formulation.

A total of 55/80 (68.8%) subjects in the safety population received all 4 infusions. Reasons for subjects not receiving all 4 infusions included AE (19.2% CSL112; 14.3% placebo), subject decision (5.8% CSL112; 10.7% placebo), death (1.9% CSL112 ; 3.6% placebo), key indicators of kidney function (0 CSL112; 3.6% placebo), physician's decision (1.9% CSL112; 0 placebo) and others (1.9% CSL112; 0 placebo).

Study formulation was discontinued in 4 subjects due to renal related adverse events, 3 (3.8%) and 1 (3.4%) subjects in the 6 g CSL112 dose group and the placebo group, respectively. In the 6 g CSL112 dose group, all events were judged by the investigator to be non-compound related. Two events in 2 subjects were non-serious and each subject received 3 doses of CSL112. A third subject developed an SAE of toxic nephropathy on study day 2 after receiving 1 dose of CSL112. In the placebo group, 1 subject experienced an SAE of renal failure on study day 12 and received 2 doses of placebo. This phenomenon was assessed by the investigator as being associated with PI. One subject in the CSL112 group missed an infusion due to "increased blood creatinine" and 2 subjects in the placebo group missed an infusion, 1 due to "acute kidney injury" and 1 due to a key laboratory parameter of kidney function that met the criterion delay and stop rules for an individual subject, this was not assessed as an undesirable phenomenon.

Two subjects in the CSL112 group experienced hepatic AEs (ALT elevation, total bilirubin elevation; both mild and transient) that met protocol criteria for discontinuation of study formulation; none of the subjects in the placebo group discontinued the study due to liver related reasons.

Time to first infusion of study formulation

The median time elapsed from angiography to the first infusion of study formulation was 65.2 hours (2.7 days), with a slightly shorter time period for the 6 g CSL112 dose group (61.83 hours [2.57 days]) in compared with the placebo group (71.79 hours [2.99 days]). The median time from angiography to first infusion was 59.47 hours (2.48 days) for subjects in whom an MI was classified as STEMI, compared with a time period of 67.2 hours (2.8 days) for those with MI classified as NSTEMI. A similar percentage of subjects with STEMI (40.0%) and NSTEMI (38.6%) received the study formulation within less than 48 hours of contrast medium administration. A small percentage of subjects (5/77, 6.5%) received their first infusion within 12 to <24 hours after angiography (Table 17).

Combined Primary Endpoint

A summary of on-treatment renal SAEs and AKI is shown in Table 18.

Treatment-related renal SAEs occurred in 1/52 (1.9%) of subjects in the 6 g CSL112 dose group compared to 4/28 (14.3%) of subjects in the placebo group. Based on the primary analysis, the difference in incidence (95% CI) between these groups was -0.124 (-0.296, -0.005). All subjects with renal SAEs experienced 1 event, with the exception of 1 subject in the placebo group who experienced 2 events.

Treatment-related AKI occurred in 2/50 (4.0%) of subjects in the 6 g CSL112 dose group compared to 4/28 (14.3%) of subjects in the placebo group. Based on the primary analysis, the difference in incidence (95% CI) between these groups was -0.103 (-0.277, 0.025). None of the subjects experienced more than 1 AKI. In 6 subjects with AKI, these events continued at the time of study completion. In subjects in both groups, based on the time between contrast medium administration and serum creatinine determination, the observed incidence of AKI was numerically lower in the CSL112 group compared to the placebo group (Table 18).

Sensitivity analyzes of the combined primary endpoints, using independently validated results for the on-treatment component of renal SAEs and local laboratory data on the on-treatment component of AKI, confirmed the results of the primary analysis.

There was no evidence that the incidence of renal SAEs or AKI was higher in the CSL112 group than in the placebo group, in subjects in the stage 3a or 3b CKD subgroups, or in subjects with diabetes. In these subgroups, a higher incidence of renal SAEs and AKI occurred in the placebo group (Table 19). The higher incidence of AKI in the CSL112 group was in subjects without a history of diabetes.

Confirmed renal serious events

Investigator's reported renal serious events were confirmed by the ERR, and of the 6 events reported by the investigator, 5 were positively confirmed: 1/2 in the CSL112 group and 4/4 in the placebo group. One event in the CSL112 group was not validated as an event because it was not serious.

All events were classified as non-obstructive (i.e., not due to physical obstruction in the kidney or ureter, such as a kidney stone), and a causal relationship was possible for 1 event in the CSL112 group, and possible or unlikely for 3 and 2 events. respectively, in the placebo group. All events were in stage 1 at diagnosis. Progression to stage 2 occurred for one positive event in the CSL112 group within 7 days of onset of AKI; in the placebo group, 2 events progressed within this time frame, 1 each to stage 2 (25%) and stage 3 (25%).

Adverse events

Unless otherwise noted, all AEs described in this section are AEs.

summary data

A summary of the AELVs described in this document is shown in Table 20.

Adverse events that occurred during treatment

A comparable number, in percentage terms, of subjects in the CSL112 and placebo groups experienced treatment-related AEs (AEs): 38 (73.1%) subjects in the 6 g CSL112 dose group and 20 (71.4%) subjects in the CSL112 dose group placebo. Events in organ system classes (OSOs) with frequent (≥10%) AELVs that were more common in the CSL112 group than in the placebo group included: cardiac disorders, investigational, respiratory disorders, thoracic and mediastinal disorders, gastrointestinal disorders and disturbances in the nervous system.

Overall, comparable percentages of CTCAE grade 3, 4, and 5 AEs occurred in the CSL112 (17.3%, 7.7%, and 3.8%, respectively) and placebo groups (35, 7%, 3.6% and 7.1% respectively). 15/52 (28.8%) subjects in the CSL112 group experienced grade 3, 4, or 5 AELV compared with 13/28 (46.4%) subjects in the placebo group. Grade 5 events occurred at a higher frequency in the placebo group (2/28, 7.1%) compared to the CSL112 group (2/52, 3.8%). Frequent (≥10% or more of subjects) AELI that occurred only in the CSL112 group included elevated blood creatinine levels, heart failure, and atrial fibrillation.

Serious adverse events

A total of 22/80 (27.5%) subjects experienced serious AELVs, with 12/52 [23.1%] and 10/28 [35.7%] subjects in the 6 g CSL112 and placebo dose groups, respectively (Table 21). Serious AELVs were noted in the following CSRs: cardiac disorders (12.5%), renal and urinary tract disorders (6.3%), infections and parasitic infestations (3.8%), gastrointestinal disorders, general disorders and complications in injection site, trauma, poisoning and procedural complications, disorders in the nervous system, as well as respiratory disorders, disorders in the chest and mediastinum (2.5% of each type), disorders in the circulatory and lymphatic systems, disorders in the external ear and labyrinth, disorders in the eye and vascular disorders (1.3% of each type).

Serious AEs reported in 2 or more subjects in the CSL112 group included (using the preferred term) atrial fibrillation (3/52, 5.8%) and heart failure (3/52, 5.8%). For subjects in the placebo group, serious AELI reported in 2 or more subjects included congestive heart failure (2/28, 7.1%) and AKI (2/28, 7.1%).

Heart failure and all renal events of interest

Adverse events that have been evaluated in more detail include heart failure and all renal events.

Treatment-related adverse events in the form of heart failure that were reported included, using the preferred term: heart failure, congestive heart failure, and acute heart failure. More, in percentage terms, the number of subjects in the CSL112 group (7/52, 13.5%) compared to the placebo group (2/28, 7.1%) had AEHF in the form of heart failure. Treatment-related SAEs in the form of heart failure occurred at similar rates in the CSL112 (4/52, 7.6%) and placebo (2/28, 7.1%) groups. One subject in each of the CSL112 and placebo groups had heart failure, which resulted in death.

Renal events that occurred during treatment included, using the preferred term, renal failure, toxic nephropathy, AKI, impaired renal function, and elevated blood creatinine levels. These events occurred with similar frequency in subjects in the CSL112 (17.3%) and placebo (14.3%) groups. As noted previously (see the Combined Primary Endpoint section), treatment-related renal SAEs occurred at a lower frequency in subjects in the CSL112 group (1.9%) than in the placebo group (14.3%).

Bleeding during treatment

Bleeding that occurred during treatment was noted by the investigators and confirmed by the clinical events review panel based on criteria developed by the Bleeding Academic Research Consortium (BARC). Similar frequency and severity of bleeding was observed in all treatment groups. All of the subjects who had a bleed had bleeds of grade 3 or less on the BARC scale. A total of 3/52 (5.8%) of subjects in the 6 g CSL112 dose group experienced BARC grade 3 bleeding compared to 1/28 (3.6%) of subjects in the placebo group. None of the subjects in any of the treatment groups had BARC grade 4 or 5 bleeding. There were no bleeding-related deaths and no central nervous system bleeding.

Adverse drug reactions or suspected adverse drug reactions

Treatment-related AEs classified as NRLS or presumptive NRLS based on the FDA ¹ definition occurred at a higher frequency in the CSL112 group (57.7%) than in the placebo group (14.3%).

The classification of a large percentage of NEPs in the CSL112 group as suspected NRLS was a consequence of applying the definition in Part 4 of the FDA document to a study with a small sample size. According to the fourth criterion, if 1 subject in the active formulation group, and none of the subjects in the placebo group, has an event, then the event should be classified as suspected NRLS. Given the small sample size, the data obtained were insufficient to determine whether all the AEs reported in the study were NRLS (i.e., causally related to CSL112).

Results of clinical laboratory tests

Tests for changes in kidney function

In addition to the staging of renal SAEs, the Clinical Events Review Panel reviewed laboratory results for increases in levels consistent with the definition of AKI in Kidney Disease: Improving Global Outcomes (KIDGO, 2012). None of the subjects in the CSL112 or placebo arms experienced stage 3 AKI (serum creatinine levels ≥3× baseline or ≥4.0 mg/dL [353.6 μmol/L]), based on serum creatinine values obtained in central or local laboratory (Table 22). For two subjects, baseline serum creatinine data from the central laboratory were lost. Most elevated serum creatinine values (67.3% 6 g CSL112; 64.3% placebo) ranged from >0 to <0.3 mg/dL increase from baseline. For each of these categories, with an increase in absolute value from baseline ranging from ≥0.3 to ≤0.5 mg/dL and an increase in serum creatinine >0.5 mg/dL from baseline, less, in percentage terms, the number subjects were in the 6 g CSL112 dose group compared to the placebo group. In one (1.9%) subject in the CSL112 group and 4 (14.3%) subjects in the placebo group, an increase in serum creatinine from baseline ranging from ≥0.3 to ≤0.5 mg/dL occurred during ≥24 hours. One (1.9%) subject in the 6 g CSL112 dose group had an increase in serum creatinine >0.5 mg/dL for ≥24 hours. None of the subjects had serum creatinine levels ≥2 times baseline.

