ES2821474T3 - Treatment methods for high cardiovascular risk patients with hypercholesterolemia - Google Patents

Abstract

An inhibitor of proprotein convertase subtilisin / human kexin type 9 (PCSK9), wherein said PCSK9 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to PCSK9 and comprises the amino acid sequence of the variable region of the heavy chain (HCVR) set forth in SEQ ID NO: 1, and the amino acid sequence of the light chain variable region (LCVR) set forth in SEQ ID NO: 6, for use in the treatment of hypercholesterolemia in a patient cardiovascular risk patients who have: (a) a serum low-density lipoprotein cholesterol (LDL-C) level greater than 70 mg / dL despite taking a stable maximum daily tolerated dose of statin therapy for at least 4 weeks; and (b) established coronary heart disease (CHD) or CHD risk equivalents, the equivalents being defined as including one or more of the following four criteria: 1) peripheral arterial disease (PAD); 2) ischemic stroke; 3) chronic kidney disease; and / or 4) history of diabetes mellitus and 2 or more additional risk factors selected from the group consisting of: a) history of hypertension, b) history of ankle-brachial index <= 0.90, c) history of microalbuminuria or macroalbuminuria or dipstick urinalysis at screening visit with> 2+ protein, d) history of preproliferative or proliferative retinopathy or laser treatment for retinopathy, and e) known family history of premature CHD.

Description

DESCRIPTION

Treatment methods for high cardiovascular risk patients with hypercholesterolemia

FIELD OF THE INVENTION

The present invention relates to the field of therapeutic treatments for diseases and disorders that are associated with elevated levels of lipids and lipoproteins. More specifically, the invention relates to the use of PCSK9 inhibitors to treat high cardiovascular risk patients with hypercholesterolemia and established coronary heart disease (CHD) or CHD risk equivalents that are not sufficiently controlled by maximum tolerated dose statin therapy.

BACKGROUND

Hypercholesterolemia, particularly an increase in low-density lipoprotein (LDL) cholesterol (LDL-C) levels, constitutes a significant risk for the development of atherosclerosis and coronary heart disease (CHD) (Sharrett et al., 2001, Circulation 104: 1108-1113). Low-density lipoprotein cholesterol is identified as the primary target of cholesterol-lowering therapy and is accepted as a valid surrogate therapeutic endpoint. Numerous studies have shown that lowering LDL-C levels reduces the risk of CHD with a strong direct relationship between LDL-C levels and CHD events; For every 1 mmol / L (~ 40 mg / dL) reduction in LDL-C, mortality and morbidity from cardiovascular disease (CVD) is reduced by 22%. Greater reductions in LDL-C produce greater reduction in events, and comparative data of intense versus standard statin treatment suggest that the lower the LDL-C level, the greater the benefit in patients at cardiovascular (CV) risk. very high.

Current LDL-C lowering medications include statins, cholesterol absorption inhibitors (eg, ezetimibe [EZE]), fibrates, niacin, and bile acid sequestrants. Statins are the most commonly prescribed, as they have shown a greater ability to lower LDL-C and reduce CHD events. However, many patients at risk for cardiovascular disease (CVD) have poorly controlled low-density lipoprotein cholesterol (LDL-C) despite statin therapy. Sullivan et al. (JAMA Dec 19, 2012, vol.

308, no. 23) report the randomized GAUSS trial and an effect of the PCSK9 monoclonal antibody evolocumab on LDL-C levels in statin intolerant patients. Hirayama et al. report the YUKAWA phase 2 study and the effects of evolocumab in Japanese hypercholesterolemic patients treated with statins at high cardiovascular risk. Patent document EP 2706 070 A1 describes treatments for reducing blood LDL-C levels by administration of the monoclonal antibody against PCSK9 alirocumab.

BRIEF SUMMARY OF THE INVENTION

The present invention provides a human proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor, wherein said PCSK9 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to PCSK9 and comprises the amino acid sequence of the heavy chain variable region (HCVR) set forth in SEQ ID NO: 1, and the amino acid sequence of the light chain variable region (LCVR) set forth in SEQ ID NO: 6, for use in the treatment of hypercholesterolemia in a high cardiovascular risk patient who has:

(a) a serum low-density lipoprotein cholesterol (LDL-C) level greater than 70 mg / dL despite taking a stable maximum daily tolerated dose of statin therapy for at least 4 weeks; Y

(b) established coronary heart disease (CHD) or CHD risk equivalents, the equivalents being defined as including one or more of the following four criteria: 1) peripheral arterial disease (PAD); 2) ischemic stroke; 3) chronic kidney disease; and / or 4) history of diabetes mellitus and 2 or more additional risk factors selected from the group consisting of: a) history of hypertension, b) history of ankle-brachial index <0.90, c) history of microalbuminuria or macroalbuminuria or dipstick urinalysis at screening visit with> 2+ protein, d) history of preproliferative or proliferative retinopathy or laser treatment for retinopathy, and e) known family history of premature CHD.

According to one aspect, the uses of the present invention comprise administering one or more doses of the PCSK9 inhibitor to a high cardiovascular risk patient with hypercholesterolemia and established coronary heart disease or CHD risk equivalents that are not sufficiently controlled by statin therapy of maximum tolerated dose (ie, hypercholesterolaemia that is not sufficiently controlled by maximum tolerated dose statin therapy in the absence of a PCSK9 inhibitor, with or without other lipid modifying therapy). According to certain embodiments of the present invention, the PCSK9 inhibitor is administered to the high cardiovascular risk patient as an adjunct therapy to the patient's existing statin therapy.

According to another aspect, the uses of the present invention comprise selecting a high cardiovascular risk patient who receives a therapeutic regimen comprising a daily dose of a statin (for example, a maximum tolerated dose statin therapy), and administering to the patient one or more doses of a PCSK9 inhibitor in combination with (ie, "in addition to") statin therapy.

One aspect of the invention includes the use in treating a high cardiovascular risk patient with hypercholesterolemia and established coronary heart disease (CHD) or CHD risk equivalents that are not sufficiently controlled by maximum tolerated dose statin therapy with or without other lipid-lowering therapy comprising administering one or more doses of the proprotein convertase inhibitor subtilisin / kexin type 9 (PCSK9) to the patient, where the patient has insufficient control of hypercholesterolemia despite treatment with dose statin therapy maximum tolerated with or without other lipid-lowering therapy in the absence of the PCSK9 inhibitor.

Another aspect of the invention includes the use in lowering low-density lipoprotein cholesterol (LDL-C) in a high cardiovascular risk patient with hypercholesterolemia and established coronary heart disease (CHD) or CHD risk equivalents that are sufficiently controlled. by maximum tolerated dose statin therapy with or without another lipid-lowering therapy that comprises administering one or more doses of the proprotein convertase inhibitor subtilisin / kexin type 9 (PCSK9) to the patient, where the patient has insufficient control of LDL- C despite treatment with maximum tolerated dose statin therapy with or without other lipid-lowering therapy in the absence of the PCSK9 inhibitor.

Another aspect of the invention includes the use in the treatment of hypercholesterolemia in a high cardiovascular risk patient with hypercholesterolemia and established coronary heart disease (CHD) or CHD risk equivalents that are not sufficiently controlled by maximum tolerated dose statin therapy with or without other lipid-lowering therapy that comprises administering one or more doses of the proprotein convertase inhibitor subtilisin / kexin type 9 (PCSK9) to the patient, where the patient has insufficient control of hypercholesterolemia despite treatment with statin therapy maximum tolerated dose with or without other lipid-lowering therapy in the absence of the PCSK9 inhibitor.

