Biomarkers to Diagnostics – The Essential Tool Box for Drug Development - Presentation delivered by Johan Luthman, Vice President, Neuroscience Clinical Development, Eisai Pharmaceuticals at the marcus evans Evolution Summit Fall 2015 in Las Vegas

1. Session:
Monday September 21, 2015 at 11:45-12:30
Biomarkers to Diagnostics
The Essential Tool Box for Drug DevelopmentThe Essential Tool Box for Drug Development
Johan LuthmanJohan Luthman,
VP Neuroscience Clinical Development
Eisai Neuroscience & General Medicine Product Creation Unit,
Wood Cliff Lake NJ USA
Evolution Summit;
Wood Cliff Lake, NJ, USA
;
September 20-22, 2015, Red Rock Resort & Spa, Las Vegas, NV

2. Critical Tools - Animal Models & Biomarkers
Overall Program Risk
Beyond target validationy g
ELstrong
MEDIUM LOW
MODE
MEDIUM LOW
Validated model
No biomarker
Validated model
Validated biomarker
NIMAL
MEDIUMHIGH
N d l
AN
none
e
g
No model
No biomarker
No model
Validated biomarker
BIOMARKER
none
stron

3. Steps from Biomarker to
Diagnostic/Outcome Measure
Regulatory Process
Clinical Qualification
Diagnostic
g y
Approved Diagnostic
Accepted Outcome measure
Diagnostic
Outcome measure (surrogate)
Assay Validation
Prototype assay to Assay “lock down”
A f t i ( kit)
Clinical Application
“Fit for purpose”
Assay manufacturing (e.g. kit)
Assay standardization
Exploratory Biomarker
Exploration of candidate biomarker
Fit for Purpose Assay
Custom developed assay
Biomarker Identification
Hypothesis driven or Un-biased
Modality? / Invasive or Non-invasive?
p

4. Biomarkers in Early Development
Drug Presence & Target Engagement (TE)
Drug reaches target organ & interacts with target
1
g g g g
• Proof of Distribution / Presence - Reaching target organ
• Proof of Target Occupancy - Binding to molecular target (TE)
Proof of Mechanism (PoM)Proof of Mechanism (PoM)
Target mechanism = Pharmacodynamic (PD) readout
• Proof of Biological Activity (PoBA)
• Mechanism of Action (MoA)
2
• Mechanism of Action (MoA)
Proof of Principle (PoP)
Mechanism influences pathophysiology
I ti t b t l h lth l t if h i l i t th h i l
3
• In patients, but also healthy volunteers if physiology approximates pathophysiology
• Also called “PoC Lite”
Proof of Concept (PoC)4 p ( )
Mechanism can be used to treat disease
• Traditionally Phase IIB study, however strive is to obtain PoC as early as possible in
custom designed small patient studies
4

5. Target Engagement Determination:
PET imaging Key Technology
• Valid PoC requires adequate receptor occupancy
C ffi i t b hi t ll t l t d d ?– Can sufficient occupancy be achieve at well tolerated doses ?
– Is it worthwhile testing efficacy?
No occupancy - no efficacy – not surprising
New molecule needed
Full occupancy – no efficacy- concept flawed
Do something else
• PET helps dose selection for efficacy trials
Open therapeutic window and limit manufacturing costs– Open therapeutic window and limit manufacturing costs
Borsook, Becerra and Hargreaves (2006) Nature Reviews Drug Discovery 5: 411-425h

6. Target Engagement – PET Occupancy
Translational biomarker (animal-Ph0-Ph1)
PET set doses for H3 Inverse Agonist PoC Study
•PET imaging of H3 receptorB s lin
7.5 mg 50 mg
PET imaging of H3 receptor
occupancy in humans
•H3 PET tracer allowed dose
selection of MK-0249 in PoC study
Baseline 6h post-dose 6h post-dose
•Acceleration of Phase I to IIB
94%80%AN04
POC f E i D ti Sl iPOC for Excessive Daytime Sleepiness:
Program termination:Program termination:
MK-0249 in POC study
had excellent dose –
occupancy range, butp y g ,
kept humans awake in
sleep period

