DGAT2

Significant improvement in steatohepatitis with >2 point improvement in NAS score without worsening fibrosis, the primary endpoint of the study Achieved key secondary endpoint of MASH resolution without worsening of fibrosis More ION224 treated patients had an improvement of >1 stage fibrosis compared to placebo ION224 was safe and well-tolerated in this study with once-monthly subcutaneous dosing CARLSBAD, Calif., March 13, 2024 /PRNewswire/ -- Ionis Pharmaceuticals, Inc. (Nasdaq: IONS) announced positive results from a Phase 2 study of ION224, an investigational DGAT2 antisense inhibitor in development for the treatment of metabolic dysfunction-associated steatohepatitis (MASH), previously referred to as nonalcoholic steatohepatitis (NASH). The study met its primary endpoint at both doses (120 mg and 90 mg), achieving liver histologic improvement, and also met the important secondary endpoint of MASH resolution. Key highlights from the 160-patient study at 51 weeks included: ION224 achieved statistically significant liver histologic improvement as measured by at least a 2-point reduction in NAFLD Activity Score (NAS)* (p<0.001 (120 mg) and p=0.015 (90 mg)). Subgroup analysis indicated that significant improvements in the primary endpoint were observed in patients with both F2 and F3 (advanced) fibrosis. ION224 achieved statistically significant MASH resolution without worsening of fibrosis, as measured by biopsy (p=0.039). 44% of patients treated with 120 mg achieved ≥50% relative reduction in liver steatosis as measured by MRI-PDFF compared to 3% for placebo. 32% of patients treated with 120 mg achieved a ≥1 stage improvement in fibrosis without worsening steatohepatitis as measured by biopsy compared to 12.5% for placebo. ION224 was safe and well-tolerated in the study. "This Phase 2 trial of ION224 is the first to demonstrate clinical evidence that the reduction of hepatic fat after DGAT2 inhibition correlates with improvements in MASH histological endpoints," said Rohit Loomba, MD, MHSc, professor of medicine and chief, division of gastroenterology and hepatology, University of California San Diego; founding director, MASLD Research Center, University of California San Diego. "I believe ION224 offers a unique precision medicine opportunity with an approach that is potentially complementary to others in development for MASH, and I look forward to continued evaluation of this important investigational medicine." MASH is the more severe form of metabolic dysfunction-associated steatotic liver disease (MASLD) and can lead to liver fibrosis, cirrhosis and liver-related death. ION224 is an investigational LIgand- Conjugated Antisense (LICA) medicine designed to reduce the production of diacylglycerol acyltransferase 2 (DGAT2) to treat patients with MASH. "Reducing the production of DGAT2 enzyme decreases the overproduction of triglycerides that contribute to excess liver fat, which can result in liver damage and inflammation. We are encouraged by these ION224 data, showing that a monthly subcutaneous medicine targeting DGAT2 has the potential to improve MASH and prevent its progression to more severe stages, including advanced liver fibrosis and cirrhosis," said Sanjay Bhanot, MD, PhD, senior vice president and chief medical officer at Ionis. "The inhibition of DGAT2 represents a novel approach for MASH, a progressive disease in need of better treatment options. We look forward to sharing the full results from this study at an upcoming medical conference and discussing next steps to advance this potentially promising therapy for patients." In this study, ION224 was safe and well-tolerated in MASH participants. Those in the ION224 study arms did not experience any worsening of hepatic or renal function or gastrointestinal side effects, and there was a lower rate of early termination compared to placebo. Additionally, there were no on-study deaths or treatment-related serious adverse events. The adaptive Phase 2, two-part, multi-center, randomized, double-blind, placebo-controlled study was designed to assess the efficacy, safety and pharmacokinetics of multiple doses of ION224 when administered subcutaneously once-monthly in adults with MASH. The study enrolled 160 patients to receive ION224 or placebo over a period of 49 weeks. In Part 1, 93 patients were randomized 1:1:1 to the three dose cohorts (60, 90, and 120 mg) and within each dose cohort, randomized 3:1 to receive ION224 or placebo. In Part 2, an additional 67 patients were randomized 1:1 to two selected dose cohorts (90 and 120 mg) and then in a 2:1 ratio to receive either ION224 or placebo within each cohort. The study was powered for the primary endpoint, which was the percentage of patients who achieved MASH histologic