Another aspect of the invention includes the use to improve the serum level of one or more lipid components in a high cardiovascular risk patient with hypercholesterolemia and established coronary heart disease (CHD) or CHD risk equivalents that are sufficiently controlled by statin therapy. maximum tolerated dose with or without other lipid-lowering therapy that comprises administering one or more doses of the proprotein convertase inhibitor subtilisin / kexin type 9 (PCSK9) to the patient, where the patient has insufficient control of the lipid component despite treatment with maximum tolerated dose statin therapy with or without other lipid-lowering therapy in the absence of the PCSK9 inhibitor. In certain aspects, the invention provides a decrease in the serum level of a lipid component selected from the group consisting of LDL-C, Apo B, non-HDL-C, total cholesterol, Lp (a), and triglycerides. In certain aspects, the invention provides an increase in the serum level of a lipid component selected from the group consisting of HDL-C and ApoA-1.

In certain respects, established CHD is defined by a history of CHD, which includes one or more of the following: acute myocardial infarction (MI), silent MI, unstable angina, coronary revascularization procedure, and clinically significant CHD diagnosed by invasive tests or non-invasive.

The risk equivalents of CHD include one or more of the following four criteria: 1) peripheral arterial disease (PAD); 2) ischemic stroke; 3) chronic kidney disease (CKD); and / or 4) unknown history of diabetes mellitus and 2 or more additional risk factors, including: a) history of hypertension, b) history of ankle-brachial index <0.90, c) history of microalbuminuria or macroalbuminuria or analysis urine per dipstick at screening visit with> 2+ protein, d) history of preproliferative or proliferative retinopathy or laser treatment for retinopathy, and e) known family history of premature CHD.

The PCSK9 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to PCSK9. The antibody or antigen-binding fragment thereof comprises the light and heavy chain complementarity determining regions (CDRs) of a pair of heavy chain variable region / light chain variable region (HCVR) amino acid sequences / LCVR) of SEQ ID NOs: 1/6. The antibody or antigen-binding fragment thereof comprises heavy and light chain CDR amino acid sequences having SEQ ID NOs: 2, 3, 4, 7, 8 and 10. In some aspects, the antibody or binding fragment antigen thereof binds to the same epitope on PCSK9 as an antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NOs: 12, 13, 14, 16, 17 and 18. In some aspects, the antibody or antigen-binding fragment thereof competes to bind PCSK9 with an antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NOs: 12, 13, 14, 16, 17, and 18.

In certain aspects, the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient in a dose of about 75 mg at a frequency of once every two weeks. In some aspects, the dose of approximately 75 mg is maintained if the patient's LDL-C measured after five or more doses is <70 mg / dL. In some aspects, the approximately 75 mg dose is discontinued if the patient's LDL-C measured after five or more doses remains> 70 mg / dL, and the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is subsequently administered to the patient in one dose approximately 150 mg at a frequency of once every two weeks. In some aspects, the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient in a dose of about 150 mg at a frequency of once every two weeks.

In certain aspects, the PCSK9 inhibitor is administered to the patient in combination with maximum tolerated dose statin therapy. In some aspects, maximum tolerated dose statin therapy comprises a daily dose of from about 40 mg to about 80 mg of atorvastatin. In some aspects, the maximum tolerated dose statin therapy comprises a daily dose of about 20 mg to about 40 mg of rosuvastatin. In some aspects, the maximum tolerated dose statin therapy comprises a daily dose of approximately 80 mg of simvastatin. In some aspects, the PCSK9 inhibitor is administered to the patient in combination with the other lipid-lowering therapy, wherein the other lipid-lowering therapy comprises a therapeutic agent selected from the group consisting of ezetimibe, a fibrate, niacin, an omega-3 fatty acid, and a bile acid resin.

In certain aspects, the method improves at least one parameter associated with hypercholesterolemia selected from the group consisting of: (a) reduction of the patient's low-density lipoprotein cholesterol (LDL-C) by at least 40%; (b) reduction of the patient's apolipoprotein B100 (ApoB) by at least 35%; (c) reduction of the patient's non-high-density lipoprotein (non-HDL-C) cholesterol by at least 35%; (d) reduction of the patient's total cholesterol by at least 20%; (e) increase in the patient's high-density lipoprotein cholesterol (HDL-C) by at least 1%; (f) reduction of triglycerides of the patient by at least 1%; (g) reduction of the patient's lipoprotein a (Lp (a)) by at least 10%; and (h) increase in the patient's apolipoprotein A-1 by at least 1%.

Other embodiments of the present invention will be apparent from a review of the following detailed description.

BRIEF DESCRIPTION OF THE FIGURES

Figure 1A is a graphical representation of the study design for ODYSSEY COMBO I. Figure 1B is a graphical representation of the study design for ODYSSEY COMBO II. LDL-C, low-density lipoprotein cholesterol; THL, lipid-lowering therapy; NCEP ATP III, National Cholesterol Education Program Adult Treatment Panel III; PO, by mouth; every 2 weeks, every 2 weeks; R, randomization; SC, subcutaneous; TLC, therapeutic lifestyle changes.

Figure 2 is a graph showing the mean percent change by MC of calculated LDL-C (+/- SD) from baseline for placebo and alirocumab over time for the ITT analysis - ITT population in the ODYSSEY COMBO I study. Note: Least squares (LC) means and standard errors (SE) taken from MMRM analysis (mixed effects model with repeated measures). The model includes the fixed categorical effects of the treatment group, randomization strata according to IVRS, moment of time, interaction of treatment by moment of time, interaction of strata by moment of time, as well as the continuous fixed covariates of the LDL-C value. baseline and baseline LDL-C interaction by moment of time.

Figure 3 is a graph showing the mean percent change by MC of calculated LDL-C (+/- SD) from baseline for placebo and alirocumab over time for analysis during treatment - ITTm population in the ODYSSEY study. COMBO I. The treatment efficacy period ends on the date of the last injection 21 days. Note: Least squares means (LC) and standard errors (SE) taken from MMRM analysis (mixed effects model with repeated measures). The model includes the fixed categorical effects of treatment group, randomization strata according to IVRS, moment of time, interaction of treatment by moment of time, interaction of strata by moment of time, as well as the continuous fixed covariates of the LDL-C value. baseline and baseline LDL-C interaction by moment of time.

Figure 4 is a graph of LDL-C levels over time for patients treated with alirocumab with / without dose escalation at week 12 in the ODYSSEY COMBO I study.

Figure 5 is a graph of the percent reduction in LDL-C from baseline at Week 24 for various demographic subgroups of alirocumab and placebo in the ODYSSEY COMBO I study.

Figure 6 is a graph showing the mean percent change by MC of calculated LDL-C (+/- SD) from baseline over time for the ITT population in the ODYSSEY COMBO II study. Note: Least squares means (LC) and standard errors (SE) taken from MMRM analysis (mixed effects model with repeated measures). The model includes the fixed categorical effects of treatment group, randomization strata according to IVRS, moment of time, interaction of treatment by moment of time, interaction of strata by moment of time, as well as the continuous fixed covariates of the LDL-C value. baseline and baseline LDL-C interaction by moment of time.

Figure 7 is a graph of LDL-C concentrations achieved at 24 weeks by decile of baseline LDL-C in patients for the alirocumab and ezetimibe groups in the ODYSSEY COMBO II study.

Figure 8 is a graph of LDL-C concentrations versus study time by dose escalation status (intention-to-treat analysis) for the alirocumab and ezetimibe groups in the ODYSSEY COMBO II study. MC = least squares; SD = standard deviation; SE = standard error.