7. Cerebrospinal fluid (CSF) Aβ peptide
Target-Proximal Translational PD biomarker (animal-Ph2)
BACE Inhibitors Potently Reduces Aβ40 Peptide in CSF and Cortex
Reduction of brain and CSF Aβ levels
in rat and CSF in monkeys after single
Dose-dependent >90% reduction in CSF Aβ
levels in human healthy volunteers after
multiple dosing of MK 8931in rat and CSF in monkeys after single
dose administration BACE inhibitor
multiple dosing of MK-8931
Data presented at the Alzheimer’s Association International Conference. 2012.

8. Quantitative & Qualitative Pharma EEG
Target-Distal Partially Translational Biomarker (animal-Ph1-Ph2)
Compound Class- EGG Fingerprint
“Pharmaco EEG”Pharmaco-EEG
Fingerprinting of pharmacological response
Across species translatability?
Great need for harmonization & standardization
Consortia efforts
International Pharmaco-EEG Society

9. Pharmacodynamic/Efficacy & Safety Biomarker
Target-Distal Partially Translational Complex Biomarker (Ph1-Ph2)
Car driving – On the road or Simulator
Efficacy read-out in e.g. Excessive Daytime Sleepiness patientsEfficacy read out in e.g. Excessive Daytime Sleepiness patients
Safety data on CNS active drugs
Differentiation from Standard of Care (sedative/hypnotics)
Standard Deviation of Lane Position (SDLP)
Assesses “weaving”
Differentiation from Standard of Care (sedative/hypnotics)
Verster, 2006
National Advanced Driving Simulator
(NADS, U of Iowa) MiniSim

10. Notch Signature in Hair Follicles Reveals Side
Effect Liability with γ-Secretase Inhibitors
Identified Notch pathway target genes signature
MK0752 (γ Secretase Inhibitor) in Ph 1
Notch Signature:
ADAM19
CCND1
DVL1
ore
MK0752 (γ-Secretase Inhibitor) in Ph-1
DVL1
HES4
HES5
HEY1
HEYL
hSignaturesco
HEYL
NOTCH1
NRARP
RefinedNotch
Program termination:
Dose (mg):
Time (hr):
MK-0752 caused gene signature down-regulation in 10/10
subjects at 1000 mg dose and 5/6 subjects at 350 mg
(required dose for Aβ40 lowering)

11. Early Development Biomarkers
I t l d i i kiInternal decisions making
Standards & criteria defined internally
Go/No-Go tests of molecules & hypotheses
Target interaction, Dose guiding & Safety margin
Development toolsDevelopment tools
Rarely commercialization of biomarker itself
Often use of commercialized technology platforms

12. Getting the Efficacious Dose Right
Transitioning Early to Late Development
Dialing in Dose via use of Biomarkers in Adative Designg g
E lExample:
Alzheimer’s BACi Ph-2/3

13. Steps from Biomarker to
Diagnostic/Outcome Measure
Regulatory Process
Clinical Qualification
Diagnostic
g y
Approved Diagnostic
Accepted Outcome measure
Diagnostic
Outcome measure (surrogate)
Assay Validation
Prototype assay to Assay “lock down”
A f t i ( kit)
Clinical Application
“Fit for purpose”
Assay manufacturing (e.g. kit)
Assay standardization
Exploratory Biomarker
Exploration of candidate biomarker
Fit for Purpose Assay
Custom developed assay
Biomarker Identification
Hypothesis driven or Un-biased
Modality? / Invasive or Non-invasive?
p