Tests for changes in liver function

Mean baseline levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AP), and total and direct bilirubin were similar in the placebo and 6 g CSL112 dose groups. These parameters were not increased after CSL112 infusion.

The percentage of subjects in both the placebo group and the 6 g CSL112 dose group for whom ALT or total bilirubin data were not available was low. For all visits, the maximum number, in percentage terms, of subjects with missing data was 7.5% combined for ALT and total bilirubin.

None of the subjects, in either the 6 g CSL112 dose group or the placebo group, had a simultaneous increase in total or direct bilirubin to more than 2× ULN and ALT or AST to more than 3× ULN during the active treatment period ( Table 22). There were no subjects with an increase in ALT >3x ULN during the active treatment period. One (1.9%) subject in the CSL112 group had a single episode of AST increase to >5x TLN at Visit 3, which resolved by the time of Visit 4. During the active treatment period, 3 (5.8%) subjects in the CSL112 group, there was a transient increase in total bilirubin (or direct bilirubin for subjects with Gilbert's syndrome) to >1.5x ULN at visit 3, 24-48 hours after the start of the infusion, which was not seen again at visit 4 compared with no such subjects in the placebo group.

Other biochemical parameters of serum

No clinically significant differences in other serum biochemical parameters were found between treatment groups and, in general, no clinically significant trends were found.

Hematology

No clinically significant differences in hematological parameters were found between treatment groups and, in general, no clinically significant trends were found.

A total of 9/80 (11.3%) subjects had a decrease in hemoglobin levels of ≥2 g/L from baseline throughout the study, with the number of subjects, in percentage terms, being greater in the 6 g CSL112 dose group (7/ 52, 13.5%) than in the placebo group (2/28, 7.1%).

Analysis of urine

No clinically significant differences in urine parameters were found in the analysis between treatment groups and, in general, no clinically significant trends were found. Cases of changes in hemoglobin levels from baseline and qualitative determination of total protein in the urine were few and, if such changes occurred, they occurred by no more than 1 category. Single urine protein/creatinine and cystatin C/creatinine ratios showed a slight, transient increase in mean values 24-48 hours after the first CSL112 infusion, with great variability in the data.

Abnormalities in laboratory results

None of the subjects had grade 4 laboratory test abnormalities for hemoglobin, serum creatinine, eGFR, glucose (serum and urine), ALT, AST, ALP, or bilirubin (direct, indirect, or total). Grade 3 laboratory abnormalities occurred in subjects in both treatment groups for eGFR (3.8% CSL112; 7.4% placebo) and glucose (13.5% CSL112; 22.2% placebo). The only Grade 3 laboratory abnormality for AST was found in the 6 g CSL112 dose group (see section: Liver function tests).

Immunogenicity

At baseline, all subjects had reciprocal antibody titers that were found to be negative (10 or 11). None of the subjects in either the 6 g CSL112 dose group or the placebo group showed a change from baseline in reciprocal anti-CSL112 or anti-apoA-I antibody titers at the end of the active treatment period (Visit 7) or after completion of research (visit 8).

Pharmacokinetic analysis

Relative to baseline and relative to the placebo group, mean plasma concentrations of both apoA-I and PC were increased in the CSL112 group, with peak mean values occurring at the end of infusion 1 (Visit 2) and 4 (Visit 6).

A similar increase in apoA-I and PC plasma concentrations was observed in CSL112-treated subjects in each renal function subgroup at the completion of infusion 1 (Visit 2) and 4 (Visit 6).

Mean baseline-adjusted maximum observed plasma concentrations (C _max ) for apoA-I and PC were increased in the 6 g CSL112 dose group relative to the placebo group after the first and fourth infusions (Table 24). The accumulation ratio values for C _max after the 4th infusion relative to the 1st infusion for apoA-I and PC were 1.20 (20%) and 1.00 (0%), respectively. For both CSL112 analytes, plasma accumulation was low.

Total RCT was 13% higher (P < 0.001) at baseline in patients in the 2001 study compared to the AEGIS-I study patient population (Example 1). In particular, the total RCT, in %, was 9.8 ± 2.7 (n=78) in the CSL112_2001 study compared to 8.7 ± 2.7 (n=1204) in the AEGIS-I study. Similarly, ABCA1-dependent RCT was 35% higher (P < 0.001) at baseline in patients in the 2001 study compared to patients in the AEGIS-I study. ABCA1-dependent RCT, in %, was 3.6 ± 2.0 (n=78) in the CSL112_2001 study versus 2.6 ± 1.8 (n=1204) in the AEGIS-I study. There was no difference in ABCA1-independent RTC, with ABCA1-independent RTC, in %, being 6.2 ± 1.7 (n=78) in the CSL112_2001 study versus 6.0 ± 1.5 (n=1204) in the AEGIS-I study. These observations were consistent with the RCT pattern observed in subjects with moderate PN compared with subjects with normal renal function in the CSL112_2001 study (Example 2).

Cumulative renal function parameter data: AEGIS I and CSL112_2001

A pooled analysis of changes from baseline in serum creatinine and eGFR is provided in this document for AEGIS-I (study CSLCT-HDL-12-77) and CSL112_2001. The purpose of this data analysis was to determine the overall impact, as well as the impact, depending on the time of infusion of CSL112 relative to the time of angiography, on renal function in subjects with varying degrees of renal insufficiency. The AEGIS-I study evaluated CSL112 in MI subjects with either normal kidney function or mild RI. In the CSL112_2001 study, an assessment was made for AMI subjects with moderate PI. The pooled analysis of these data allowed an estimate to be made for the range of kidney function conditions expected in the target population of the Phase 3 study. In both studies, enrolled subjects are representative of the target population of the Phase 3 study in terms of age, sex, comorbid medical conditions (e.g., diabetes, hypertension ) and chronic concomitant medications (eg, statins in dual antiplatelet therapy).

Serum creatinine

The pooled analysis (FIG. 10) showed little change from baseline in mean serum creatinine levels in subjects treated with CSL112 or placebo with eGFR ≥60 mL/min/1.73 m ² and in subjects with eGFR 45-60 ml / min / 1.73 m ² during periods of active treatment and up to 7-10 days after the last infusion. In subjects with eGFR values of 30-<45 ml/min/1.73 m ^{2 ,} a decrease from baseline in mean serum creatinine levels was observed in both treatment groups starting on study day 15. Relatively comparable reductions in mean serum creatinine levels were observed in subjects in the CSL112 and placebo groups.

Analysis of changes from baseline (central laboratory) in serum creatinine levels based on typical renal function status and time between angiography and first dose showed a decrease from baseline in subjects with eGFR ranging from 30 to <45 ml /min/1.73 m ² both in the window from 24 to <48 hours and in the window ≥48 hours (Figure 11). For subjects with an eGFR of 45 to <60 ml/min/1.73 m ² dosed over a window of 24 to <48 hours, most subjects had a change in creatinine of less than 0.3 mg/dl relative to initial values. The amount of data is insufficient to draw conclusions for subjects dosed <24 hours after angiography.

Estimated glomerular filtration rate

Pooled analysis (Fig. 12) showed little change from baseline in eGFR in subjects with eGFR ≥60 ml/min/1.73 m ² and in subjects with eGFR 45-<60 ml/min/1.73 m ² during periods of active treatment and up to 7-10 days after the last infusion. In subjects with eGFR 30-<45 ml/min/1.73 m ² , a slight increase in mean change from baseline in eGFR was observed in subjects treated with both CSL112 and placebo starting on study day 15. Summary tables of aggregate eGFR data are shown in Figures 10-12.

results

Combined Primary Endpoints

The incidence of kidney-related serious and non-serious adverse events was similar in the treatment groups (Table 19). There was no evidence for a higher incidence of elevated creatinine in the CSL112 group compared to the placebo group in both central and local laboratory analyses. In most cases, the increase in creatinine levels from baseline was mild and temporary.

Analysis of adverse events

Treatment-related AEs occurred in approximately the same percentage of subjects in the CSL112 (73.1%) and placebo (71.4%) groups. There was no apparent imbalance in CSR events between treatment groups, and the most common AEs were expected based on the patient population with acute MI and moderate FR. The incidence of associated AEs was low, with 4 cases in the CSL112 group (ALT increase, blood bilirubin increase, infusion site swelling, and hyperventilation); there was 1 suspected AE in the form of renal failure in the placebo group. There were no cases of hemolysis, and a similar frequency and severity of bleeding was observed in both treatment groups. There were no cases of fatal or central nervous system bleeding during the study.

Liver function tests and other laboratory results

In terms of liver function tests, none of the subjects met the High's law criteria for drug-induced liver injury, as there was no concomitant increase in ALT levels to >3x ULN and total bilirubin to >2x ULN in subjects in all treatment groups. . A slight transient increase in bilirubin levels, or direct bilirubin, in subjects with Gilbert's syndrome was observed 24-48 hours after initiation of 1 CSL112 infusion in a small number (5.8%) of subjects treated with CSL112. This transient increase in bilirubin levels has been previously observed in the program and is not considered clinically significant or associated with changes in liver function.

As for other laboratory results, no clinically significant differences were observed between treatment groups in hematological or biochemical parameters. No safety concerns were found in total urine protein or clinically significant changes or differences between treatment groups in urine protein/creatinine ratios. No clinically significant differences were found between treatment groups in serum cystatin C levels. No antibodies to CSL112 or apoA-I were detected.

Pharmacokinetics

A pharmacokinetic study showed that there was no accumulation of apoA-I or PC with CSL112 (4th infusion versus 1st infusion) in subjects with acute MI and moderate HF, indicating that the 6 g CSL112 dose was acceptable in this population. A similar increase in apoA-I levels from baseline was seen in CSL112-treated subjects with stage 3a CKD (eGFR=45 - <60 ml/min/1.73 m ² ) and 3b (eGFR=30 - <45 ml/min/1, 73 ^m2 ).