Figure 9 is a diagram of the percent change from baseline to week 24 in LDL-C in various subgroups (ITT analysis) of the alirocumab and ezetimibe groups in the ODYSSEY COMBO II study. BMI = body mass index; CI = confidence interval; CKD = chronic kidney disease; MC = least squares; MI = myocardial infarction; SC = subcutaneous; TG = triglyceride.

Figure 10 is a graphical representation of the study design for ODYSSEY LONG TERM. Telephone visits are indicated in italics, and continue every 4 weeks between on-site visits until the end of the double-blind treatment period visit. Study design labels are defined as follows: HFhe: heterozygous familial hypercholesterolemia; LDL-C: low-density lipoprotein cholesterol; THL: lipid-lowering therapy; every 2 weeks: every two weeks; and SC: subcutaneous.

Figure 11 is a graph showing the mean percent change by MC of calculated LDL-C (+/- SD) from baseline for placebo and alirocumab over time for the ITT population in the ODYSSEY LONG TERM study at the time of the previously specified analysis. Note: Least squares means (LC) and standard errors (SE) taken from MMRM analysis (mixed effects model with repeated measures). The model includes the fixed categorical effects of treatment group, randomization strata according to IVRS, moment of time, interaction of treatment by moment of time, interaction of strata by moment of time, as well as the continuous fixed covariates of the LDL-C value. baseline and baseline LDL-C interaction by moment of time.

Figure 12 is a set of graphs showing the mean percentage change by MC (EE) from baseline to week 24 for LDL-C in the populations with HeNFH and with HeHF from the ODYSSEY LONG TERM (A) study, thus as the same population of patients with HeFH separated by baseline LDL-C levels (<160 mg / dL and> 160 mg / dL (B); and <190 mg / dL and> 190 mg / dL. (C)). All patients received a prior statin (at the maximum tolerated level). A subset of patients also received additional lipid-lowering therapy.

Figure 13 is a graph showing the difference in mean percent change by MC (SE) from baseline to week 24 in different subgroups of the ODYSSEY LONG TERM study. The labels on the graph are defined as follows: CKD: chronic kidney disease; TG: triglycerides. All patients received a prior statin (at the maximum tolerated level). A subset of patients also received additional lipid-lowering therapy.

Figure 14 is a graph demonstrating the difference in mean percent change by MC (SE) from baseline to week 24 in the ODYSSEY LONG TERM study specific statin and THL use subgroups. All patients received a prior statin (at the maximum tolerated level). A subset of patients also received additional lipid-lowering therapy.

Figure 15 is a graph showing the mean percent change by MC of calculated LDL-C (+/- SD) from baseline for placebo and alirocumab over time for the ITT population in the ODYSSEY LONG TERM study. Values above the data points indicate mean absolute LDL cholesterol levels by MC, values below the data points indicate mean% change by MC from baseline. The values below the diagram indicate the number of patients with LDL cholesterol values available for ITT analysis at each point in time, that is, LDL cholesterol measurements taken both during treatment and after treatment (for patients who had discontinued treatment). study treatment but had returned to the clinic for evaluations). Missing data were taken into account to use a mixed effects model with repeated measures.

DETAILED DESCRIPTION

Before describing the present invention, it should be understood that the present invention is not limited to the particular experimental methods and conditions described, as such methods and conditions may vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning that is commonly understood by one of ordinary skill in the art to which the present invention pertains. As used herein, the term "about", when used in reference to a particular quoted numerical value, means that the value can vary from the quoted value by more than 1%. For example, as used herein, the term "about 100" includes 99 and 101 and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.).

Hypercholesterolaemia and established coronary heart disease or CHD risk equivalents not sufficiently controlled by maximum tolerated dose statin therapy

The present invention relates, in general, to the PCSK9 inhibitor and to compositions for treating patients at high cardiovascular risk who have hypercholesterolemia and established CHD or equivalent risk of CHD that are not sufficiently controlled by statins, that is, hypercholesterolemia is not controlled. sufficiently for a therapeutic regimen comprising a maximum daily tolerated dose of a statin. As used herein, the term "not sufficiently controlled", in reference to hypercholesterolemia, means that the concentration of low-density lipoprotein cholesterol (LDL-C) in the patient's serum, the concentration of total cholesterol, and / or the triglyceride concentration is not reduced to a recognized medically acceptable level (taking into account the patient's relative risk of coronary heart disease) after at least 4 weeks on a therapeutic regimen comprising a stable daily dose of a statin. For example, "a patient with hypercholesterolemia that is not sufficiently controlled by a statin" includes patients with a serum LDL-C concentration greater than about 70 mg / dL, 100 mg / dL, 130 mg / dL, 140 mg / dL, or more (depending on the patient's underlying heart disease risk) after the patient has been on a stable daily statin regimen for at least 4 weeks.

The high cardiovascular risk patient who is treatable by the PCSK9 inhibitor of the present invention has hypercholesterolemia (a serum LDL-C concentration greater than or equal to 70 mg / dL) despite taking a stable daily dose of a statin (with or without other lipid modifying therapy) for at least 4 weeks, 5 weeks, 6 weeks, or more. Hypercholesterolemia in the high cardiovascular risk patient is insufficiently controlled by maximum tolerated dose statin therapy (also referred to herein as "maximum daily tolerated dose statin regimen").

As used herein, "maximum tolerated dose statin therapy" means a therapeutic regimen comprising the administration of daily doses of a statin that is the maximum tolerated dose for a particular patient. Maximum tolerated dose means the highest dose of statin that can be administered to a patient without causing unacceptable adverse side effects in the patient. Maximum tolerated dose statin therapy includes, but is not limited to, for example, atorvastatin 40-80 mg daily, rosuvastatin 20-40 mg daily, or simvastatin 80 mg (if already on this dose for> 1 year). However, patients who are unable to tolerate the above statin dose could take a lower daily dose of atorvastatin, rosuvastatin or simvastatin provided there is an acceptable reason for not using the higher dose. Some examples of acceptable reasons for a patient to take a lower statin dose include: adverse effects with higher doses, older age, low body mass index (BMI), regional practices, local prescribing information, concurrent medications, concern for cognitive adverse events and associated conditions such as impaired fasting glucose / glucose intolerance, hyperglycemia, glycated hemoglobin, liver disease or increased liver enzymes, and muscle symptoms and / or elevated creatine phosphokinase.

The present invention also includes uses for treating high cardiovascular risk patients with hypercholesterolemia and established CHD or CHD risk equivalents that are not sufficiently controlled by maximum tolerated dose statin therapy comprising daily administration of other statins such as cerivastatin, pitavastatin , fluvastatin, lovastatin, and pravastatin.

Selection of patients

The present invention includes a PCSK9 inhibitor and compositions useful for treating high cardiovascular risk patients who have hypercholesterolemia and established CHD or CHD risk equivalents that are not sufficiently controlled by a statin regimen at the maximum daily tolerated dose.

Established CHD is defined as a documented history of CHD, which includes one or more of the following: acute myocardial infarction (MI), silent MI, unstable angina, coronary revascularization procedure (for example, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CVR]), and clinically significant CHD diagnosed by invasive or non-invasive tests (such as coronary arteriography, treadmill stress test, stress echocardiography, or nuclear imaging).