14. Intended use of Biomarkers in
Late Drug Developmentg p
• Disease Diagnosis
– Supportive in clinical diagnosis, or fine tuning of diagnosis
E l di i t i k di i ( t d t bi k )– Early diagnosis – at risk diagnosis (antecedent biomarkers)
• Prognostic (Predictive) – Disease progression
– Diagnosis of disease aggressivenessg gg
• Prognostic (Predictive) – Treatment effect
– Outcome measure in trialsOutcome measure in trials
– Ultimate goal surrogate outcome measure
Surrogacy qualification time-consuming & costly
• Predictive – Drug safety assessmentPredictive Drug safety assessment
• Stratification
– Segmentation into predetermined categoriesg p g
• Enrichment
– Inclusion criteria in trials
– Companion Diagnostics 14

15. Role of Diagnostic Biomarkers
• Clinical phenotype – Different diagnostic criteria
• Histopathology gold-standard in biomarker qualificationHistopathology gold standard in biomarker qualification
Bridging clinical & histopathology phenotypes
(Alzheimer’s disease as example)
Clinical Phenotype Histopathology PhenotypeBiomarker Phenotype
( )
IWG
criteria
Clinical Phenotype
Mayo
criteria
Histopathology Phenotype
Neuro-
fibrillary
Amyloid
plaques
Biomarker Phenotype
CSF
Aβ42
ApoE
isotype
2007
IWG-2
criteria
NIA-AA
criteria
1999 tangles
Neuro-
degen-
Inflamm
ation
plaquesAβ42
Amyloid
PET
isotype
CSF
Taucriteria
2014
criteria
2011
g
ration
ation
15
HCV
MRI
PET Tau

16. Regulatory Process Biomarkers to Diagnostics
“Context of Use” Acceptance
Purpose of the measurement (“Clinical Qualification”)Purpose of the measurement ( Clinical Qualification )
– Stand Alone or Companion Diagnostic
– Outcome Measure - Surrogate Outcome Measure
“Assay” Approval
Test performing the measurement (“Assay Validation”)
– Medical Device
• In Vivo Ex Vivo or In Vitro application• In Vivo, Ex Vivo or In Vitro application
• Do not work via chemical action in the body
– IND / IMP
• In Vivo application
• Work via chemical action in the body, e.g. PET ligand

17. Context of Use
Qualification of Drug Development Tools (DDT)
FDA - Drug Development Tools Qualification Programs
– Allows use in the qualified Context of Use during drug developmentAllows use in the qualified Context of Use during drug development
• Office of Translational Sciences evaluation
• No need CDER reconfirming DDT suitability for the qualified context of use
EMA - Qualification of Novel Methodologies for Drug
Development
– Voluntary pathway to CHMP opinion (public) or a Scientific Advice– Voluntary pathway to CHMP opinion (public) or a Scientific Advice
(confidential) on novel methodologies or methods & drug
development tools
• Qualification of biomarkers for a specific intended useQualification of biomarkers for a specific intended use
Biomarkers qualification requires a reliable measurement method
of the biomarker, but is conceptually independent of the specificof the biomarker, but is conceptually independent of the specific
test performing the measurement
• Qualification does not mean approval of a specific test device

18. Biomarker Context of Use Qualification
Critical Path Institute (Tucson, Arizona)
Bridging the Gap between Science & Regulatory acceptance
RegulatoryE l t
Bridging the Gap between Science & Regulatory acceptance
Regulatory
Application of
Biomarkers
Exploratory
Biomarkers Bmx Qual
• Independent, non-profit organization “Executive” spin-out based
on the Critical Path Initiative (FDA)
• Bringing FDA, industry & academia together to improve path forBringing FDA, industry & academia together to improve path for
innovative new drugs & diagnostics
• Several projects for DDT qualification with FDA & EMA

19. Assay Approval
“Fluid” Biomarker Assay Maturity FDA (EMA) Terminology
Research Use Only (RUO)
– Not for diagnostic use
E l t d i & f– Evaluate design & performance
– Developing knowledge related to human disease
Investigational Use Only (IUO)Investigational Use Only (IUO)
– Undergoing performance evaluation
– Used for diagnosis or treatment decisions or used as part of a drug trial to
determine which arm of the trial subjects will be placed inj p
– Meet criteria for Investigational Device Exemption (IDE)
• Pre-IDE consultations and IDE submission is a useful pathway when evaluating
the clinical utility of a diagnostic product
In Vitro Diagnostic (IVD) Medical Device (kit)
– For diagnosis - to cure, mitigate, treat, or prevent disease
– FDA - CDRH (Center for Devices & Radiologic Health)– FDA - CDRH (Center for Devices & Radiologic Health)
• Pre-market and post-market controls
• Commercialized to CLIA certified labs
– EMA: IVD Devices have to meet the requirements for Self-Declaration