The study showed that the pharmacokinetic profile of the dose of 6 g is suitable for patients with acute MI with moderate FR. A dose of 6 g CSL112 resulted in an increase in RCT to a similar extent in subjects in the CSL112_2001 study and subjects in the AEGIS-I study (Example 1). At the end of infusion time points, the relative increase in RCT was similar in both studies (Figures 13-15). ABCA1 dependent RCT was increased over time in subjects in the CSL112_2001 study, consistent with what was observed in UPN patients treated with CSL112 in the CSL112-1001 study (Example 2).

Cumulative analysis of laboratory data

A pooled analysis of laboratory data from the AEGIS-I and CSL112_2001 studies was performed to examine changes from baseline in serum creatinine and eGFR, and showed no negative effect of CSL112 infusion on these parameters of renal function in subgroups of subjects with moderate renal failure compared to subjects with mild PN or normal kidney function. Changes from baseline in serum creatinine levels were similar across groups of patients with different renal function status, regardless of the timing of the first dose of CSL112 relative to the administration of the contrast agent.

Conclusion

The CSL112_2001 study in subjects with acute MI and moderate HF confirmed renal safety with 4 weekly infusions of a 6 g dose of CSL112 compared with placebo in this population. The overall safety profile was favorable and there were no new warning signs suggesting the need for special monitoring in subjects with moderate renal failure compared to subjects with normal renal function or mild renal failure.

The purpose of this specification was to describe the preferred embodiments of the invention, without limiting the invention to any one embodiment or a particular set of features. Various changes and modifications to the described and illustrated embodiments may be made without departing from the spirit of the present invention.

The description of each patent and scientific paper, computer program and algorithm referenced in this specification is incorporated herein by reference in its entirety.

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Table 1

Initial characteristics

Characteristic CSL112, 2 g
(N=419) CSL112, 6 g
(N=421) placebo
(N=418) 3-way analysis
p-value Age, years - mean ± SD 57.7 ± 10.1 59.2 ± 9.9 58.1 ± 10.6 0.08 Male gender - number (%) 337 (80.4%) 323 (76.7%) 341 (81.6%) 0.19 Race - Number (%) 0.57 White 404 (96.7%) 406 (96.7%) 409 (97.9%) black 9 (2.2%) 5 (1.2%) 4 (1.0%) Asians 1 (0.2%) 4 (1.0%) 1 (0.2%) Other 4 (1.0%) 5 (1.2%) 4 (1.0%) BMI, kg / m ² - mean ± SD 29.2 ± 6.3 28.5±5.0 28.6±5.2 0.15 eGFR, ml/min - mean ± SD 86.1 ± 16.1 86.6 ± 14.9 87.4 ± 15.7 0.49 Kidney function - number (%) 0.70 Normal kidney function 194 (46.4%) 183 (43.5%) 188 (45.0%) Mild kidney failure 200 (47.9%) 219 (52.0%) 212 (50.7%) Moderate/Severe renal failure 24 (5.7%) 19 (4.5%) 18 (4.3%) Index Phenomenon - Quantity (%) 0.20 STEMI 250 (59.7%) 274 (65.1%) 251 (60.1%) NSTEMI 169 (40.3%) 147 (34.9%) 167 (40.0%) Intervention index procedure - number (%) 0.55 PCI 386 (92.1%) 397 (94.3%) 390 (93.3%) US 2 (0.5%) 0 (0.0%) 1 (0.2%) Medical therapy 31 (7.4%) 24 (5.7%) 27 (6.5%) Anamnesis - number (%) Previous MI 65 (15.5%) 58 (13.8%) 71 (17.0%) 0.44 stable angina 65 (15.5%) 63 (15.0%) 58 (13.9%) 0.79 Congestive heart failure 24 (5.7%) 11 (2.6%) 18 (4.3%) 0.08 Peripheral artery disease 15 (3.6%) 14 (3.3%) 25 (6.0%) 0.11 cerebrovascular disease 20 (4.8%) 21 (5.0%) 17 (4.1%) 0.80 hypertension 269 (64.2%) 257 (61.1%) 240 (57.4%) 0.13 Dyslipidemia 222 (53.0%) 220 (52.3%) 222 (53.1%) 0.96 Diabetes requiring treatment 104 (24.8%) 81 (19.2%) 95 (22.7%) 0.15 Smoking/tobacco use 299 (71.4%) 292 (69.4%) 312 (74.6%) 0.23 Time between first infusion and angiography - number (%) 12 h to <24 h 9 (2.2%) 6 (1.5%) 9 (2.2%) 0.35 24 h to <48 h 55 (13.5%) 76 (18.5%) 66 (16.2%) ≥48 h 344 (84.3%) 329 (80.1%) 332 (81.6%) Time between first infusion and first medical contact, hours - median (IQR) 103 (72.5-133.3) 95.5 (65.3-133.5) 98.5 (70.3-135.5) 0.20 Related formulations* - quantity (%) Statins 391 (94.2%) 375 (90.1%) 387 (93.7%) 0.05 High intensity or dose 144 (34.7%) 132 (31.7%) 138 (33.4%) 0.66 Low intensity or dose 247 (59.5%) 243 (58.4%) 249 (60.3%) 0.86 Other lipid-lowering agents ^† 14 (3.4%) 11 (2.6%) 13 (3.2%) 0.82 ACE inhibitor or ARB 323 (77.8%) 325 (78.1%) 322 (78.0%) 0.99 Beta blockers 333 (80.2%) 319 (76.7%) 321 (77.7%) 0.44 Aspirin 406 (97.8%) 394 (94.7%) 400 (96.9%) 0.05 Antiplatelet agents 385 (92.8%) 395 (95.0%) 392 (94.9%) 0.31 Anticoagulants 34 (8.2%) 37 (8.9%) 42 (10.2%) 0.60

Baseline characteristics were calculated for patients at randomization.

For categorical variables, a chi-square test was used to calculate the p-value; for parametric continuous variables, ANOVA analysis and the Kruskal-Wallis test were used.

eGFR was calculated using a formula developed by the Chronic Kidney Disease Epidemiology Collaboration (2009). Pooled eGFR values are values derived from serum creatinine values obtained from the central laboratory at screening. In the absence of data from the central laboratory, data obtained from the local laboratory were used.

For the time between the first infusion and randomization, multiple pairwise comparisons were made: (6 g vs. placebo=0.002) and (2 g vs. placebo=0.1059) and (6 g vs. 2 g=0.3462).

^† Ezetimibe or PCSK9 inhibitors

ACE stands for angiotensin-converting enzyme, ARB stands for angiotensin receptor blocker, BMI stands for body mass index, CABG stands for coronary artery bypass grafting, eGFR stands for estimated glomerular filtration rate, MI stands for myocardial infarction, NSTEMI stands for non-ST elevation myocardial infarction, PCI stands for percutaneous intervention on coronary vessels, SD - standard deviation and STEMI - myocardial infarction with ST segment elevation.

table 2

Combined primary safety endpoints

Combined primary safety endpoint n(%) Differences in the frequency of cases (CSL11 - placebo) 95% CI ^a Upper limit 95% CI ^b p-value ^c Liver ≤4% CSL112 2 g (N=415) 4 (1.0%) 1.0 (-0.1, 2.5) Yes 0.12 CSL112 6 g (N=416) 2 (0.5%) 0.5 (-0.5, 1.7) Yes 0.50 Placebo (N=413) 0 (0.0%) kidneys <5% CSL112 2 g (N=415) 0 (0.0%) -0.2 (-1.4, 0.7) Yes 0.50 CSL112 6 g (N=416) 3 (0.7%) 0.5 (-0.7, 1.9) Yes 0.62 Placebo (N=413) 1 (0.2%)

CI=confidence interval.

^a 95% confidence intervals for differences in subject incidence were calculated using the Newcomb-Wilson method.

^b Yes means meeting the non-inferiority criterion.

^c P-values were calculated using Fisher's exact test.

The upper limit of the two-tailed 95% confidence interval was established for the combined primary endpoints compared to the established endpoint cut-offs to assess hepatic and renal safety to assess non-inferiority. This gives a one-sided 2.5% Type I error for each of the endpoints for assessing hepatic and renal safety, and was based on the use of the Bonferroni method to control for a total Type I error of 5%.

The results, in percentage terms, are based on the number of subjects with data.

The liver function endpoint of interest was defined if any subject had one of the following two results: ALT >3x ULN, total bilirubin >2x ULN, confirmed in a follow-up test at least 24 hours but within 1 week from the original test.

An endpoint for renal function was defined when serum creatinine increased to ≥1.5x baseline, confirmed by a repeat test at least 24 hours later but within 1 week, or when renal replacement therapy became necessary.

Table 3

SNSS Endpoints in the ITT Population

End point of SNSS 2 g (419) 6 g (421) Placebo (418) RR (2 g vs. placebo) p-value (2 g vs P) RR (6 g vs. placebo) p-value
(6 g vs P) Combined 2 endpoint 27 (6.4%) 24 (5.7%) 23 (5.5%) 1.18 (0.67, 2.05) 0.5733 1.02 (0.57, 1.80) 0.9717 Combined 1 16 (3.8%) 20 (4.8%) 17 (4.1%) 0.93 (0.47, 1.84) 0.8391 1.15 (0.60, 2.20) 0.6664 Combined 2 16 (3.8%) 20 (4.8%) 17 (4.1%) 0.93 (0.47, 1.85) 0.8393 1.15 (0.60, 2.20) 0.6660 Combined 3 18 (4.3%) 20 (4.8%) 18 (4.3%) 0.99 (0.51, 1.90) 0.9705 1.09 (0.57, 2.05) 0.7992 Combined 4 34 (8.1%) 29 (6.9%) 31 (7.4%) 1.10 (0.67, 1.78) 0.7107 0.91 (0.55, 1.51) 0.7008 Death from CV disease 2 (0.5%) 4 (1.0%) 0 (0.0%) - 0.3146 - 0.0477 Non-fatal MI 14 (3.3%) 13 (3.1%) 14 (3.3%) 0.99 (0.47, 2.09) 0.9828 0.91 (0.43, 1.93) 0.7944 Ischemic stroke 0 (0.0%) 3 (0.7%) 3 (0.7%) - 0.1297 0.99 (0.20, 4.91) 0.9918 Hospitalization for unstable angina 13 (3.1%) 6 (1.4%) 7 (1.7%) 1.87 (0.75, 4.69) 0.1460 0.84 (0.28, 2.51) 0.7766 Death for any reason 5 (1.2%) 4 (1.0%) 1 (0.2%) 4.95 (0.58, 42.37) 0.1253 3.94 (0.44, 35.21) 0.2526 Death not related to CV disease 3 (0.7%) 0 (0.0%) 1 (0.2%) 2.92 (0.30, 28.09) 0.2341 - 0.5319 Hemorrhagic stroke 0 (0.0%) 1 (0.2%) 0 (0.0%) - 0.9914 - 0.2217 Stroke - indeterminate 0 (0.0%) 0 (0.0%) 0 (0.0%) - - - - Any strokes 0 (0.0%) 4 (1.0%) 3 (0.7%) - 0.1597 1.32 (0.30, 5.90) 0.6515 Heart failure 5 (1.2%) 4 (1.0%) 1 (0.2%) 5.02 (0.59, 43.01) 0.1205 3.96 (0.44, 35.41) 0.2525 Coronary revascularization 26 (6.2%) 17 (4.0%) 25 (6.0%) 1.05 (0.60, 1.81) 0.8669 0.66 (0.36, 1.22) 0.1934

All values are based on analysis of time to first SNES in the ITT population.