The risk equivalents of CHD include one or more of the following 4 criteria: 1) peripheral arterial disease (PAD); 2) ischemic stroke; 3) chronic kidney disease; and / or 4) unknown history of diabetes mellitus and 2 or more additional risk factors, including: a) history of hypertension (established with antihypertensive medication), b) history of ankle-brachial index <0.90, c) history of microalbuminuria or macroalbuminuria or dipstick urinalysis at screening visit (week -2) with> 2+ protein, d) history of preproliferative or proliferative retinopathy or laser treatment for retinopathy, e) known family history of premature CHD ( ECC in father or brother before 55 years; ECC in mother or sister before 65 years).

As used herein, in peripheral arterial disease (PAD), one of the following criteria must be met [a, b, or c]): a) current intermittent claudication (lower extremity muscle discomfort caused by exercise that is both reproducible and relieved by 10-minute rest) of presumed atherosclerotic origin together with an ankle-brachial index equal to or less than 0.90 in any resting leg, or b) a history of intermittent claudication in conjunction with endovascular procedure or surgery on one or both legs due to atherosclerotic disease, or c) a history of critical ischemia of the extremities in conjunction with thrombolysis, endovascular procedure, or surgery on one or both legs due to atherosclerotic disease.

As used herein, documented ischemic stroke includes ischemic stroke with a focal ischemic neurological deficit that persisted for more than 24 hours, which was considered to be of atherothrombotic origin. Computed tomography (CT) or magnetic resonance imaging (MRI) may be done to rule out hemorrhage and nonischemic neurologic disease.

As used herein, chronic kidney disease (CKD) is defined by an estimated glomerular filtration rate (eGFR) of> 30- <60 mL / min / 1.73 m2 for 3 months or longer.

According to certain embodiments, the high cardiovascular risk patient may be selected on the basis of having one or more additional risk factors selected from the group consisting of age (eg, greater than 40, 45, 50, 55, 60, 65, 70 , 75 or 80 years old), race, national origin, gender (male or female), exercise habits (for example, person who exercises regularly, person who does not exercise), other pre-existing medical conditions (for example, type diabetes II, high blood pressure, etc.) and current medication status (for example, currently taking beta-blockers, niacin, ezetimibe, fibrates, omega-3 fatty acids, bile acid resins, etc.).

According to the present invention, high cardiovascular risk patients can be selected based on a combination of one or more of the above selection criteria or therapeutic characteristics.

Administration of a PCSK9 inhibitor as adjunctive therapy to maximum tolerated dose statin therapy

The present invention includes uses where a high cardiovascular risk patient with hypercholesterolemia and established CHD or CHD risk equivalents that are not sufficiently controlled by a stable therapeutic regimen with statins at the maximum daily tolerated dose in the absence of a PCSK9 inhibitor a PCSK9 inhibitor is administered according to a particular administration amount and frequency, and wherein the PCSK9 inhibitor is administered as an adjunct to the patient's statin regimen. For example, according to certain embodiments, if a high cardiovascular risk patient has hypercholesterolemia and established CHD or CHD risk equivalents that are not sufficiently controlled despite being on a stable therapeutic regimen with statins at the maximum daily tolerated dose comprising, For example, 40-80 mg of atorvastatin, the high cardiovascular risk patient can be administered with the PCSK9 inhibitor in a particular amount and administration interval while the patient continues his stable daily statin regimen.

The uses of the present invention include adjuvant regimens wherein the PCSK9 inhibitor is administered as adjunctive therapy to the same stable statin regimen at the maximum daily tolerated dose (i.e., same amount of statin administration) with which it was the high cardiovascular risk patient before receiving the PCSK9 inhibitor. In other embodiments, the PCSK9 inhibitor is administered as adjunctive therapy to a statin regimen at the maximum daily tolerated dose comprising a statin in an amount that is higher or lower than the dose of statin the patient was on prior to treatment. receive the PCSK9 inhibitor. For example, after starting a therapeutic regimen comprising a PCSK9 inhibitor administered at a particular frequency and amount of administration, the daily dose of statin administered or prescribed to the patient may (a) remain the same, (b) increase, or ( c) decrease (for example, upward adjustment or downward adjustment) compared to the daily dose of statin that the high cardiovascular risk patient is taking before the start of the PCSK9 inhibitor regimen, depending on the therapeutic needs of the patient.

Therapeutic efficacy

The uses of the present invention will result in improvement in the serum level of one or more lipid components selected from the group consisting of LDL-C, ApoB, non-HDL-C, total cholesterol, HDL-C, ApoA-1, triglycerides. and Lp (a). For example, according to certain embodiments of the present invention, the administration of a pharmaceutical composition comprising the PCSK9 inhibitor to a high cardiovascular risk patient with hypercholesterolemia and established CHD or CHD risk equivalents that are not sufficiently controlled by a therapeutic regimen stable with statins at the maximum tolerated daily dose (for example, administration of the PCSK9 inhibitor in addition to the patient's maximum tolerated dose statin therapy) will result in a mean percentage reduction from baseline in low-density lipoprotein cholesterol Serum (LDL-C) of at least approximately 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53 %, 54%, 55%, 56%, 57%, 58%, 59%, 60%, or greater; a mean percentage reduction from baseline in ApoB of at least about 35%, 36%, 37%, 38%, 39%, 40%, or greater; a mean percentage reduction from baseline in non-HDL-C of at least approximately 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45% , 46%, 47%, 48%, 49%, 50%, or greater; a mean percentage reduction from baseline in total cholesterol of at least about 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31 %, 32%, 33%, 34%, 35%, or greater; a mean percentage increase from baseline in HDL-C of at least minus about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, or greater; a mean percentage increase from baseline in ApoA-1 of at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, or greater; a mean percent reduction from baseline in triglycerides of at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, or greater; and / or a mean percentage reduction from baseline in Lp (a) of at least about 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19% , 20%, 21%, 22%, 23%, 24%, 25%, or greater.

PCSK9 inhibitors

The uses of the present invention comprise administering to a high cardiovascular risk patient a therapeutic composition comprising the PCSK9 inhibitor. As used herein, a "PCSK9 inhibitor" is any agent that binds to or interacts with human PCSK9 and inhibits the normal biological function of PCSK9 in vitro or in vivo. Non-limiting examples of categories of PCSK9 inhibitors include small molecule PCSK9 antagonists, peptide-based PCSK9 antagonists (eg, "peptibody" molecules), and antibodies or antigen-binding fragments of antibodies that specifically bind to Human PCSK9.

The term "human proprotein convertase subtilisin / kexin type 9" or "human PCSK9" or "hPCSK9", as used herein, refers to PCSK9 having the nucleic acid sequence shown in SEQ ID NO: 197 and comprising the amino acid sequence of SEQ ID NO: 198, or a biologically active fragment thereof.

The term "antibody", as used herein, is intended to refer to immunoglobulin molecules comprising four polypeptide chains, two heavy (H) chains, and two light (L) chains interconnected by disulfide bonds, as well as multimers of the themselves (eg IgM). Each heavy chain comprises a heavy chain variable region (abbreviated herein HCVR or V ^h ) and a heavy chain constant region. The heavy chain constant region comprises three domains, C ^h 1, C ^h 2, and C ^h 3. Each light chain comprises a light chain variable region (abbreviated herein LCVR or V ^l ) and a constant region of the light chain. The constant region of the light chain comprises a domain ( ^C1 ). The V ^h and V ^l regions can be further subdivided into regions of hypervariability, termed complementarity determining regions (CDR), interspersed with regions that are more conserved, termed framework regions (FR). Each V ^h and V ^l is composed of three CDRs and four FRs, arranged from the amino end to the carboxy end in the following order: FR1, CDR1, FR2, c DR2, FR3, CDR3, FR4. In different embodiments of the invention, the FRs of the anti-PCSK9 antibody (or antigen-binding portion thereof) may be identical to human germline sequences, or they may be naturally or artificially modified. A consensus amino acid sequence can be defined based on a direct comparative analysis of two or more CDRs.

