1

A. Glanville1, M. Musk2, M. Zamora3, T. Hodges4, S. Arcasoy5, U. Sommerwerck6, J. DeVincenzo7, V. Karsten8, S. Shah8, J. Cehelsky8, S. Nochur8, J. Gollob8, A. Vaishnaw8, A. Simon8,

Jens Gottlieb9 (1Sydney, 2Perth, Australia, 3Aurora, 4Phoenix, 5New York, 7Memphis, 8Cambridge, US, 6Essen, 9Hannover, Germany)

Results of a Phase 2b Multi-Center, Randomized,

Double-Blind, Placebo-Controlled Study of an RNAi

Therapeutic, ALN-RSV01, in Respiratory Syncytial

Virus (RSV)-Infected Lung Transplant Patients

Disclosure Slide

2

• Sponsored institutional grants for Alnylam

Pharmaceuticals for $10,001–$50,000

• Consultancy fees for Chiesi, Novartis for $5,001–$10,000

• Lecture fees from Roche, Astellas, Boehringer, Astra-

Zeneca, Novartis, Merck for $ 5,001–$10,000

• Travel and accommodation grants for Astellas, Nycomed,

Merck, Novartis $5,001–$10,000.

• BOS is major cause of morbidity and

mortality in lung transplant patients

• Re-transplantation remains only

definitive BOS treatment

• Community acquired respiratory virus

(CARV) infections occur in 8-10% of

transplant patients annually

• Up to 25% of CARV infections are

due to RSV

• Three prospective studies confirm

role of CARV, including RSV, in BOS

development in lung transplant

patients

Gottlieb J et al., Transplantation, 2009

Gottlieb J et al., Transplant, 87: 1530-37 (2009)

Hopkins P et al., Am J Respir Crit Care Med ., 178: 876-81 (2008)

Kumar D et al, Am J Transplant, 5:2031-36 (2005)

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Bronchiolitis Obliterans Syndrome (BOS) The Role of RSV Infection

RNA Interference (RNAi) ALN-RSV01

• Natural biologic process regulating gene expression mediated by small

interfering RNA (siRNA)

• Utilize siRNA to silence endogenous (host genes) or exogenous (infectious

organism gene) disease-causing targets

• ALN-RSV01: inhaled siRNA directed against nucleocapsid (N) gene of RSV

required for RSV replication

• Hypothesis: decreasing RSV viral load will decrease infection severity and

ameliorate airway injury and chronic allograft dysfunction, i.e. BOS

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Zamore Nat Struct Biol. 8(9):746-50. (2001); Bartel Cell 116(2): 181-197 (2004)

ALN-RSV01

siRNA targeting

RSV N gene

RNAi-mediated cleavage

of RSV mRNA

Cleaved

RSV

mRNA

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 Study Day

ALN-RSV01 Placebo

% I

nfe

cte

d

P=0.0069

Human experimental infection study showed ALN-RSV01 significantly decreased infection

rate in healthy volunteers infected with RSV intranasally (p=0.0069)1

Randomized, double-blind, PBO-controlled trial (n=24) in RSV-infected lung transplant

patients demonstrated significantly decreased BOS at Day 90 (p=0.02)2

1. PNAS;107:8800-5 (2010)

2. Am J Respir Crit Care Med.; 183:531-8 (2011)

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Incidence of Infection

Phase IIa Experimental Infection Study1 Incidence of BOS

0

10

20

30

40

50

ALN-RSV01 Placebo

% N

ew

or

Pro

gre

ssiv

e B

OS

Phase IIa Lung Transplant Study2

P=0.02

ALN-RSV01 RNAi Therapeutic for RSV Infection; Key Prior Studies

ALN-RSV01 Phase IIb Study Design Eligibility Criteria and Endpoints

Key Inclusion Criteria • Adults ≥ 18 yo

• Greater than 90 days post-transplant

• Rejection-free ≥ 30 days

• Confirmed RSV by local or central lab

Key Exclusion Criteria • Rx for other acute lung infection

• BOS Grade 3

• Unstable FEV1 over prior 3 months

• Mechanical intubation

• Use of alemtuzumab within 9 mo of screen; anti-thymocyte globulin within 90 days of

screen

Stratification Factors at Randomization • Time from symptom onset (< 5 days vs > 5days)

• Pre-infection BOS grade (BOS 0 vs BOS 0P,1 or 2)

Primary Endpoint • Effect of ALN-RSV01 on incidence of new or progressive BOS at Day 18 BOS

• BOS adjudicated by independent committee blinded to study site and treatment

Key Secondary Endpoints • BOS at Day 90, anti-viral activity, symptom score, survival, acute lung rejection

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ALN-RSV01 Phase IIb Study Schema and Analysis Populations

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CARV

Infection

N=3985

RSV+

N=218

Days 0 1 2 3 4

Placebo + SOC*

(N=42)

ALN-RSV01 + SOC*

(N=45)