The results, in percentage terms, are based on the number of subjects with data.

All phenomena were confirmed by RTC.

Relative risk scores are based on a proportional hazards model with factors for treatment group and renal function.

Relative risk <1 favors CSL112.

A p-value <0.05 for the stratified log-rank test indicates that the time to first ESOS was significantly different in the CSL112 group compared to the placebo group.

The composite secondary endpoint of SIOS consists of death from CV disease, non-fatal MI, ischemic stroke, and hospitalization for unstable angina.

Exploratory composite endpoint 1 in the form of SIOS consists of death from CV disease, non-fatal MI, and ischemic stroke.

Investigational composite endpoint 2 in the form of SIOS consists of death from CV disease, non-fatal MI, and any strokes.

Exploratory composite endpoint 3 in the form of SIOS consists of non-fatal MI, death from any cause, and any stroke.

Exploratory composite endpoint 4 in the form of SIOS consists of hospitalization for unstable angina, death from any cause, any stroke, heart failure, and coronary revascularization.

Table 4

BARC rating categories for the most severe bleeding in the population to assess safety

Bleeding CSL112 2 g (415) CSL112 6 g (416) Placebo (413) Type 0 377 (90.8%) 378 (90.9%) 362 (87.7%) Type 1 19 (4.6%) 17 (4.1%) 30 (7.3%) Type 2 16 (3.9%) 17 (4.1%) 15 (3.6%) Type 3 2 (0.5%) 3 (0.7%) 6 (1.5%) Type 3a 0 0 2 Type 3b 2 3 3 Type 3c 0 0 1 Type 4 0 (0.0%) 0 (0.0%) 0 (0.0%) Type 5 1 (0.2%) 1 (0.2%) 0 (0.0%) Type 5a 0 0 0 Type 5b 1 1 0

Type 0 includes subjects who did not bleed for consideration.

If a patient had more than one bleeding, the most severe bleeding was counted.

Bleeding was counted from the time of randomization.

Table 5

Baseline lipid and cardiovascular biomarkers

Biomarker CSL112 2 g CSL112 6 g placebo p-value Plasma biomarkers ApoA-I mg/dl - mean ± SD 124.6 ± 24.6 127.7 ± 25.2 126.1 ± 24.7 0.2155 Phosphatidylcholine mg/dl - mean ± SD 185.9 ± 36.6 190.1 ± 39.2 187.3 ± 37.7 0.2835 Lipid biomarkers Apolipoprotein B mg/dl - mean ± SD 90.8 ± 24.3 92.8 ± 25.3 91.9±25.4 0.5308 Total cholesterol mg/dl - mean ± SD 164.7 ± 39.3 169.3 ± 41.0 166.5 ± 41.6 0.2735 HDL-cholesterol mg/dl - mean ± SD 40.2 ± 11.0 41.6 ± 10.7 40.8 ± 11.0 0.1606 Non-HDL cholesterol mg/dl - mean ± SD 124.2 ± 38.9 127.6 ± 40.4 125.8 ± 40.9 0.4780 LDL cholesterol mg/dl - mean ± SD 92.1 ± 35.0 94.7 ± 34.9 92.1 ± 34.4 0.4966 Triglycerides mg/dl - mean ± SD 168.8 ± 99.5 168.0 ± 91.3 170.2 ± 95.1 0.9450 reverse cholesterol transport Total return transport %/4 h - mean ± SD 8.4±2.3 8.8 ± 2.9 8.8±2.7 0.1299 ABCA1 reverse transport %/4 h - mean ± SD 2.6 ± 1.7 2.6 ± 1.9 2.8 ± 1.9 0.2097 Non-ABCA1 reverse transport %/4 h - mean ± SD 5.9±1.4 6.2 ± 1.6 6.0±1.5 0.0305 Total TX/apoA-I ratio %/4h/mg/dl - mean+SD 0.068 ± 0.017 0.069 ± 0.020 0.070 ± 0.021 0.3304 ABCA1 TX/apoA-I ratio %/4h/mg/dl - mean+SD 0.021 ± 0.013 0.021 ± 0.014 0.022 ± 0.015 0.1401 Cardiovascular biomarkers Troponin I ng/ml - mean ± SD 53.9 ± 400.2 48.2 ± 187.9 67.8 ± 361.6 0.8618 Fibrinogen mg/dl - mean ± SD 481.7 ± 122.0 482.2 ± 125.0 476.3 ± 125.6 0.7588 hsCRP mg/l - mean ± SD 18.9 ± 28.9 18.7 ± 23.7 18.4 ± 27.5 0.9677 IL-6 pg/ml - mean ± SD 9.2 ± 45.8 8.3 ± 21.5 7.4 ± 9.8 0.6754

All analyzes were performed on patients with available data.

RCT=reverse cholesterol transport, CI=confidence interval.

ABCA1 means ATP-binding cassette A1, HDL is high density lipoprotein, hsCRP is highly sensitive C-reactive protein, IL-6 is interleukin 6, LDL is low density lipoprotein, NT-proBNP is the N-terminal fragment of the prohormone brain natriuretic peptide and SD is standard deviation.

^a Comparison of treatment groups using ANOVA with conditions for the treatment group.

Table 6

Reverse transport values of cholesterol, HDL-cholesterol and apoA-I immediately after CSL112 infusion

Parameter Arithmetic mean ± SD Magnification Total reverse cholesterol transport (%/4h) CSL112 2 g (N=394) 15.8 ± 3.8 1.87 ^# CSL112 6 g (N=404) 20.8 ± 3.8 2.45 ^# Placebo (N=403) 8.3±2.7 0.94 ^# ABCA1-dependent reverse cholesterol transport (%/4 h) CSL112 2 g (N=394) 7.9±2.6 3.67 ^# CSL112 6 g (N=404) 8.9±2.4 4.30 ^# Placebo (N=403) 2.4 ± 1.8 0.82 ^# ApoA-I (mg/dl) CSL112 2 g (N=402) 161 ± 33.4 1.29 ^# CSL112 6g (N=406) 263±58.2 2.06 ^# Placebo (N=405) 121 ± 25.7 0.96 ^# HDL cholesterol mg/dl CSL112 2 g (N=404) 43.9 ± 11.8 1.09 ^# CSL112 6 g (N=407 52.5 ± 12.1 1.27 ^# Placebo (N=405) 39.3 ± 10.9 0.97 ^#

All analyzes were performed on patients with available data.

#Magnification times from baseline, calculated as the geometric mean of the ratios for individual patients.

Table 7

Sensitivity analyzes of combined primary endpoints to assess safety

Combined primary safety endpoint n(%) Differences in the frequency of cases (CSL11 - placebo) 95% CI ^a Upper limit 95% CI ^b p-value ^c Liver - No confirmatory result ≤4% CSL112 2 g (N=415) 9 (2.2%) -0.5 (-2.8, 1.7) Yes 0.64 CSL112 6 g (N=416) 5 (1.2%) -1.5 (-3.6, 0.5) Yes 0.13 Placebo (N=413) 11 (2.7%) Kidney - No confirmatory result <5% CSL112 2 g (N=415) 4 (1.0%) -0.5 (-2.3, 1.2) Yes 0.55 CSL112 6 g (N=416) 7 (1.7%) 0.2 (-1.7, 2.1) Yes 0.79 Placebo (N=413) 6 (1.5%)

CI=confidence interval.

^a 95% confidence intervals for differences in subject incidence were calculated using the Newcomb-Wilson method.

^b Yes means meeting the non-inferiority criterion.

^c *P-values were calculated using a chi-square test or Fisher's exact test when the expected number of cells was <5.

*Results, in percentage terms, are based on the number of subjects with data.

*For this sensitivity analysis, the liver function endpoint of interest was determined if any subject had one of the following two results: ALT >3x ULN, total bilirubin >2x ULN, not confirmed at a follow-up retest at least 24 hours later but within 1 week of the original test.

*For this sensitivity analysis, a renal event was defined when serum creatinine increased to ≥1.5x baseline or when renal replacement therapy became necessary, without confirmation in a follow-up retest at least 24 hours but within 1 week from the original test.

Table 8

Post hoc sensitivity analysis of combined primary safety endpoints with Bonferroni adjustment for multiple comparisons of treatment options

Combined primary safety endpoint n(%) Differences in the frequency of cases (CSL11 - placebo) 97.5% CI ^a Upper limit 97.5% CI ^b p-value ^c Liver ≤4% CSL112 2 g (N=415) 4 (1.0%) 1.0 (-0.4, 2.8) Yes 0.12 CSL112 6 g (N=416) 2 (0.5%) 0.5 (-0.8, 2.0) Yes 0.50 Placebo (N=413) 0 (0.0%) kidneys <5% CSL112 2 g (N=415) 0 (0.0%) -0.2 (-1.7, 1.0) Yes 0.50 CSL112 6 g (N=416) 3 (0.7%) 0.5 (-1.0, 2.2) Yes 0.62 Placebo (N=413) 1 (0.2%)

CI=confidence interval.