The term "antibody", as used herein, also includes antigen-binding fragments of whole antibody molecules. The terms "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, and the like, as used herein, include any naturally occurring, enzymatically obtainable, synthetic polypeptide or glycoprotein. , or genetically engineered, that specifically binds to an antigen to form a complex. Antigen-binding fragments of an antibody can be derived, for example, from whole antibody molecules using any suitable conventional technique, such as proteolytic digestion or recombinant genetic engineering techniques involving the manipulation and expression of variable and optionally constant domains. of antibodies that encode DNA. Such DNAs are known as and / or readily available from, for example, commercial sources, DNA libraries (including, for example, phage-antibody libraries), or can be synthesized. DNA can be sequenced and manipulated chemically or using molecular biology techniques, for example, to arrange one or more variable and / or constant domains in a suitable configuration, or to introduce codons, create cysteine residues, modify, add or delete amino acids , etc.

Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F (ab ') 2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single chain Fv molecules (scFv); (vi) dAb fragments; and (vii) minimal recognition units consisting of amino acid residues that mimic the hypervariable region of an antibody (eg, an isolated complementarity determining region (CDR) such as a CDR3 peptide), or a FR3-CDR3 peptide. -FR4 limited. Also encompassed within the term "antigen-binding fragment" as used herein are other engineered molecules, such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, grafted antibodies. with CDRs, diabodies, tribodies, tetrabodies, minibodies, nanobodies (eg monovalent nanobodies, bivalent nanobodies, etc.), small modular immunopharmaceuticals (SMIPs), and shark variable IgNAR domains.

An antigen-binding fragment of an antibody will typically comprise at least one variable domain. The variable domain can be of any size or amino acid composition and will generally comprise at least one CDR that is adjacent to or in frame with one or more framework region sequences. In antigen-binding fragments having a V ^h domain associated with a V ¹ domain, the V ^h and V ¹ domains can be located in any suitable arrangement relative to each other. For example, the variable region can be dimeric and contain V ^h -V ^h , V ^h -V ^l or V ^l -V ^l dimers. Alternatively, the antigen-binding fragment of an antibody may contain a monomeric ^{V h} or V ^{l domain.}

In certain embodiments, an antigen-binding fragment of an antibody may contain at least one variable domain covalently linked to at least one constant domain. Exemplary non-limiting variable and constant domain configurations that may be found within an antigen-binding fragment of an antibody of the present invention include: (i) V ^h -C ^h 1; (ii) V ^h -C ^h 2; (iii) V ^h -C ^h 3; (iv) V ^h -C ^h 1 ^{-C h} 2; (v) V ^h -C ^h 1 ^{-C h} 2 -C ^h 3; (vi) V ^h -C ^h 2 ^{-C h} 3; (vii) V ^h -C ^l ; (viii) V ^l -C ^h 1; (ix) V ¹ -C ^h 2; (x) V ^l -C ^h 3; (xi) V ^l -C ^h 1 ^{-C h} 2; (xii) V ^l -C ^h 1 ^{-C h} 2 -C ^h 3; (xiii) V ^l -C ^h 2 ^{-C h} 3; and (xiv) V ^l -C ^l . In any configuration of variable and constant domains, including any of the exemplary configurations listed above, the variable and constant domains can be either directly linked to each other, or they can be linked by a total connector or hinge region or partial. A hinge region can consist of at least 2 (eg, 5, 10, 15, 20, 40, 60 or more) amino acids that result in a flexible or semi-flexible bond between adjacent variable and / or constant domains in a single molecule of polypeptide. Furthermore, an antigen-binding fragment of an antibody of the present invention may comprise a homodimer or heterodimer (or other multimer) of any of the variable and constant domain configurations listed above in non-covalent association with each other and / or with one or more more ^{monomeric V h} or V ^l domains (eg, by disulfide bond (s)).

As with whole antibody molecules, antigen-binding fragments can be monospecific or multispecific (eg, bispecific). A multispecific antigen-binding fragment of an antibody will typically comprise at least two different variable domains, where each variable domain is capable of specifically binding a separate antigen or a different epitope on the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody formats disclosed herein, can be adapted for use in the context of an antigen-binding fragment of an antibody of the present invention, using available routine techniques. in technique.

The constant region of an antibody is important in an antibody's ability to bind complement and mediate cell-dependent cytotoxicity. Thus, the isotype of an antibody can be selected based on whether it is desired that the antibody mediates cytotoxicity.

The term "human antibody", as used herein, is intended to include antibodies that have variable and constant regions derived from human germline immunoglobulin sequences. The human antibodies of the invention can, however, include amino acid residues not encoded by human germline immunoglobulin sequences (eg, mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo). However, the term "human antibody", as used herein, is not intended to include antibodies in which CDR sequences derived from the germline of other mammalian species have been grafted onto human framework sequences. like a mouse.

The term "recombinant human antibody", as used herein, is intended to include all human antibodies that are prepared, expressed, created, or isolated by recombinant means, such as antibodies expressed using a recombinant expression vector transfected into a host cell. (described below), antibodies isolated from a recombinant combinatorial library of human antibodies (described below), antibodies isolated from an animal (e.g., a mouse) that is transgenic for human immunoglobulin genes (see, e.g., Taylor et al. (1992) Nucl. Acids Res. 20: 6287-6295) or antibodies prepared, expressed, created, or isolated by any other means involving splicing of human immunoglobulin gene sequences with other DNA sequences . Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. In certain embodiments, however, said recombinant human antibodies are subjected to in vitro mutagenesis (or, when using a transgenic animal for human Ig sequences, to somatic mutagenesis in vivo) and thus the amino acid sequences of the V ^h and Recombinant antibody V ^l are sequences that, although derived from and related to ^{human germline V h} and V ^l sequences, cannot naturally exist within the human germline antibody repertoire in vivo.

Human antibodies can exist in two forms that are associated with hinge heterogeneity. In one form, an immunoglobulin molecule comprises a stable four-chain construct of approximately 150-160 kDa in which the dimers are held together by an interchain heavy chain disulfide bond. In a second form, the dimers are not linked via interchain disulfide bonds and a molecule of approximately 75-80 kDa is formed composed of a covalently coupled heavy and light chain (half antibody). These forms have been extremely difficult to separate, even after affinity purification.

The frequency of occurrence of the second form in the various intact IgG isotypes is due to, but is not limited to, structural differences associated with the isotype of the hinge region of the antibody. A single amino acid substitution in the hinge region of human IgG4 can significantly reduce the occurrence of the second form (Angal et al. (1993) Molecular Immunology 30: 105) to levels normally seen using an IgG 1 hinge. human. The present invention encompasses antibodies that have one or more mutations in the hinge region, C ^h 2 or C ^h 3 which may be desirable, for example, in production, to enhance the yield of the desired form of antibody.

An "isolated antibody", as used herein, means an antibody that has been identified and separated and / or recovered from at least one component of its natural environment. For example, an antibody that has been separated or removed from at least one component of an organism, or from a tissue or cell in which the antibody exists naturally or occurs naturally, is an "isolated antibody" for the purposes herein. invention. An isolated antibody also includes an antibody in situ within a recombinant cell. Isolated antibodies are antibodies that have undergone at least one purification or isolation step. According to certain embodiments, an isolated antibody can be substantially free of other cellular material and / or chemicals.