Primary Endpoint

New/ Progressive

BOS Day180

Secondary Endpoint

New/Progressive

BOS Day 90

N=87

Rx: 0.6 mg/kg/d x 5d aerosolized *SOC-Standard of care per site protocol

Study Metrics • 33 sites from 6 countries (Australia, Austria, Germany, France, Canada, USA) screened

lung transplant patients with respiratory symptoms

• Enrollment occurred from Feb 2010-Nov 2011

Pre-specified Analysis Populations • ITT: Randomized patients that received at least one dose of study medication (missing

Day 180 data = treatment failure

• ITT central (ITTc): ITT patients who are RSV positive by central laboratory (missing Day

180 data = treatment failure

• PP: ITTc patients with Day 180 BOS assessment and no major protocol violations

• Enrollment occurred from Feb 2010-Nov 2011

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Baseline Characteristic Placebo (N=33) ALN-RSV01 (N=44)

Age Median (Range) 56 (28 – 72) 53.5 (20 – 72)

Sex Male

Female

20 (61%)

13 (39%)

23 (52%)

21 (48%)

Type of Lung Transplant Bilateral

Single

27 (82%)

6 (18%)

36 (82%)

8 (18%)

Transplant Indication Emphysema/COPD

Idiopathic Pulmonary Fibrosis

Cystic Fibrosis

Other

12 (36%)

9 (27%)

7 (21%)

5 (15%)

10 (23%)

14 (32%)

10 (23%)

10 (23%)

Years from Transplant Median (Range) 2.9 (0.6-16.8) 3.1 (0.3 – 21.5)

Pre-infection BOS Grade 0

0p

1

2

14 (42%)

14 (42%)

4 (12%)

1 (3%)

19 (43%)

16 (36%)

6 (14%)

3 (7%)

FEV1 Change from Pre-Infection to Screening

Median (Range)

-13.4% (-48.1 - 8.6)

-9.4% (-56.3 - 10.1)

Mean Viral Load (SD) Nasal Swab

[Log10 Copies/ml] Oropharyngeal Wash

6.9 (2.3)

4.3 (1.4)

6.7 (2.3)

4.2 (1.5)

Days from Symptom Onset to Treatment

<5 Days

≥5 Days

7 (21%)

26 (79%)

12 (27%)

32 (72%)

RSV Treatment Pulse Dose Steroids*

Ribavirin

IVIG

Palivizumab

21 (64%)

27 (82%)

4 (12%)

3 (9%)

34 (77%)

33 (75%)

4 (9%)

3 (7%)

ALN-RSV01 Phase IIb Study Results Baseline Patient Characteristics (ITTc)

No statistically significant differences in baseline characteristics between groups

* Pulse Dose Steroids: steroids above standard maintenance regimen

ALN-RSV01 Phase IIb Study Results Incidence of Day 90 and Day 180 BOS

Treatment effect of ALN-RSV01 on Day 90 and Day 180 BOS ranges from 52-65%

Per Protocol

0

10

20

30

40

% N

ew

or

Pro

gre

ss

ive

BO

S

Day 90 Day 180

Placebo ALN-RSV01 Placebo ALN-RSV01

p=0.044 p=0.058

ITTc

30.3%

13.6%

33.3%

15.9%

0

10

20

30

40

Day 90 Day 180

Placebo ALN-RSV01 Placebo ALN-RSV01

% N

ew

or

Pro

gre

ss

ive

BO

S

p=0.028 p=0.025

28.1%

9.8%

29.0%

10.3%

p-value from Cochran-Mantel-Haenszel (CMH) test adjusting for randomization strata 9

ALN-RSV01 Phase IIb Study Results Ribavirin Pulse and Dose Steroids: Impact on Day 180 BOS (ITTc)

ALN-RSV01 treatment effect was preserved in patients who received pulse dose steroids

Subgroup

Placebo

N=33

ALN-RSV01

N=44 p-value

Ribavirin 9/27

(33%)

6/33

(18%) 0.098^^

No Ribavirin 1/6

(17%)

0/11

10

* Pulse Dose Steroids: steroids above standard maintenance regimen

^^ CMH Test (adjusted for steroid or ribavirin use)

Subgroup

Placebo

N=33

ALN-RSV01

N=44 p-value

Pulse Dose Steroid*

9/21

(43%)

6/34

(18%) 0.028^^

No Pulse Dose Steroid 1/12

(8%)

0/10

PBO

N=33

RSV01

N=44 p-value

< 5 Days from Symptom Onset to

First Dose

5/7

(71%)

1/12

(8%) 0.0095^

≥ 5 Days from Symptom Onset to First

Dose

5/26

(19%)

5/32

(16%) 0.740^

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ALN-RSV01 Phase IIb Study Results Time to Treatment: Impact on Day 180 BOS (ITTc)

Strong treatment effect (88%) observed in patients treated with ALN-RSV01 < 5 days from symptom onset

^Fisher’s Exact Test

Multiple Logistic Regression Model: Determines effect of each individual variable on odds of developing

Day 180 BOS while adjusting for effects of other variables

Conclusion

• ALN-RSV01 treatment effect is robust – the most significant variable among 18 considered