improvement, defined as achieving at least a 2-point reduction in NAS with at least 1-point improvement in hepatocellular ballooning or lobular inflammation, and without worsening of fibrosis at end of the treatment period. About ION224 ION224 is an investigational LIgand- Conjugated Antisense (LICA) medicine designed to reduce the production of diacylglycerol acyltransferase 2 (DGAT2) to treat patients with MASH. DGAT2 is an enzyme that catalyzes the final step in triglyceride synthesis in the liver. Reducing the production of DGAT2 should therefore decrease triglyceride synthesis in the liver. Additionally, there is evidence of an increase in both fatty acid oxidation and oxidative gene expression associated with antisense inhibition of DGAT2. ION224 offers a unique approach, which is potentially complementary to other therapies currently in clinical development. About Metabolic dysfunction-associated steatohepatitis (MASH) MASH is the more severe form of metabolic dysfunction-associated fatty liver disease (MASLD). It is related to the epidemic of obesity, pre-diabetes and diabetes. Unlike liver disease caused by alcohol consumption, MASH is the result of an accumulation of fat in the liver, which can lead to inflammation and cirrhosis, an advanced scarring of the liver that prevents the liver from functioning normally. About 20% of MASH patients are reported to develop cirrhosis, which is associated with increased risk of liver-related and overall mortality.i MASH is the fastest growing indication for liver transplantation in the U.S. and Europe.ii In 2023, several multinational liver societies made the recommendation to update NAFLD to metabolic dysfunction-associated steatotic liver disease (MASLD) and to update non-alcoholic steatohepatitis (NASH) to metabolic dysfunction-associated steatohepatitis (MASH). Ionis has adopted the use of MASH to describe this Phase 2 trial. ION224-CS2 is registered on clinicaltrials.gov as a study in patients with non-alcoholic steatohepatitis (NASH) and was registered before the recommended update. About Ionis Pharmaceuticals, Inc. For three decades, Ionis has invented medicines that bring better futures to people with serious diseases. Ionis currently has five marketed medicines and a leading pipeline in neurology, cardiology, and other areas of high patient need. As the pioneer in RNA-targeted medicines, Ionis continues to drive innovation in RNA therapies in addition to advancing new approaches in gene editing. A deep understanding of disease biology and industry-leading technology propels our work, coupled with a passion and urgency to deliver life-changing advances for patients. To learn more about Ionis, visit Ionispharma.com and follow us on X (Twitter) and LinkedIn. Forward-looking Statements This press release includes forward-looking statements regarding Ionis' business and the therapeutic and commercial potential of ION224, additional medicines and technologies. Any statement describing Ionis' goals, expectations, financial or other projections, intentions, or beliefs is a forward-looking statement and should be considered an at-risk statement. Such statements are subject to certain risks and uncertainties, including but not limited to those related to our commercial products and the medicines in our pipeline, and particularly those inherent in the process of discovering, developing and commercializing medicines that are safe and effective for use as human therapeutics, and in the endeavor of building a business around such medicines. Ionis' forward-looking statements also involve assumptions that, if they never materialize or prove correct, could cause its results to differ materially from those expressed or implied by such forward-looking statements. Although Ionis' forward-looking statements reflect the good faith judgment of its management, these statements are based only on facts and factors currently known by Ionis. Except as required by law, we undertake no obligation to update any forward-looking statements for any reason. As a result, you are cautioned not to rely on these forward-looking statements. These and other risks concerning Ionis' programs are described in additional detail in Ionis' annual report on Form 10-K for the year ended Dec. 31, 2023, which is on file with the SEC. Copies of this and other documents are available at . Ionis Pharmaceuticals® is a registered trademark of Ionis Pharmaceuticals, Inc. * Nonalcoholic Fatty Liver Disease Activity Score (NAS) with at least 1-point improvement in hepatocellular ballooning or lobular inflammation, and without worsening in fibrosis stage. iLe MH, et al. Clin Mol Hepatology 2022;28:841–850. iiEstes C, et al. Hepatology. 2018;67(1):123-133. SOURCE Ionis Pharmaceuticals, Inc.