The term "specifically binds to", or the like, means that an antibody or antigen-binding fragment thereof forms a complex with an antigen that is relatively stable under physiological conditions. Methods of determining whether an antibody specifically binds to an antigen are well known in the art, and include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, an antibody that "specifically binds to" PCSK9, as used in the context of the present invention, includes antibodies that bind to PCSK9 or a portion thereof with a K ^{d of} less than about 1000 nM, less than about 500 nM, less than about 300 nM, less than about 200 nM, less than about 100 nM, less than about 90 nM, less than about 80 nM, less than about 70 nM, less than about 60 nM, less than about 50 nM , less than about 40 nM, i about 30 nM, less than about 20 nM, less than about 10 nM, i about 5 nM, less than about 4 nM, less than about 3 nM, less than about 2 nM, less than about 1 nM or less than about 0.5 nM, as measured in a surface plasmon resonance assay. An isolated antibody that specifically binds to human PCSK9 may, however, be cross-reactive with other antigens, such as PCSK9 molecules from other (non-human) species.

In general, anti-PCSK9 antibodies may comprise one or more amino acid substitutions, insertions and / or deletions in the structural region and / or CDR regions of the variable domains of the heavy and light chain compared to the germline sequences. from which the antibodies were derived. Such mutations can be easily established by comparing the amino acid sequences disclosed herein with germline sequences available from, for example, public antibody sequence databases. Methods are disclosed that involve the use of antibodies, and antigen-binding fragments thereof, which are derived from any of the amino acid sequences disclosed herein, wherein one or more amino acids within one or more framework regions and / or CDR regions are mutated to the corresponding residue (s) of the germline sequence from which the antibody was derived, or to the corresponding residue (s) of another sequence of the human germline, or to a conservative amino acid substitution of the corresponding germline residue (s) (such sequence changes are collectively referred to as "germline mutations"). One of ordinary skill in the art, starting from the heavy and light chain variable region sequences disclosed herein, can readily produce numerous antibodies and antigen-binding fragments comprising one or more individual germline mutations or combinations of the same. All framework region and / or CDR residues within the V ^h and / or V ^l domains can be back-mutated to residues found in the original germline sequence from which the antibody was derived. Therefore, only certain residues can be back-mutated to the original germline sequence, for example, only the mutated residues found within the first 8 amino acids of FR1 or within the last 8 amino acids of FR4, or only the mutated residues found. within CDR1, CDR2 or CDR3.

Thus, one or more of the framework and / or CDR residues can be mutated to the corresponding residues of a different germline sequence (i.e., a germline sequence that is different from the germline sequence from which the antibody was originally derived). Furthermore, antibodies can contain any combination of two or more germline mutations within framework regions and / or CDRs, for example, where certain individual residues are mutated to the corresponding residue of a particular germline sequence while Certain other residues that differ from the original germline sequence are maintained or mutated to the corresponding residue from a different germline sequence. Once obtained, antibodies and antigen-binding fragments containing one or more germline mutations can be readily tested for one or more desired properties such as improved binding specificity, increased binding affinity, improved antagonist or agonist biological properties. or enhanced (as the case requires), reduced immunogenicity, etc.

Furthermore, methods are disclosed that involve the use of anti-PCSK9 antibodies comprising variants of any of the HCVR, LCVR and / or CDR amino acid sequences disclosed herein that have one or more conservative substitutions. For example, the present invention includes the use of anti-PCSK9 antibodies having HCVR, LCVR and / or CDR amino acid sequences with, for example, 10 or less, 8 or less,

6 or less, 4 or less, etc., conservative amino acid substitutions with respect to any of the HCVR, LCVR and / or CDR amino acid sequences disclosed herein.

The term "surface plasmon resonance", as used herein, refers to an optical phenomenon that allows the analysis of interactions in real time by detecting alterations in the concentrations of protein within a biosensor matrix, for example using the BIAcore ™ system (Biacore Life Sciences, division of GE Healthcare, Piscataway, NJ).

The term "KD", as used herein, is intended to refer to the equilibrium dissociation constant of a particular antibody-antigen interaction.

The term "epitope" refers to an antigenic determinant that interacts with a specific antigen-binding site in the variable region of an antibody molecule known as a paratope. A single antigen can have more than one epitope. Thus, different antibodies can bind to different areas on an antigen and can have different biological effects. Epitopes can be either conformational or linear. A conformational epitope is produced by spatially juxtaposed amino acids from different segments of the linear polypeptide chain. A linear epitope is one produced by adjacent amino acid residues in a polypeptide chain. In certain circumstances, an epitope can include saccharide moieties, phosphoryl groups, or sulfonyl groups on the antigen.

According to certain embodiments, the anti-PCSK9 antibody used in accordance with the present invention is an antibody with pH-dependent binding characteristics. As used herein, the term "pH-dependent binding" means that the antibody or antigen-binding fragment thereof exhibits "reduced binding to PCSK9 at acidic pH compared to neutral pH" (for the purposes herein disclosure, both expressions can be used interchangeably). For example, antibodies "with pH-dependent binding characteristics" include antibodies and antigen-binding fragments thereof that bind to PCSK9 with higher affinity at neutral pH than at acidic pH. In certain embodiments, the antibodies and antigen-binding fragments of the present invention bind to PCSK9 with an affinity of at least 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60. , 65, 70, 75, 80, 85, 90, 95, 100, or more times higher, at neutral pH than at acidic pH.

According to this aspect of the invention, anti-PCSK9 antibodies with pH-dependent binding characteristics may possess one or more amino acid variations relative to the parent anti-PCSK9 antibody. For example, an anti-PCSK9 antibody with pH-dependent binding characteristics may contain one or more histidine substitutions or insertions. Thus, methods are disclosed which comprise administering an anti-PCSK9 antibody comprising CDR amino acid sequences (eg, heavy and light chain CDRs) that are identical to the CDR amino acid sequences of a parent anti-PCSK9 antibody, except for the substitution of one or more amino acids of one or more CDRs of the parent antibody with a histidine residue. Anti-PCSK9 antibodies with pH-dependent binding may possess, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9, or more, histidine substitutions, either within a single CDR of a parental antibody or distributed across multiple (eg, 2, 3, 4, 5, or 6) CDRs of a parental anti-PCSK9 antibody. For example, the use of pH-dependent binding anti-PCSK9 antibodies comprising one or more histidine substitutions in HCDR1, one or more histidine substitutions in HCDR2, one or more histidine substitutions in HCDR3, one or more substitutions is disclosed. of histidine in LCDR1, one or more histidine substitutions in LCDR2, and / or one or more histidine substitutions in LCDR3, of a parental anti-PCSK9 antibody.

As used herein, the term "acidic pH" means a pH of 6.0 or less (eg, less than about 6.0, less than about 5.5, less than about 5.0, and so on. ). The term "acidic pH" includes pH values of about 6.0, 5.95, 5.90, 5.85, 5.8, 5.75, 5.7, 5.65, 5.6, 5, 55, 5.5, 5.45, 5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1.5.05, 5.0, or less. As used herein, the term "neutral pH" means a pH of from about 7.0 to about 7.4. The term "neutral pH" includes pH values of about 7.0, 7.05, 7.1,7,15, 7.2, 7.25, 7.3, 7.35, and 7.4.

Preparation of human antibodies

Methods of generating human antibodies in transgenic mice are known in the art. Any such known method can be used to prepare human antibodies that specifically bind to human PCSK9.