^a The upper limit of the two-tailed 95% confidence interval was established to test the combined primary endpoints against established endpoint thresholds to assess hepatic and renal safety to assess non-inferiority. This gives a one-sided 2.5% Type I error for each of the endpoints for assessing hepatic and renal safety, and was based on the use of the Bonferroni method to control for a total Type I error of 5%. No multiplicity adjustment was applied to the pairwise comparison of the two treatment groups for each combined primary endpoint. This table provides a more conservative estimate using a two-tailed 97.5% confidence interval that additionally applies a Bonferroni post hoc correction to treatment comparisons to achieve an individual one-tailed 1.25% Type I error for each of the treatment comparisons.

^b Yes means meeting the non-inferiority criterion.

^c P-values were calculated using Fisher's exact test.

Results, in percentage terms, are based on the number of subjects with data.

The liver function endpoint of interest was defined if any subject had one of the following two results: ALT >3x ULN, total bilirubin >2x ULN, confirmed in a follow-up test at least 24 hours but within 1 week from the original test.

An endpoint for renal function was defined when serum creatinine increased to ≥1.5x baseline, confirmed by a repeat test at least 24 hours later but within 1 week, or when renal replacement therapy became necessary.

Table 9

Ratio of reverse cholesterol transport and apoA-I immediately after CSL112 infusion

Parameter Arithmetic mean ± SD Magnification Total reverse cholesterol transport/apoA-I ratio (%/4 h/mg/dl) CSL112 2 g (N=394) 0.099 ± 0.023 1.44 ^@ CSL112 6 g (N=404) 0.082 ± 0.019 1.18 ^@ Placebo (N=403) 0.069 ± 0.019 - ABCA1 reverse cholesterol transport/apoA-I ratio (%/4 h/mg/dL) CSL112 2 g (N=394) 0.050 ± 0.017 2.51 ^@ CSL112 6 g (N=404) 0.035 ± 0.013 1.78 ^@ Placebo (N=403) 0.020 ± 0.014 -

All analyzes were performed on patients with available data.

^@ fold change from placebo, calculated as the ratio of the arithmetic means of the treatment groups.

Table 10

Adverse events that occurred during treatment, the frequency of events in the population for safety assessment

Adverse event (class of organ systems) CSL112 2 g (696) CSL112 6 g (620) Placebo (639) circulatory and lymphatic systems 11 (1.6%) 2 (0.3%) 5 (0.8%) Heart 74 (10.6%) 61 (9.8%) 61 (9.6%) Hereditary, family and genetic 0 (0.0%) 1 (0.2%) 1 (0.2%) Ear and labyrinth 2 (0.3%) 7 (1.1%) 6 (0.9%) Endocrine system 1 (0.1%) 1 (0.2%) 5 (0.8%) Eyes 3 (0.4%) 10 (1.6%) 6 (0.9%) Gastrointestinal system 61 (8.8%) 67 (10.8%) 68 (10.6%) General disorders and complications in the injection zone 122 (17.5%) 92 (14.8%) 92 (14.4%) Hepatobiliary system 7 (1.0%) 0 (0.0%) 6 (0.9%) The immune system 2 (0.3%) 2 (0.3%) 0 (0.0%) Infections and parasitic infestations 61 (8.8%) 49 (7.9%) 42 (6.6%) Injury, poisoning and procedural complications 25 (3.6%) 30 (4.8%) 27 (4.2%) Research 39 (5.6%) 54 (8.7%) 57 (8.9%) Metabolism and nutrition 24 (3.5%) 10 (1.6%) 21 (3.3%) Musculoskeletal system and connective tissue 46 (6.6%) 42 (6.8%) 33 (5.2%) Neoplasms benign, malignant and indeterminate (including cysts and polyps) 0 (0.0%) 6 (1.0%) 7 (1.1%) Nervous system 66 (9.5%) 52 (8.4%) 53 (8.3%) Line-up problems 2 (0.3%) 0 (0.0%) 0 (0.0%) Psychiatric conditions 14 (2.0%) 9 (1.5%) 10 (1.6%) Kidneys and urinary tract 16 (2.3%) 6 (1.0%) 15 (2.4%) Reproductive system and mammary glands 5 (0.7%) 6 (1.0%) 4 (0.6%) Respiratory system, chest and mediastinum 63 (9.1%) 52 (8.4%) 58 (9.1%) Skin and subcutaneous tissue 17 (2.4) 24 (3.9%) 17 (2.7%) Vascular system 35 (5.0%) 37 (6.0%) 45 (7.0%) Other Adverse events associated with the study formulation? 44 (6.3%) 50 (8.1%) 34 (5.3%) Adverse events associated with the procedures in the study 27 (3.9%) 43 (6.9%) 15 (2.4%) Adverse events leading to death 3 (0.4%) 2 (0.3%) 1 (0.2%) Adverse events leading to indefinite discontinuation of study formulation 11 (1.6%) 8 (1.3%) 9 (1.4%) Severity of adverse events* Degree 1 409 (58.8%) 374 (60.3%) 388 (60.7%) Degree 2 151 (21.7%) 165 (26.6%) 147 (23.0%) Grade 3 114 (16.4%) 76 (12.3%) 92 (14.4%) Degree 4 18 (2.6%) 3 (0.5%) 11 (1.7%) Degree 5 4 (0.6%) 2 (0.3%) 1 (0.2%) Serious adverse events 109 (15.7%) 77 (12.4%) 78 (12.2%) Serious related adverse events 1 (0.8%) 0 (0.0%) 2 (5.9%)

N means the total number of adverse events in each treatment group.

Table 11

Adverse events that occurred during treatment, the number, in percentage terms, of patients in the population for safety assessment

Adverse event (class of organ systems) CSL112 2 g (N=415) CSL112 6 g (N=416) Placebo (N=413) circulatory and lymphatic systems 10 (2.4%) 2 (0.5%) 4 (1.0%) Heart 51 (12.3%) 48 (11.5%) 40 (9.7%) Hereditary, family and genetic 0 (0.0%) 1 (0.2%) 1 (0.2%) Ear and labyrinth 2 (0.5%) 7 (1.7%) 5 (1.2%) Endocrine system 1 (0.2%) 1 (0.2%) 4 (1.0%) Eyes 3 (0.7%) 6 (1.4%) 4 (1.0%) Gastrointestinal system 42 (10.1%) 42 (10.1%) 46 (11.1%) General disorders and complications in the injection zone 84 (20.2%) 62 (14.9%) 62 (15.0%) Hepatobiliary system 6 (1.5%) 0 (0.0%) 5 (1.2%) The immune system 2 (0.5%) 2 (0.5%) 0 (0.0%) Infections and parasitic infestations 47 (11.3%) 39 (9.4%) 38 (9.2%) Injury, poisoning and procedural complications 18 (4.3%) 17 (4.1%) 24 (5.8%) Research 31 (7.5%) 37 (8.9%) 41 (9.9%) Metabolism and nutrition 19 (4.6%) 10 (2.4%) 18 (4.4%) Musculoskeletal system and connective tissue 35 (8.4%) 35 (8.4%) 24 (5.8%) Neoplasms benign, malignant and indeterminate (including cysts and polyps) 0 (0.0%) 6 (1.4%) 7 (1.7%) Nervous system 47 (11.3%) 45 (10.8%) 30 (7.3%) Line-up problems 2 (0.5%) 0 (0.0%) 0 (0.0%) Psychiatric conditions 13 (3.1%) 8 (1.9%) 9 (2.2%) Kidneys and urinary tract 16 (3.9%) 6 (1.4%) 14 (3.4%) Reproductive system and mammary glands 4 (1.0%) 6 (1.4%) 4 (1.0%) Respiratory system, chest and mediastinum 43 (10.4%) 42 (10.1%) 42 (10.2%) Skin and subcutaneous tissue 14 (3.4%) 22 (5.3%) 17 (4.1%) Vascular system 30 (7.2%) 32 (7.7%) 38 (9.2%) Other Adverse Events Associated with Study Formulation 33 (8.0%) 33 (7.9%) 26 (6.3%) Adverse events leading to death 3 (0.7%) 2 (0.5%) 1 (0.2%) Adverse events leading to indefinite discontinuation of study formulation 11 (2.7%) 8 (1.9%) 9 (2.2%) Severity of adverse events* Degree 1 73 (17.6%) 91 (21.9%) 88 (21.3%) Degree 2 60 (14.5%) 69 (16.6%) 52 (12.6%) Degree 3 69 (16.6%) 50 (12.0%) 56 (13.6%) Degree 4 5 (1.2%) 2 (0.5%) 8 (1.9%) Degree 5 3 (0.7%) 2 (0.5%) 1 (0.2%) Serious adverse events 66 (15.9%) 53 (12.7%) 54 (13.1%) Serious related adverse events 1 (0.2%) 0 (0.0%) 2 (0.5%)

N means the number, in percentage terms, of patients experiencing an adverse event in each treatment group.

*If a patient experienced more than one adverse event, the severity of the adverse event was determined by the most severe event.

Table 12

Summary data on fatal outcomes, by study period

Treatment period 2 g 6 g placebo Main study (N=10) 5 4 1 Period of active treatment (ID 1-29) 1 2 0 Follow-up period for safety assessment (ID 30-112) 2 0 1 Follow-up period for SNSS (ID 113-387) 2 2 0 Safety determination lead-in period (N=1) 1 0 0 Period of active treatment (ID 1-29) 0 0 0 Follow-up period for safety assessment (ID 30-90) 1 0 0

Table 13

Calculation of the sample size and power of the endpoints for the SNSS required to establish a ≥15% risk reduction with a two-tailed significance level of 0.05

end point
SNSS Frequency of events in the placebo group Quantity per group required for 90% capacity Capacity in the case of 420 subjects per group Combined 2 endpoint 5.5% 14.907 8.4% Combined 1 4.1% 20.271 7.5% Combined 2 4.1% 20.271 7.5% Combined 3 4.3% 19.291 7.7% Combined 4 7.4% 10.874 9.8% Death from CV disease 0.0% - - Non-fatal MI 3.3% 25.379 7.0% Ischemic stroke 0.7% 122.620 5.4% Hospitalization for unstable angina 1.7% 50.019 6.0% Death for any reason 0.2% 431.171 5.1% Death not related to CV disease 0.2% 431.171 5.1% Hemorrhagic stroke 0.0% - - Stroke - indeterminate 0.0% - - Any strokes 0.7% 122.620 5.4% Heart failure 0.2% 431.171 5.1% Coronary revascularization 6.0% 13.598 8.8%

Sample size and study power were calculated from the frequency of events in the placebo group using Pearson's chi-square test.