20. FDA IVD Classification
Likely Class II
• Information not used for diagnosis
Likely Class III
•Screens for a serious disease or
diti
• Predicate device is available
• Likelihood of misuse is small or
i ld t t i
condition
•Test information is diagnostic -
patient has a disease or not
misuse would not create a serious
situation
• 510(k)s - a predicate device
•Likelihood or harm of misuse is
significant / serious
clearance
• de novo 510(k)s - no predicate
device clearance
•Information tells physician which
drug to use, not use, or how much
to use
•Pre-Market Approval (PMA)
•Performance of device against a
gold standard or other establishedgold standard or other established
end point

21. USA – Oversight Diagnostics
• Laboratory Developed Test (LDT, “homebrews”)
D l d & d ithi l b– Developed & used within one lab
• Not available to other labs
• Clinical Laboratory Improvement Amendments (CLIA) standard
• FDA has a “risk-based” oversight of LDTs
• “Complementary” Diagnostics
– FDA developing frame work for new regulatory category
• Provide additional information on drug use• Provide additional information on drug use
– Distinct from “companion diagnostics,” (essential for drug use)
– Example - gene “signature” pattern linked to a certain disease.
• No test yet labeled as complementary diagnostics

22. Europe: CE Mark
• Requirements of the In Vitro Diagnostic Directive
98/79/EC
– Manufacturer's declaration that the product conforms
with “Essential Requirements”with Essential Requirements
Self-declaration
Verified by “Notified Body” (accredited to validate
compliance)
Permits products’ access to the market
CE Marking is not approval by a Health Authority
CE M ki i t lid ti f li i l tilit• CE Marking is not validation of clinical utility
• CE Marking is not intended for consumer assurance

23. Stand- Alone Diagnostic
“Independent” diagnostic
–Not associated with specific drug treatmentot assoc ated t spec c d ug t eat e t
–“Gold standard" against which to judge
performanceperformance
Other established diagnostic
Post mortem histopathologyPost mortem histopathology

24. Companion Diagnostic Pathway
Drug
Pharmaceutical Drug
Clinical phases RegulatoryDrug
Discovery
Biochemical Biomarker
Preclinical
Phase I Phase II Phase III
Regulatory
filing
Launch
PMA/CE
Biomarker
Discovery
Feasibility Verification
RUO assay Prototype
Regulatory
review
Commer-
cialization
IVC
IUO
assay
Clinical
Qualification
Identifies condition for use of a therapeutic product
Ensures the safe & effective use of a therapeutic productEnsures the safe & effective use of a therapeutic product
Context of Use established by drug treatment effect
No "gold standard" requirement to judge performance
• Collaboration between Center for Drug Evaluation and Research (CDER)
and CDRH (Center for Devices & Radiologic Health)
•Commonly a Class III device (Requiring Pre-Market Approval)

25. Companion Diagnostic - EMA
• CoDx viewed as low risk - CE markingCoDx viewed as low risk CE marking
• Drug approvals not held up for kit to be CE marked
• Not yet requiring intended uses of diagnostic products toNot yet requiring intended uses of diagnostic products to
change when companion diagnostic associated
• Emerging new EMA regulation:
• CoDx will be viewed as class C (high risk)( g )
• Increased Notified Body & Competent authority involvement

26. Alzheimer‘s Disease
Progressive deficits in cognition (memory),
activities of daily living (ADL) & behavior
• Neuropathology:
–Extracellular amyloid plaques • Decreased brain
activities of daily living (ADL) & behavior
–Extracellular amyloid plaques
–Intracellular neurofibrillary tangles
–Neuro-degeneration
Decreased brain
metabolism
• Brain atrophy
–Neuroinflammation