Using VELOCIMMUNE® technology (see, for example, US Patent 6,596,541, Regeneron Pharmaceuticals) or any other known method for generating monoclonal antibodies, high affinity chimeric antibodies are initially isolated for PCSK9 having a human variable region and a constant region of mouse. The VELOCIMMUNE® technology involves generation of a transgenic mouse having a genome comprising human heavy and light chain variable regions operably linked to endogenous mouse constant region loci such that the mouse produces an antibody comprising a human variable region and a mouse constant region in response to antigenic stimulation. DNA encoding the antibody heavy and light chain variable regions is isolated and operably linked to DNA encoding the human heavy and light chain constant regions. The DNA is then expressed in a cell capable of expressing the fully human antibody.

Generally, a VELOCIMMUNE® mouse is exposed to the antigen of interest, and lymphatic cells (such as B lymphocytes) are recovered from the mice expressing the antibodies. Lymphatic cells can be fused with a myeloma cell line to prepare immortal hybridoma cell lines, and such hybridoma cell lines they are screened and selected to identify hybridoma cell lines that produce antibodies specific for the antigen of interest. DNA encoding the heavy chain and light chain variable regions can be isolated and linked to desirable isotypic heavy chain and light chain constant regions. Such an antibody protein can be produced in a cell, such as a CHO cell. Alternatively, DNA encoding antigen-specific chimeric antibodies or heavy and light chain variable domains can be isolated directly from antigen-specific lymphocytes.

Initially, high affinity chimeric antibodies having a human variable region and a mouse constant region are isolated. Antibodies are characterized and selected for desirable characteristics, including affinity, selectivity, epitope, etc., using standard procedures known to those of skill in the art. The mouse constant regions are substituted for a desired human constant region to generate the fully human antibody of the invention, for example non-mutant or modified IgG1 or IgG4. While the selected constant region may vary according to specific use, high affinity antigen binding and target specificity characteristics reside in the variable region.

In general, antibodies possess high affinities, as described above, when measured by binding to antigen either immobilized on solid phase or in solution phase. The mouse constant regions are substituted for desired human constant regions to generate the fully human antibodies. Although the constant region selected may vary according to specific use, high affinity antigen binding and target specificity characteristics reside in the variable region.

Specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 include any antibody or antigen-binding fragment that comprises all three heavy chain CDRs (HCDR1, HCDR2, and HCDR3) contained within a region heavy chain variable (HCVR) that has an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 and 11, or a substantially similar sequence thereof that is at least 90%, at least 95%, at least 98% or at least 99% sequence identity. Alternatively, specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 include any antibody or antigen-binding fragment that comprises the three heavy chain CDRs (HCDR1, HCDR2, and HCDR3) contained within a heavy chain variable region (HCVR) having an amino acid sequence selected from the group consisting of SEQ ID NOs 37, 45, 53, 61, 69, 77, 85, 93, 101, 109, 117, 125, 133 , 141, 149, 157, 165, 173, 181, and 189, or a substantially similar sequence thereof that has at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. The antibody or antigen-binding fragment may comprise all three light chain CDRs (LCVR1, LCVR2, LCVR3) contained within a light chain variable region (LCVR) having an amino acid sequence selected from the group consisting of SEQ ID NOs 6 and 15, or a substantially similar sequence thereof that has at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. Alternatively, the antibody or antigen-binding fragment may comprise all three light chain CDRs (LCVR1, LCVR2, LCVR3) contained within a light chain variable region (LCVR) having an amino acid sequence selected from the group consisting of in SEQ ID NOs 41,49, 57, 65, 73, 81,89, 97, 105, 113, 121, 129, 137, 145, 153, 161, 169, 177, 185 and 193, or a substantially similar sequence of the same one that has at least 90%, at least 95%, at least 98% or at least 99% sequence identity.

An antibody or antigen-binding fragment comprises the six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) of the pairs of heavy and light chain variable region (HCVR / LCVR) amino acid sequences selected from the group consisting of SEQ ID NOs: 1/6 and 11/15. Alternatively, an antibody or antigen-binding protein comprises the six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) of the pairs of heavy and light chain variable region amino acid sequences (HCVR / LCVR). selected from the group consisting of SEQ ID NOs: 37 / 41,45 / 49, 53/57, 61/65, 69/73, 77 / 81,85 / 89, 93/97, 101/105, 109/113, 117/121, 125/129, 133/137, 141/145, 149/153, 157/161, 165/169, 173/177, 181/185 and 189/193.

An anti-PCSK9 antibody, or antigen-binding fragment, is disclosed having the amino acid sequences HCDR1 / HCDR2 / HCDR3 / LCDR1 / LCDR2 / LCDR3 selected from SEQ ID NOs: 2/3/4/7/8/10 ( mAb316P) and 12/13/14/16/17/18 (mAb300N) (see US Patent Application Publication No. 2010/0166768).

An antibody or antigen-binding fragment thereof is disclosed comprising pairs of HCVR / LCVR amino acid sequences selected from the group consisting of SEQ ID NOs: 1/6 and 11/15. Alternatively, the antibody or antigen-binding protein comprises the heavy and light chain variable region (HCVR / LCVR) amino acid sequence pairs selected from the group consisting of SEQ ID NOs: 37/41, 45/49, 53/57, 61/65, 69/73, 77/81, 85/89, 93/97, 101/105, 109/113, 117/121, 125/129, 133/137, 141/145, 149 / 153, 157/161, 165/169, 173/177, 181/185 and 189/193.

Pharmaceutical compositions and administration methods comprising administering the PCSK9 inhibitor of the invention for use according to the invention, wherein the PCSK9 inhibitor is contained in a pharmaceutical composition. The pharmaceutical compositions of the invention are formulated with suitable carriers, excipients, and other agents that provide adequate transfer, delivery, tolerance, and the like. A multitude of appropriate formulations can be found in the form known to all pharmaceutical chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, lipid-containing vesicles (cationic or anionic) (such as LIPOFECTIN ™), DNA conjugates, anhydrous absorption pastes, oil emulsions in water and water in oil, Carbowax emulsions (polyethylene glycols of various molecular weights), semisolid gels and semisolid mixtures containing Carbowax. See also Powell et al. "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52: 238-311.

Various delivery systems are known and can be used to deliver the pharmaceutical composition of the invention, for example, encapsulation in liposomes, microparticles, microcapsules, recombinant cells capable of expressing the mutant viruses, receptor-mediated endocytosis (see, for example, Wu et al., 1987, J. Biol. Chem. 262: 4429-4432). Methods of administration include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, and oral routes. The composition can be administered by any convenient route, eg, by infusion or bolus injection, by absorption through the epithelial or mucocutaneous linings (eg, oral mucosa, rectal and intestinal mucosa, etc.) and can be administered together with other biologically active agents.

A pharmaceutical composition of the present invention can be administered subcutaneously or intravenously with a standard needle and syringe. Furthermore, with respect to subcutaneous administration, a pen delivery device easily has applications in administering a pharmaceutical composition of the present invention. Such a pen delivery device can be reusable or disposable. A reusable pen delivery device generally uses a replaceable cartridge that contains a pharmaceutical composition. Once all of the pharmaceutical composition has been delivered into the cartridge and the cartridge is empty, the empty cartridge can easily be discarded and replaced with a new cartridge containing the pharmaceutical composition. The pen delivery device can then be reused. In a disposable pen delivery device, there is no replaceable cartridge. Instead, the disposable pen delivery device comes pre-filled with the pharmaceutical composition contained in a reservoir within the device. Once the reservoir of pharmaceutical composition is emptied, the entire device is discarded.