Ionis Pharmaceuticals staked its position in an increasingly-crowded liver disease field on Wednesday, revealing that its antisense inhibitor for metabolic dysfunction-associated steatohepatitis (MASH) met the primary endpoint and key secondary goal in a Phase II trial.ION224 is an experimental ligand-conjugated antisense (LICA) treatment designed to reduce production of DGAT2, an enzyme that catalyses the final step in triglyceride synthesis in the liver, a hallmark of MASH. Boehringer Ingelheim is also taking an RNA-targeted approach for the disease; in January, the pharma partnered with Suzhou Ribo Life Science to use the latter’s small interfering RNA (siRNA) liver-targeting delivery technology to develop candidates for MASH.The study randomised 160 participants to receive placebo or a once-monthly injection of ION224 at either the 60mg, 90mg or 120mg dose level. At 51 weeks, the middle and high doses achieved statistically significant liver histologic improvement as measured by a ≥2 stage reduction in non-alcoholic fatty liver disease (NAFLD) activity score, the primary endpoint.Those two doses also achieved statistically significant MASH resolution without worsening of fibrosis, as measured by biopsy (p=0.039).The study showed that ION224 appears to be safe as well, with no treatment-related serious adverse events or on-study deaths. Patients who received the antisense inhibitor had a lower early trial termination rate than the placebo arm, and did not experience any worsening of hepatic or renal function or gastrointestinal side effects.Ionis expects to share the trial’s full results at an upcoming medical conference."This Phase II trial of ION224 is the first to demonstrate clinical evidence that the reduction of hepatic fat after DGAT2 inhibition correlates with improvements in MASH histological endpoints," said Rohit Loomba, the founding director of the MASLD Research Center at the University of California San Diego. He was not involved in the study.

Pictured: Illustration depicting a damaged liver/iStock, Mohammed Haneefa Nizamudeen A Phase II clinical trial of Ionis Pharmaceuticals’ metabolic dysfunction-associated steatohepatitis drug candidate has hit its primary endpoint, the company said Wednesday. Investigators randomized 160 people with metabolic dysfunction-associated steatohepatitis (MASH), the liver disease formerly known as nonalcoholic steatohepatitis, to receive placebo or one of three doses of ION224 subcutaneously once a month. Ionis designed the ligand-conjugated antisense medicine to cut production of DGAT2, an enzyme that studies have linked to fatty liver disease. After 51 weeks, the proportion of patients who had MASH histologic improvement without worsening of fibrosis was significantly higher in the top two dose cohorts than in the placebo group. The significant differences caused the trial to meet its primary endpoint. Ionis shared the p values for the successful 90-mg and 120-mg doses—0.015 and less than 0.001, respectively—but is yet to provide a closer look at the primary endpoint data. Subgroup analyses found patients with both F2 and F3 fibrosis, the middle scores on a four-point scarring severity scale, improved after taking ION224. The biotech published some secondary endpoint data. ION224 beat placebo on an endpoint that looked at MASH resolution without worsening of fibrosis, as measured by biopsy. At the highest dose, 44% of patients had a 50% or greater relative reduction in liver steatosis, as measured by imaging, while 3% of people on placebo experienced such an improvement. Ionis also saw a trend favoring ION224 for a liver scarring endpoint. In the high-dose arm, 32% of people had at least a one stage improvement in fibrosis without worsening of steatohepatitis as measured by biopsy, compared to 12.5% of their peers in the placebo cohort. The FDA asks sponsors to show a one stage improvement in fibrosis with no worsening of MASH or the resolution of MASH with no worsening of fibrosis in Phase III clinical trials. The first wave of MASH assets failed to clear that bar but recent studies have fared better, with Madrigal Pharmaceuticals hitting both the endpoints in Phase III. The FDA is set to decide whether to approve Madrigal’s resmetirom by Thursday. The success of resmetirom, a THR-β agonist, in clinical trials is part of a series of events that suggest Ionis will face competition if it delivers its own pivotal study victory and brings ION224 to market. Companies are working on MASH molecules against a range of targets, from Boehringer Ingelheim’s glucagon/GLP-1 receptor dual agonist survodutide to Akero Therapeutics’ FGF21 analog efruxifermin. Other companies are interested in Ionis’ MASH target, DGAT2. Pfizer axed one DGAT2 inhibitor after Phase I but still has another candidate, PF-06865571, in mid-stage development. Data from the Phase II clinical trial are imminent, according to ClinicalTrials.gov. Other companies including Sinew Pharma and Viking Therapeutics are working on DGAT1 inhibitors. Nick Paul Taylor is a freelance pharmaceutical and biotech writer based in London. He can be reached on LinkedIn.