• When only early pulse steroids (Day 0-4) was evaluated in the LR model, steroid treatment no longer had a

significant impact on BOS, but the ALN-RSV01 treatment effect remained (OR=4.7, CI 0.9, 22.7)

Log (Odds Ratio)

Pulse Steroids*

5% FEV1 Drop

ALN-RSV01

-1 0 1 2

Day 180 BOS Risk: DECREASED INCREASED

OR 8.5 (CI 1.7,41.7)

OR 1.2 (CI 1.0,1.6)

OR 17.5 (CI 1.6,187.9)

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ALN-RSV01 Phase IIb Study Results Logistic Regression Model

*Pulse steroids: any dose above maintenance given during the study

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Study Outcome

PBO

N=33

RSV01

N=44 p-value

Cumulative Total Symptom Score Day 0-14Ϯ

Median (range)

73.0

(7 – 246)

85.0

(4 – 638)

NS

Overall Viral Load (AUC 0-6) (SD)

[Log10 copies/ml x Day]

Nasal Swabs

Oropharyngeal Wash

33.1 (13.8)

21.3 (9.2)

33.4 (14.6)

20.6 (9.5)

NS

NS

Duration of Hospitalization for RSV Infection

[Days] Median (range)

6.5 (5-18)

8.0 (2-52)

NS

Respiratory Infection after D30 7 (21%) 10 (23%) NS

Acute Rejection 2 (6% ) 5 (11%) NS

Survival* 33 (100% ) 43 (98% ) NS

*3 deaths occurred during the study in the ITT population :

• 1 in ALN-RSV01 and 2 in Placebo (neither were RSV+)

• None related to study drug

• None related to BOS as determined by Clinical Adjudication Committee

ALN-RSV01 Phase IIb Study Results Key Secondary Endpoints (ITTc)

ϮScale of 10 symptoms with max. 60 points per day

Serious Adverse Events • 12 SAEs in 9 patients between Day 0-30: ALN-RSV01 n=5 (11%);

Placebo n=7 (17%)

• 1 SAE considered possibly related to study drug

Deaths • 3 deaths: 1 in ALN-RSV01 and 2 in Placebo (neither RSV+)

• No deaths study drug related, as determined by study investigators

• No deaths BOS-related, as determined by adjudication committee

ALN-RSV01 Phase IIb Study Results Safety (ITT)

Treatment Emergent Respiratory

Events > 5%

Placebo

N=42

n (%)

ALN-RSV01

N=45

n (%)

Wheezing^ 0 4 (9%)

Cough 1 (2%) 3 (7%)

Dyspnea 3 (7%) 2 (4%)

Epistaxis 3 (7%) 0

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Serious Adverse Events (SAEs) (ITT)

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Treatment

Arm Description of SAE ID Start Stop Severity

Relationship to

study drug

ALN-

RSV01

Deep vein thrombosis 011-001 Day 17 Day 168 Moderate Unrelated

Atrial flutter 031-003 Day 3 Day 67 Severe Unrelated

Right pneumothorax 201-018 Day 0 Day 10 Severe Possibly

Worsening anemia 400-008 Day 24 Day 28 Moderate Unrelated

Pseudomonas LRTI 404-001 Day 8 Day 19 Severe Unrelated

Placebo

Abdominal pain 005-002 Day 5 Day 10 Severe Unrelated

Bronchitis 005-002 Day 13 Day 23 Moderate Unrelated

Kidney Stones 005-002 Day 27 Day 43 Moderate Unrelated

GI infection 202-001 Day 3 Day 8 Moderate Unrelated

Pulmonary embolism 306-002 Day 20 Day 29 Moderate Unrelated

Deep vein thrombosis 306-002 Day 20 Day 29 Moderate Unrelated

RSV bronchiolitis 401-003 Day 3 Day 9 Mild Unrelated

12 SAEs were reported in 9 patients between Day 0 and Day 30

1 SAE considered possibly related to ALN-RSV01: pneumothorax in patient with prior history of spontaneous

pneumothorax 12 hrs post-study drug administration

ALN-RSV01 Phase IIb Study Results Summary

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ALN-RSV01 is a promising therapeutic for RSV-induced

BOS, a significant cause of morbidity and mortality in lung

transplant patients ● Effective in reducing BOS in RSV-infected lung transplant patients

» Reduced incidence of new or progressive BOS at Days 90 and 180

by 50% or more

» Treatment effect enhanced when given < 5 days from symptom

onset

» Significant treatment effect observed in logistic regression analysis

adjusting for multiple other variables

» Results consistent with prior Phase IIa study showing decreased

Day 90 BOS

● No significant differences on viral parameters or symptom scores

● Safe and well tolerated

Acknowledgements

ALN-RSV01 Clinical Investigators and Site Staff

ALN-RSV01-109 Committee Members » Viral Quality Oversight Committee

» Clinical Adjudication Committee

Medpace

Veristat

Alnylam Pharmaceuticals

Lung Transplant Study Patients

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