27. “Diagnostic” use of Alzheimer’s Disease
(AD) Biomarkers( )
Pre-Dementia Dementia
Cognitive, Functional & Behavioral deficits
Mild Moderate Severe
Current diagnosis & treatment
Cognitive Impairment
MCI / Prodromal AD
Symptoms
Memory complaints
Pre-Symptomatic
No apparent symptoms
• Risk factors; family • Mild cognitive impairment • AD diagnosis based on clinical
Current diagnosis & treatmentSymptomsNo apparent symptoms
• Risk factors; family
history, old age, ApoE4
genotype, TBI, mutations
• No symptoms, or subtle
• Mild cognitive impairment
(MCI)
• Amnestic Mild Cognitive
Impairment (aMCI) - episodic
• AD diagnosis based on clinical
symptoms; cognitive deficits &
dementia of the AD type
• Biomarker evidence of ADy
cognitive deficits
(memory complaints)
• Emerging biomarker
e idence of AD
( )
memory deficits
• aMCI combined with
biomarker evidence of AD
patholog Prodromal AD
pathology may increase
specificity of diagnosis
evidence of AD
pathology
pathology = Prodromal AD

28. Biomarker & Clinical Change in
Alzheimer’s Disease
Clinical symptom stages - Occurrence
dependent on degree of reserve capacity
Asymptomatic stage - Genetic
risk & increasing biomarker signal
Max CSF Aβ42
A l id PET
dependent on degree of reserve capacityrisk & increasing biomarker signal
bnormality
Dementia
Amyloid PET
CSF Tau
MRI + FDG PET
Cognitive impairment
BiomarkerAb
MCIDetection
Threshold
CSF Cerebrospinal fl id
B
Min
Normal
Time (years)
Cognitive
impairment
Functional/ Behavioral
changes = dementia
Jack CR, et al. Lancet Neurol (2013) 12; 207.
CSF = Cerebrospinal fluid
FDG = Fluorodeoxyglucose
MRI = Magnetic resonance imaging
PET = Positron emission
tomography
p g

29. Critical Role of International Pre-competitive
Consortia in Progressing Alzheimer’s Biomarkers
World Wide Alzheimer’s Disease Neuroimaging Initiative (WW-ADNI)
Collaborative effort of scientists from around the world
N th A i ADNI (NA ADNI)
PharmaCog (European ADNI)
North American ADNI (NA-ADNI)
Chinese ADNI
Japanese ADNI
Taiwan ADNI
Korean ADNI
AIBL (Australian ADNI)
Argentinian ADNI
Source: http://www.alz.org/research/funding/partnerships/ww-adni_overview.asp.

30. Biomarkers Used to Select Prodromal Subjects or
to Demonstrate Disease Modification
• Prodromal AD patient “diagnosis” in MCI
1 B i l id PET i i1. Brain amyloid PET imaging
2. Cerebrospinal fluid (CSF) tau protein / Aβ peptide
3 volumetric MRI – hippocampal volume3. volumetric MRI – hippocampal volume
• Outcome measures
Biomarkers as secondary & exploratory endpoints to support
Disease Modification claimsDisease Modification claims
1. Hippocampal atrophy - volumetric MRI
2. Cerebrospinal fluid total-tau or P-tau
3. Brain amyloid PET imaging (treatment effect)

31. Amyloid PET For Prodromal AD
Diagnosis & Trial Enrichment
Amyloid Negative Example
Amyloid Positive Example:Amyloid Positive Example:
Diffuse
Amyloid Positive Example:
Diffuse + Focal
Sevigny AAN 2014
31