For this study power calculation, the number of patients in both the treatment and placebo groups was standardized to 420.

Table 14: Initial characteristics

NFP n=16 Mind. PN n=16 Age, years 55±7 69 ± 9 Gender, n (%) male 11 (68.8) 11 (68.8) Body weight, kg 78 ± 10.8 80.5 ± 16.6 BMI, kg / m ² 26.23 ± 2.89 27.88 ± 4.64 eGFR, ml/min/1.73 ^m2 100.5±6.0 49.1 ± 7.7 BMI, body mass index; Mean values are given ± standard deviation.

Table 15: Baseline Cholesterol Reverse Transport Parameters and Lipoprotein Parameters in Renal Function Status Groups

NFP n=16 Mind. PN n=16 p-value to compare ApoA-I mg/dl 141 ± 19.0 143 ± 21.3 0.8 Total OT, % of reverse transport/4 h 9.03±1.75 11.50±2.49 0.003 ABCA1-independent RTX, % reverse transport/4 h 7.02 ± 1.29 7.85 ± 1.56 0.1 ABCA1-dependent RT, % reverse transport/4 h 2.01 ± 1.22 3.65 ± 1.68 0.004 Pre-β1-HDL, mcg/ml 16.1 ± 3.2 22.8 ± 9.8 0.01 Cholesterol, mg/dl 191 ± 36 188 ± 34 0.8 HDL-cholesterol, mg / dl 52±8 53 ± 12 0.7 HDL-non-esterified cholesterol, mg/dl 15±3 15±3 1.0 HDL-esterified cholesterol, mg/dL 37±6 38 ± 9 0.7 Non-HDL-cholesterol, mg/dl 140 ± 37 136 ± 31 0.7 Apolipoprotein B, mg/dl 91 ± 24 89±18 0.8 Triglycerides, mg/dL 132 ± 57 141 ± 63 0.7 C-reactive protein, mg/l 1.7 ± 3.5 2.3 ± 3.9 0.6 Mean values are given ± standard deviation.

Table 16: Characteristics of the Study Population

CSL112 6 g placebo Total Characteristics (N=55) (N=28) (N=83) Age (years) N 55 28 83 Average (SD) 70.6 (10.95) 71.9 (10.12) 71.1 (10.63) Median 73.0 74.0 73.0 1st quartile, 3rd quartile 65.0, 79.0 69.0, 78.0 66.0, 78.0 Min, Max 36, 86 44, 89 36, 89 Age group (years), n (%) ≥ 18 - <65 11 (20.0) 4 (14.3) 15 (18.1) ≥ 65 - <75 20 (36.4) 11 (39.3) 31 (37.3) ≥ 75 - <85 22 (40.0) 12 (42.9) 34 (41.0) ≥ 85 2 (3.6) 1 (3.6) 3 (3.6) Gender n (%) Men 37 (67.3) 18 (64.3) 55 (66.3) Women 18 (32.7) 10 (35.7) 28 (33.7) Ethnicity, n (%) Hispanic or Latino 0 2 (7.1) 2 (2.4) Not Hispanic or Hispanic 53 (96.4) 26 (92.9) 79 (95.2) unknown 2 (3.6) 0 2 (2.4) Race n, (%) Asians 1 (1.8) 0 1 (1.2) Black or African American 2 (3.6) 0 2 (2.4) White 52 (94.5) 28 (100) 80 (96.4) Country, n (%) Germany 12 (21.8) 4 (14.3) 16 (19.3) Hungary 20 (36.4) 8 (28.6) 28 (33.7) Israel 5 (9.1) 5 (17.9) 10 (12.0) Netherlands 8 (14.5) 2 (7.1) 10 (12.0) USA 10 (18.2) 9 (32.1) 19 (22.9) BMI (kg / m ² ) N 55 28 83 Average (SD) 30.0 (5.30) 28.5 (4.68) 29.5 (5.12) Median 29.4 28.4 29.1 1st quartile, 3rd quartile 26.5, 32.2 25.0, 31.1 25.9, 31.6 Min, Max 19.8, 46.1 21.3, 43.1 19.8, 46.1 Kidney function (at randomization) ^a , n (%) eGFR 30-<45 ml/min/1.73 ^m2 26 (47.3) 13 (46.4) 39 (47.0) eGFR 45-<60 ml/min/1.73 ^m2 29 (52.7) 15 (53.6) 44 (53.0) Kidney function (central laboratory) ^b , n (%) eGFR <30 ml/min/1.73 ^m2 3 (5.5) 1 (3.6) 4 (4.8) eGFR 30-<45 ml/min/1.73 ^m2 18 (32.7) 15 (53.6) 33 (39.8) eGFR 45-<60 ml/min/1.73 ^m2 26 (47.3) 11 (39.3) 37 (44.6) eGFR ≥60 ml/min/1.73 ^m2 4 (7.3) 1 (3.6) 5 (6.0) eGFR (TIO) at randomization ^c , ml/min/1.73 m ² N 55 28 83 Average (SD) 46.15 (7.165) 46.41 (7.785) 46.24 (7.334) Median 45.91 45.16 45.61 1st quartile, 3rd quartile 40.71, 52.92 39.59, 53.36 40.33, 52.92 Min, Max 30.2, 57.8 33.5, 59.2 30.2, 59.2 eGFR (central) at randomization ^d , ml/min/1.73 m ² N 51 28 79 Average (SD) 46.82 (9.697) 45.40 (9.988) 46.32 (9.761) Median 48.99 42.50 45.44 1st quartile, 3rd quartile 38.53, 55.10 37.71, 53.91 38.10, 55.10 Min, Max 27.3, 64.4 29.8, 70.9 27.3, 70.9 Diabetes requiring current treatment with any anti-diabetic formulation ^e , n (%) Yes 23 (41.8) 12 (42.9) 35 (42.2) No 32 (58.2) 16 (57.1) 48 (57.8) Type of index MI, n (%) STEMI 16 (29.1) 6 (21.4) 22 (26.5) NSTEMI 39 (70.9) 22 (78.6) 61 (73.5)

BMI=Body Mass Index, eIRC=electronic individual registration card, eGFR=estimated glomerular filtration rate, TI=interactive response technology, ITT=all patient population initially enrolled in the study, Max=maximum, MI=myocardial infarction, Min=minimum, NSTEMI=non-ST elevation myocardial infarction, SD=standard deviation, STEMI=ST-segment elevation myocardial infarction

^a Typical group into which the subject was assigned based on the eGFR originally calculated by the TIE system based on the subject's age, sex, race, and their serum creatinine score at Visit 2 (Study Day 1).

^b Typical group to which the subject belongs based on eGFR calculation using the Chronic Kidney Disease Epidemiology Collaboration formula and central laboratory-determined serum creatinine obtained at Visit 2 (Study Day 1).

^c eGFR recorded in the TIO system

^d Pooled eGFR was calculated using a formula developed by the Collaborative for the Epidemiology of Chronic Kidney Disease based on serum creatinine values obtained from the central laboratory at Visit 2 (Study Day 1).

^e History of diabetes noted in eRCI.

Note: Results, in percentage terms, are based on the number of subjects randomized to each treatment group. Age was automatically calculated based on date of birth and date of informed consent. Baseline values in case of missing laboratory data were determined based on the last pre-infusion non-missing value obtained before, or at the time of, the date of administration of the first dose of study formulation.

Table 17: Summary of time periods to first infusion (ITT population)

Total STEMI NSTEMI Timing characteristics Descriptive statistics CSL112 6g (N=55) Placebo (N=28) Total (N=83) CSL112 6g (N=55) Placebo (N=28) Total (N=83) CSL112 6g (N=55) Placebo (N=28) Total (N=83) Time from index MI to angiography (h) N 54 26 80 16 5 21 38 21 59 Average (SD) 16.64 (17.347) 20.47 (20.242) 17.89 (18.298) 4.54 (6.718) 2.58 (2.627) 4.07 (5.997) 21.74 (17.966) 24.73 (20.290) 22.80 (18.707) Time from angiography to randomization (h) N 54 26 80 16 5 21 38 21 59 Average (SD) 57.95 (28.724) 70.36 (42.897) 61.98 (34.207) 53.81 (26.074) 63.58 (30.071) 56.14 (26.625) 59.69 (29.929) 71.98 (45.881) 64.07 (36.504) Time from angiography to first infusion (h) ^a N 51 26 77 15 5 20 36 21 57 Average (SD) 61.83 (28.187) 71.79 (42.621) 65.20 (33.804) 57.70 (25.561) 64.78 (29.772) 59.47 (26.037) 63.55 (29.383) 73.46 (45.587) 67.20 (36.125) 12 - <24 n(%) 3 (5.9) 2 (7.7) 5 (6.5) 1 (6.7) 0 1 (5.0) 2 (5.6) 2 (9.5) 4 (7.0) 24 - <48 n(%) 18 (35.3) 7 (26.9) 25 (32.5) 6 (40.0) 1 (20.0) 7 (35.0) 12 (33.3) 6 (28.6) 18 (31.6) ≥48 n(%) 30 (58.8) 17 (65.4) 47 (61.0) 8 (53.3) 4 (80.0) 12 (60.0) 22 (61.1) 13 (61.9) 35 (61.4) Time from randomization to first infusion (h) N 52 28 80 15 6 21 37 22 59 Average (SD) 1.76 (0.841) 1.40 (0.717) 1.63 (0.813) 1.65 (0.727) 1.28 (0.625) 1.55 (0.705) 1.80 (0.888) 1.44 (0.750) 1.66 (0.851) Time from index MI to first infusion (h) N 52 28 80 15 6 21 37 22 59 Average (SD) 78.75 (29.916) 90.00 (41.008) 82.69 (34.375) 62.23 (25.245) 66.00 (25.936) 63.31 (24.846) 85.44 (29.331) 96.55 (42.339) 89.58 (34.819) Time from angiography to local lab analysis for eligibility (h) ^a N 54 26 80 16 5 21 38 21 59 Average (SD) 51.78 (28.516) 62.87 (42.894) 55.38 (33.987) 47.99 (27.115) 54.94 (30.684) 49.64 (27.366) 53.38 (29.290) 64.76 (45.739) 57.43 (36.040) 12 - <24 n(%) 14 (25.9) 6 (23.1) 20 (25.0) 4 (25.0) 0 4 (19.0) 10 (26.3) 6 (28.6) 16 (27.1) 24 - <48 n(%) 15 (27.8) 9 (34.6) 24 (30.0) 6 (37.5) 4 (80.0) 10 (47.6) 9 (23.7) 5 (23.8) 14 (23.7) ≥48 n(%) 25 (46.3) 11 (42.3) 36 (45.0) 6 (37.5) 1 (20.0) 7 (33.3) 19 (50.0) 10 (47.6) 29 (49.2)

ITT=all patient population originally selected for study, MI=myocardial infarction, NSTEMI=non-ST elevation myocardial infarction, SD=standard deviation, STEMI=ST-segment elevation myocardial infarction

^a Results, in percentage terms, are based on the number of subjects in the original category.