32. Challenges with Multi-Site Amyloid PET
Workflow for Multicenter Clinical PET imaging study
CyclotronCyclotron
((1818
F production)F production) Tracer SynthesisTracer Synthesis
GMP FacilityGMP Facility
SterileSterile
ReadyReady--toto--injectinject
Distribution to Medical ImagingDistribution to Medical Imaging
Center (~ 4Center (~ 4 h from synthesis site)-
ReadyReadytoto injectinject
tracertracer
Selection of Imaging centerSelection of Imaging center
-- Camera QualificationCamera Qualification
Data acq isitionData acquisition
Multiple referring clinical sites
Transfer of subject to imaging center
-- Selection of Imaging centerSelection of Imaging center
-- Qualification of siteQualification of site
-- Data acquisitionData acquisition
-- AnnonymizationAnnonymizationof dataof data
-- Data transfer to imagingData transfer to imaging lab
Transfer of subject to imaging center

33. Cerebrospinal Fluid Biomarkers of AD:
Aβ42 and Tauβ
Tau:
Phospho-Tau:
Plaques
Tangles Aβ42 monomers:
Tau/Aβ42 ratio:
Aβ42 Tau1200
1000
1600
1400
1200
800
600
400
1000
800
600
400
pg/mL
200
0
400
200
0
Controls Alzheimer Disease Controls Alzheimer Disease
Sunderland T et al. JAMA. (2003) 289 (16); 2094.
Controls
(n = 72)
Alzheimer Disease
(n = 131)
Controls
(n = 72)
Alzheimer Disease
(n = 131)

34. CSF Tau & Aβ42 Predict Progression From
Mild Cognitive Impairment (MCI) to AD
Mild Cognitive Impairment to AD Predicted by Tau/Aβ42
1
1.0
0.8
AD
Normal CSF
Pathological CSF
0.6
ressionto
Pathological CSF
Cut-off values for pathological CSF:
T-tau > 350 ng/L
Aβ42 < 530 ng/L
P-tau181 > 60 ng/L
0.4
0.2
Noprog
P tau181 > 60 ng/L
Aβ42/P-tau181 ratio < 6.5
0
0 10 20 30 40 50 60
CSF = Cerebrospinal fluid
1. Hansson O et al. Lancet Neurol. (2006) 5(3); 228.
Time (months)

35. Example of Receiver Operating Characteristic Curve for
Tau/Aβ42 Assay in Cerebrospinal Fluid
Alzheimer’s Disease (n=84) vs. Healthy Elderly (n=108)
ivitySensiti
1‐ Specificity

36. Inter-changeable Use of CSF Biomarkers &
Amyloid PET for Enrichment
Florbetapir Amyloid PET & CSF Aβ42 relationship
374 recently-recruited ADNI-GO/2 subjects
Concordance CSF/PET has consistently been shown to be >85%
Key comparison Visual Read on Amyloid PET & CSF assay cut point
36

37. C-Path Institute - CAMD Project Pipeline

38. FDA Issues Letters of Support to AD
Biomarkers
38

39. FDA Evidentiary Standards Initiative
39

40. Are Biomarker Strategies Fully Implemented?
• Are only programs with TE or PD biomarkers progressing in Clinical
studies?
Monoclonal antibodies against Aβ progressing without any TE/PD biomarkers
AD symptomatic drugs progressing with TE PET done after Phase 2
• Are Early Development Biomarkers used for clear Stop/Go
d i i ?decisions?
γ-Secretase Inhibitors semagacestat and avagacestat progressed with very small PD effects
and no safety biomarkers
A bi k d h ibl f d fi i d t i f• Are biomarkers used as much as possible for defining and staging of
diseases?
Several AD programs against amyloid progressed without amyloid stratification
“• Are “right” biomarkers being used when there are other
possibilities?
Amyloid PET instead of CSF markers for stratification
• Are the “right” validation (Assays) and qualification efforts being
done (Context of Use)?
40

41. Biomarkers in Drug R&D…..?
BiBio-
marker
Bio-
marker
Bio-
marker
Thank you for your attention!

42. For more information about theFor more information about the
marcus evans Pharma
S it iSummits series:
pharmaseries@marcusevanscy.com