Table 18: Summary of Combined Primary Endpoints for Treatment-Emerged Renal Serious Adverse Events and Acute Kidney Injury (Safety Population)

Combined Primary Treatment Endpoint Number of subjects, n Number of subjects with phenomena n (%), n' Differences in incidence between treatment groups Differences in the frequency of cases 95% CI ^a Renal SAEs CSL112 6g (N=52) 52 1 (1.9) 1 -0.124 (-0.296, 0.005) Placebo (N=28) 28 4 (14.3) 5 n/a n/a Cases of AKI CSL112 6g (N=52) 50 2 (4.0) 2 -0.103 (-0.277, 0.025) Placebo (N=28) 28 4 (14.3) 4 n/a n/a

AKI=acute kidney injury, CI=confidence interval, n/a=not applicable, n (%)=indicates the number and percentage of subjects who experienced the event, n'=indicates the number of cases, SAE=serious adverse event

^a 95% CI for differences in incidence among subjects was calculated using Newcomb-Wilson intervals when at least 1 event occurred, or otherwise, with exact one-sided upper 97.5% confidence intervals for the incidence in each of treatment groups.

Table 19: Summary of combined primary research endpoints for renal safety by subgroup (safety population

Combined Primary Endpoint Renal SAEs Cases of AKI Subgroup ^a treatment Number of subjects with data, n Number of subjects with phenomena, n (%), n' Number of subjects with data, n Number of subjects with phenomena, n (%), n' eGFR <30 ml/min/1.73 m² CSL112 6g (N=52) 3 0 3 0 Placebo (N=28) 1 0 1 0 eGFR 30-<45 ml/min/1.73 m² CSL112 6g (N=52) 18 0 18 0 Placebo (N=28) 15 3 (20.0) 4 15 1 (6.7) 1 eGFR 45-<60 ml/min/1.73 m² CSL112 6g (N=52) 25 1 (4.0) 1 25 2 (8.0) 2 Placebo (N=28) eleven 1 (9.1) 1 eleven 2 (18.2) 2 eGFR >=60 ml/min/1.73 m² CSL112 6g (N=52) 4 0 4 0 Placebo (N=28) 1 0 1 1 (100) 1 With a history of diabetes requiring current treatment with any anti-diabetic formulation CSL112 6g (N=52) 22 0 22 0 Placebo (N=28) 12 3 (25.0) 4 12 4 (33.3) 4 No history of diabetes requiring current treatment with any anti-diabetic formulation CSL112 6g (N=52) thirty 1 (3.3) 1 28 2 (7.1) 2 Placebo (N=28) 16 1 (6.3) 1 16 0

AKI=acute kidney injury, CKD-EPI=collaboration on the epidemiology of chronic kidney disease, eGFR=estimated glomerular filtration rate, MedDRA=Regulatory Medical Vocabulary, PT=preferred term, SAE=serious adverse event, SMQ=MedDRA standard questionnaire.

The results, in percentage terms, are based on the number of subjects with data.

n (%) shows the number and percentage of subjects who experienced the phenomenon, n' shows the number of cases.

^a Kidney function determined from eGFR calculated using the CKD-EPI formula from central laboratory data.

Note: Incidence rates are calculated using the number of subjects with data as the denominator. "Occurred during treatment" was defined as occurring during or after the start of the first infusion.

Table 20: Overall Summary of Adverse Events (Safety Population)

Number (%) of subjects CSL112 6g (N=52) Placebo (N=28) Total (N=80) Subjects with any NELV 38 (73.1) 20 (71.4) 58 (72.5) Any related NELV to study formulation 4 (7.7) 1 (3.6) 5 (6.3) Subjects with any serious NELV 12 (23.1) 10 (35.7) 22 (27.5) Any serious AEJ related to study formulation 0 1 (3.6) 1 (1.3) Any fatal NEV ^a 2 (3.8) 2 (7.1) 4 (5.0) Any study compound-related fatal AELV 0 0 0 Any AELV with CTCAE grade ≥3 13 (25.0) 10 (35.7) 23 (28.8) Any potential hemolysis occurring during treatment 0 0 0 Any bleeding that occurs during treatment 7 (13.5) 5 (17.9) 12 (15.0) Any suspected adverse drug reaction 30 (57.7) 4 (14.3) 34 (42.5)

CTCAE=general terminological criteria for adverse events, AELV=treatment-occurring adverse event.

^a For each treatment group, 1 death of unknown cause; 1 death due to heart failure.

Note: The results, in percentage terms, are based on the number of subjects in the safety assessment population for each treatment group.

Table 21: Treatment-Occurred Adverse Events Associated with Study Formulation by Preferred Term (Safety Population)

Number (%) of subjects Preferred Term CSL112 6g N=52) Placebo N=28) Total N=80) Subjects with any study-related AELV 4 (7.7) 1 (3.6) 5 (6.3) Increased alanine aminotransferase levels 1 (1.9) 0 1 (1.3) Increased blood levels of bilirubin 1 (1.9) 0 1 (1.3) Hyperventilation 1 (1.9) 0 1 (1.3) Swelling of the infusion site 1 (1.9) 0 1 (1.3) kidney failure 0 1 (3.6) 1 (1.3)

MedDRA=Medical Dictionary of Regulatory Activity, AELV=treatment-related adverse event.

Note: Adverse events were coded by organ system class and preferred term using MedDRA version 20.0. It is possible for a subject to record events related to more than one preferred term, but only once within the preferred term. The results, in percentage terms, are based on the number of subjects in the population to assess safety for each treatment group.

Table 22: Summary of Abnormal Serum Creatinine (Central Laboratory) During Active Treatment (Safety Population)

Number (%) of subjects Analyzes in the central laboratory Analyzes in the local laboratory CSL112 6g (N=52) Placebo (N=28) Total (N=80) CSL112 6g (N=52) Placebo (N=28) Total (N=80) Any stage 3 AKI (central laboratory) ^a n(%) 0 0 0 0 0 0 Increase in serum creatinine to ≥3x baseline n(%) 0 0 0 0 0 0 Serum creatinine ≥4.0 mg/dL (353.6 µmol/L) n(%) 0 0 0 0 0 0 Absolute increase from baseline, worst case n (%) ≤initial value 9 (17.3) 3 (10.7) 12 (15.0) 14 (26.9) 5 (17.9) 19 (23.8) >0 to <0.3 mg/dl 35 (67.3) 18 (64.3) 53 (66.3) 30 (57.7) 13 (46.4) 43 (53.8) ≥0.3 to ≤0.5 mg/dl 4 (7.7) 4 (14.3) 8 (10.0) 5 (9.6) 6 (21.4) 11 (13.8) >0.5 mg/dl 2 (3.8) 2 (7.1) 4 (5.0) 3 (5.8) 3 (10.7) 6 (7.5) Absolute increase from baseline persisting for ≥24 h, most severe case n (%) ≥0.3 to ≤0.5 mg/dl 1 (1.9) 4 (14.3) 5 (6.3) 2 (3.8) 3 (10.7) 5 (6.3) >0.5 mg/dl 1 (1.9) 0 1 (1.3) 2 (3.8) 0 2 (2.5) Increase from baseline, most severe case n (%) ≥1.5x original value 1 (1.9) 1 (3.6) 2 (2.5) 2 (3.8) 2 (7.1) 4 (5.0) ≥2x original value 0 0 0 1 (1.9) 0 1 (1.3) ≥3x original value 0 0 0 0 0 0 ≥4.0 mg/dL (353.6 µmol/L) 0 0 0 0 0 0 Increase persisting for ≥24 h, most severe case n (%) ≥1.5x original value 1 (1.9) 0 1 (1.3) 1 (1.9) 0 1 (1.3) ≥2x original value 0 0 0 0 0 0 ≥3x original value 0 0 0 0 0 0 ≥4.0 mg/dL (353.6 µmol/L) 0 0 0 0 0 0 Decrease in eGFR (central) by ≥25% from baseline ^b n(%) 5 (9.6) 4 (14.3) 9 (11.3) n/a n/a n/a ≥25% decrease in eGFR (central) from baseline that persists at last visit (Visit 8) ^b n(%) 1 (1.9) 1 (3.6) 2 (2.5) n/a n/a n/a eGFR (central) <30 ml/min/1.73 m ² at last visit (Visit 8) n(%) 0 0 0 n/a n/a n/a

AKI=acute kidney injury, eGFR=estimated glomerular filtration rate.

^a Based on an increase in serum creatinine during active treatment to ≥3× baseline or serum creatinine to ≥4.0 mg/dL, as confirmed by reanalysis using central laboratory data.

^b Based on a decrease of at least 25% initiated during active treatment.

Note: The active treatment period lasted from the time of the first infusion to the subject until the end of Visit 7. In the absence of assay data at Visit 7, the end of the active treatment period was considered the date of the subject's last administration of study formulation + 10 days. The initial value was considered the last value obtained before the date/time of the start of the first infusion of the study composition.

Table 23: Summary of Abnormal Liver Function Parameters (Regardless of Confirmation) (Central Laboratory) During the Active Treatment Period (Safety Population)

Number (%) of subjects Laboratory analysis Number of subjects, n Increase CSL112 6g (N=52) Placebo (N=28) Total (N=80) Active treatment period, most severe case ^a Total or direct bilirubin ^c 79 >1.5x VPN 3 (5.8) 0 3 (3.8) 79 >2x VPN 0 0 0 total bilirubin 79 >1.5x VPN 4 (7.7) 1 (3.7) 5 (6.3) 79 >2x VPN 1 (1.9) 0 1 (1.3) direct bilirubin 79 >1.5x VPN 2 (3.8) 0 2 (2.5) 79 >2x VPN 0 0 0 ALT ^b 79 >3x VPN 0 0 0 79 >5x VPN 0 0 0 79 >10x VPN 0 0 0 AST ^b 79 >3x VPN 1 (1.9) 0 1 (1.3) 79 >5x VPN 1 (1.9) 0 1 (1.3) 79 >10x VPN 0 0 0 Simultaneous increase in ^c 79 Total or direct bilirubin 2x, ALT >3x 0 0 0 79 Total or direct bilirubin >2x, AST >3x 0 0 0 Simultaneously increasing levels 79 Total bilirubin >2x, ALT >3x 0 0 0 79 Total bilirubin >2x, AST >3x 0 0 0 Simultaneously increasing levels 79 Direct bilirubin >2x, ALT >3x 0 0 0 79 Direct bilirubin >2x, AST >3x 0 0 0 ALT=alanine aminotransferase, AST=aspartate aminotransferase, ULN=upper limit of normal.
The results, in percentage terms, are based on the number of subjects with data.
All cases of increased levels were summed up, regardless of confirmation in reanalysis.
^a The single most unfavorable value during the active treatment period, including unscheduled tests, for all subjects in the specified treatment group is included in the pooled data.
^b Increasing levels relative to HPN ranges are gender-specific.
^c For subjects with a history of Gilbert's syndrome, direct bilirubin values were used instead of total bilirubin.
Note: The active treatment period lasted from the time of the first infusion to the subject until the end of Visit 7. In the absence of assay data at Visit 7, the end of the active treatment period was considered the date of the subject's last administration of study formulation + 10 days. Visit 7 (7-10 days after the last infusion) includes data for subjects who discontinued study formulation treatment or who discontinued participation in the study earlier (before Visit 7).

Table 24: Summary of baseline-adjusted pharmacokinetic parameters (PK population)

Parameter Treatment group Infusion n Average SD Median Q1, Q3 Min, Max ApoA-I _Cmax (mg/dl) CSL112 6g (N=52) 1 52 124.6 25.38 127.0 112.0, 142.5 49, 188 4 38 141.5 41.11 147.5 127.0, 171.0 -14, 213 Placebo (N=28) 1 28 -4.5 9.46 -2.0 -9.5, 1.5 -32, 9 4 21 1.4 23.57 0.0 -12.0, 9.0 -43, 66 PC _Cmax (mg/dl) CSL112 6g (N=52) 1 52 198.4 43.56 202.0 171.0, 229.0 80, 295 4 38 200.0 71.78 217.5 157.0, 248.0 -34, 337 Placebo (N=28) 1 28 -4.9 15.04 -7.0 -12.5, 4.5 -43, 26 4 21 -13.2 27.96 -14.0 -33.0, -3.0 -66, 45

ApoA-I=apolipoprotein AI, _Cmax= maximum concentration, PC=phosphatidylcholine, PK=pharmacokinetics, Q1=1st quartile, Q3=3rd quartile, SD=standard deviation.

Note: Baseline-adjusted scores were calculated as (value at visit - baseline). The baseline was the result of the last assay obtained before the date/time of the start of the first infusion of the study formulation.

Claims (43)

1. A method for increasing the reverse cholesterol transport (RTC) in a person after an acute myocardial infarction (MI), including the steps: within seven (7) days of an acute MI, intravenous administration to a patient of a reduced high-density lipoprotein (vHDL) formulation containing 2-6 g of apolipoprotein or a fragment thereof, a lipid, a stabilizer, where the stabilizer is sucrose, and optionally a detergent, while the ratio between apolipoprotein and lipid is from 1:20 to 1:120 mol:mol; wherein the patient is administered an angiographic contrast agent after an acute myocardial infarction and prior to the initial administration of the vHDL formulation; And subsequent intravenous administration of the vHDL formulation to a human weekly for at least four (4) weeks; which leads to an increase in reverse cholesterol transport (RTC) in humans without causing significant changes in liver and/or kidney function in humans. 2. The method according to p. 1, while the increase in total RCT is in the range from 1.5-fold to 2.5-fold. 3. The method according to claim 1, wherein the increase in ABCA1-dependent reverse cholesterol transport is in the range from 3-fold to 5-fold. 4. The method according to any one of paragraphs. 1-3, wherein the human patient is initially administered the vHDL formulation within five (5) days of the acute MI. 5. The method according to any one of paragraphs. 1-4, wherein the human patient is initially administered the vHDL formulation no earlier than 12 hours after an acute MI or after administration of an angiographic contrast agent. 6. The method according to any one of paragraphs. 1-5, wherein the vHDL formulation is administered by intravenous (IV) infusion. 7. The method according to p. 6, while the infusion rate is 1-3 g of apolipoprotein per hour. 8. The method according to any one of paragraphs. 1-7, while a significant change in liver function is determined based on the activity of alanine aminotransferase (ALT), more than 3 times the upper limit of normal (ULN), and / or an increase in the level of total bilirubin to a value of at least two ULN. 9. The method according to any one of paragraphs. 1-8, wherein a significant change in kidney function is determined based on a serum creatinine level of at least 1.5 times the baseline value and/or the need for renal replacement therapy. 10. The method according to any one of paragraphs. 1-9, wherein a significant change in kidney function is determined based on an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/m ² , including less than 60 ml/min/1.73 m ² . 11. The method according to any one of paragraphs. 1-10, with the patient receiving the first dose within 5 days of the acute MI. 12. The method of claim 11, wherein the first dose is administered to the patient at least 12 hours after the acute MI, or not earlier than 12 hours after the acute MI, or after administration of an angiographic contrast agent. 13. The method according to any one of paragraphs. 1-12, while the amount of apolipoprotein in the composition of vHDL is at least 2 g or at least 6 g. 14. The method of claim 13, wherein the apolipoprotein is apo-AI or a fragment thereof. 15. The method according to any one of paragraphs. 1-14, while the stabilizer is present in the composition of vHDL at a concentration of from 1.0% to less than 6.0% by weight; 1.0-5.9% by weight; 3.0-5.9% by weight; 4.0-5.5% by weight; 4.3-5.3% by weight or 4.6-4.8% by weight. 16. The method according to any one of paragraphs. 1-15, wherein the ratio between apolipoprotein and stabilizer is from 1:1 by weight to 1:7 by weight; from 1:1 by weight to 1:3 by weight; from 1:1 by weight to 1:2.4 by weight or from 1:1 by weight to less than 1:2 by weight. 17. The method according to any one of paragraphs. 1-16, while the ratio between apolipoprotein and lipid is from 1:20 to 1:100 mol:mol; 1:20 to 1:75 mol:mol or 1:45 to 1:65 mol:mol. 18. The method according to any one of paragraphs. 1-17, while the composition of vHDL contains a detergent. 19. The method according to p. 18, while the level of detergent is 0.5-1.5 g/l. 20. The method according to claim 18 or 19, wherein the detergent level is 0.015-0.030 g/g apolipoprotein. 21. The method according to any one of paragraphs. 18-20, wherein the detergent is a bile salt or bile acid. 22. The method of claim 21, wherein the detergent is sodium cholate. 23. The method according to any one of paragraphs. 1-22, wherein the lipid is a phospholipid. 24. The method of claim 23, wherein the phospholipid is phosphatidylcholine. 25. A method for increasing reverse cholesterol transport (RTC) in a human patient after acute myocardial infarction (MI), including the steps: within seven (7) days of an acute MI, intravenous administration to the patient of a reduced high-density lipoprotein (vHDL) formulation containing at least 2-6 g of apoA-I, phosphatidylcholine, a stabilizer where the stabilizer is sucrose, and sodium cholate at a level selected from the group consisting of 0.5-1.5 g/l and/or 0.010-0.030 g/g of apoA-I and from 1.0% to less than 6.0% by weight of sucrose, while the ratio between apoA- I and phosphatidylcholine is from 1:20 to 1:120 mol:mol; wherein the patient is administered an angiographic contrast agent after an acute myocardial infarction and prior to the initial administration of the vHDL formulation; subsequent intravenous administration of the vHDL formulation to a human weekly for at least four (4) weeks; resulting in an increase in reverse cholesterol transport (RTC) in a human patient without causing significant changes in liver and/or kidney function in humans, with a significant change in liver function defined based on an ALT value greater than 2 or 3 times the upper limit of normal (VPN); or an increase in the level of total bilirubin to an indicator at least 1.5-2 times higher than the ULN; and a significant change in kidney function is defined as a serum creatinine greater than or 1.2-1.5 times baseline and/or an eGFR significantly less than 90 ml/min/m ² , including less than 90 ml / min / 1.73 m ² . 26. Method for use according to any one of paragraphs. 1-25, further administering one or more therapeutic agents that aid or assist in the treatment, prevention, or reduction of the risk of acute myocardial infarction (MI) and/or SRSS and/or increase reverse cholesterol transport (RTC) in a human patient. 27. The method according to p. 26, while one or more therapeutic agents include: one or more lipid-modifying agents; one or more cholesterol absorption inhibitors; one or more anticoagulants, one or more antihypertensive agents, and one or more bile acid binding molecules. 28. The method of claim 27, wherein the one or more lipid modifying agents include HMG-CoA reductase inhibitors, fibrates, subtilisin kexin type 9 proprotein convertase (PCSK9) inhibitors, and niacin. 29. The method of claim 28, wherein the one or more HMG-CoA reductase inhibitors include a statin. 30. The method of claim 29, wherein the one or more statins include lovastatin, rosuvastatin, atorvastatin, pitavastatin, and simvastatin. 31. The method of claim 28, wherein the one or more fibrates include fenofibrate and gemfibrozil. 32. The method of claim 28, wherein the one or more lipid-modifying agents comprise subtilisin-kexin-type 9 (PCSK9) proprotein convertase inhibitors. 33. The method of claim 27, wherein the one or more cholesterol uptake inhibitors include ezetimibe. 34. The method of claim 27 or 33, wherein one or more cholesterol uptake inhibitors are administered with a statin. 35. The method of claim 34, wherein the one or more cholesterol uptake inhibitors are administered with one or more statins, including lovastatin, rosuvastatin, atorvastatin, pitavastatin, and simvastatin. 36. The method of claim 27, wherein the one or more anticoagulants include warfarin, vitamin K antagonists, heparin or derivatives thereof, factor Xa inhibitors, and thrombin inhibitors. 37. The method according to any one of paragraphs. 1-36, where the human patient has moderate renal insufficiency (Mr. PN).

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