Numerous reusable pen and autoinjector delivery devices have applications in the subcutaneous administration of a pharmaceutical composition of the present invention. Examples include, but are not limited to, AUTOPEN ™ (Owen Mumford, Inc., Woodstock, Ru), DISETRONIC ™ pen (Disetronic Medical Systems, Bergdorf, Switzerland), HUMALOG MIX 75/25 ™ pen, HUMALOG ™ pen, HUMALIN pen 70/30 ™ (Eli Lilly and Co., Indianapolis, IN), No Vo PEN ™ I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR ™ (Novo Nordisk, Copenhagen, Denmark), Bd ™ pen ( Becton Dickinson, Franklin Lakes, NJ), OPTIPEN ™, OPTIPEN PRO ™, OpT iPEN St A r LET ™ and OpTICLIK ™ (Sanofi-aventis, Frankfurt, Germany), to name just a few. Examples of disposable pen delivery devices that have applications in the subcutaneous administration of a pharmaceutical composition of the present invention include, but are not limited to, the SOLOSTAR ™ pen (Sanofi-aventis), FLEXPEN ™ (Novo Nordisk), and KWIKPEN. ™ (Eli Lilly), SURECLICK ™ autoinjector (Amgen, Thousand Oaks, c A), PENLET ™ (Haselmeier, Stuttgart, Germany), EPlPEN (Dey, LP) and HUMIRA ™ pen (Abbott Labs, Abbott Park IL), to name just a few.

In certain situations, the pharmaceutical composition can be administered in a controlled release system. In one embodiment, a pump can be used (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14: 201). In another embodiment, polymeric materials can be used; See, Medical Applications of Controlled Release, Langer and Wise (eds.), 1974, CRC Pres., Boca Raton, Florida. In yet another embodiment, a controlled release system can be placed in proximity to the target of the composition, thus requiring only a fraction of the systemic dose (see, for example, Goodson, 1984, in Medical Applications of Controlled Release, above , vol. 2, pp. 115-138). Other controlled release systems are discussed in the review by Langer, 1990, Science 249: 1527-1533.

Injectable preparations may include dosage forms for intravenous, subcutaneous, intracutaneous and intramuscular injections, drip infusions, etc. These injectable preparations can be prepared by known methods. For example, injectable preparations can be prepared, for example, by dissolving, suspending or emulsifying the antibody or its salt described above in a sterile aqueous medium or an oily medium conventionally used for injections. As an aqueous medium for injections there are, for example, physiological saline solution, an isotonic solution containing glucose and other auxiliary agents, etc., which can be used in combination with an appropriate solubilizing agent such as an alcohol (for example, ethanol), a polyalcohol (eg, propylene glycol, polyethylene glycol), a nonionic surfactant [eg, polysorbate 80, HCO-50 (hydrogenated castor oil polyoxyethylene (50 mole) adduct)], etc. As the oily medium, for example, sesame oil, soybean oil, etc. are employed, which can be used in combination with a solubilizing agent such as benzyl benzoate, benzyl alcohol, etc. The injection thus prepared is preferably filled into an appropriate ampoule.

Advantageously, the pharmaceutical compositions for oral or parenteral use described above are prepared in pharmaceutical forms in a unit dose suitable to be adjusted in a dose of the active principles. Such dosage unit dosage forms include, for example, tablets, pills, capsules, injections (ampoules), suppositories, etc.

Dose

The amount of the PCSK9 inhibitor administered in accordance with the uses of the present invention is, in general, a therapeutically effective amount. As used herein, the term "therapeutically effective amount" means a dose of PCSK9 inhibitor that results in a detectable improvement (at least about 5%, 10%, 15%, 20%, 25%, 30% , 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, or more from baseline) in one or more parameters selected from the group consisting of LDL-C, ApoB, not HDL-C, total cholesterol, HLDL-C, triglycerides, and Lp (a).

In the case of an anti-PCSK9 antibody, a therapeutically effective amount can be from about 0.05 mg to about 600 mg, for example, about 0.05 mg, about 0.1 mg, about 1.0 mg, about 1 , 5mg, about 2.0mg, about 10mg, about 20mg, about 30mg, about 40mg, about 50mg, about 60mg, about 70mg, about 75mg, about 80mg, about 90mg, about 100mg, about 110mg, about 120mg, about 130mg, about 140mg, about 150mg, about 160mg, about 170mg, about 180mg, about 190mg, about 200mg, about 210mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290 mg, about only 300 mg, about 310 mg, about 320 mg, about 330 mg, about 340 mg, about 350 mg, about 360 mg, about 370 mg, about 380 mg, about 390 mg, about 400 mg, about 410 mg, about 420 mg, about 430 mg, about 440 mg, about 450 mg, about 460 mg, about 470 mg, about 480 mg, about 490 mg, about 500 mg, about 510 mg, about 520 mg, about 530 mg, about 540 mg, about 550 mg, about 560 mg, about 570 mg, about 580 mg, about 590 mg, or about 600 mg, of the anti-PCSK9 antibody.

The amount of anti-PCSK9 antibody contained within individual doses can be expressed in terms of milligrams of antibody per kilogram of the patient's body weight (ie, mg / kg). For example, the anti-PCSK9 antibody can be administered to a patient at a dose of from about 0.0001 to about 10 mg / kg of the patient's body weight.

Combination therapies

As described elsewhere herein, the uses of the present invention may comprise administering a PCSK9 inhibitor to a patient at high cardiovascular risk in combination with the patient's stable statin regimen at the patient's previously prescribed maximum daily tolerated dose. . According to certain embodiments of the present invention, additional therapeutic agents, in addition to a statin, may be administered to the patient in combination with the PCSK9 inhibitor. Examples of such additional therapeutic agents include, for example, (1) an agent that inhibits cholesterol uptake and or bile acid reabsorption (eg, ezetimibe); (2) an agent that increases lipoprotein catabolism (such as niacin); and / or (3) activators of the transcription factor LXR that play a role in the removal of cholesterol, such as 22-hydroxycholesterol.

Administration guidelines

According to certain embodiments of the present invention, multiple doses of the PCSK9 inhibitor (i.e., a pharmaceutical composition comprising the PCSK9 inhibitor) can be administered to a subject for a defined time course (e.g., in addition to a statin regimen). daily). Uses according to this aspect of the invention comprise successively administering multiple doses of a PCSK9 inhibitor to a high cardiovascular risk subject. As used herein, "successively administered" means that each dose of PCSK9 inhibitor is administered to the subject at a different point in time, eg, on different days separated by a predetermined interval (eg, hours, days , weeks or months). The present invention includes uses comprising successively administering to the high cardiovascular risk patient a single initial dose of a PCSK9 inhibitor, followed by one or more secondary doses of the PCSK9 inhibitor, and optionally followed by one or more tertiary doses of the PCSK9 inhibitor. .

The terms "initial dose", "secondary dose" and "tertiary dose" refer to the sequence of temporary administration of individual doses of a pharmaceutical composition comprising a PCSK9 inhibitor. Thus, the "starting dose" is the dose given at the beginning of the treatment regimen (also called the "starting level dose");"Secondarydoses" are the doses given after the initial dose; and "tertiary doses" are the doses that are administered after the secondary doses. The initial, secondary and tertiary doses may all contain the same amount of the PCSK9 inhibitor, but in general they can be differentiated from each other in terms of frequency of administration. In certain embodiments, however, the amount of the PCSK9 inhibitor contained in the initial, secondary, and / or tertiary dose varies from one another (eg, adjusted up or down as appropriate) during the course of treatment. In certain embodiments, two or more doses are administered (e.g., 2, 3, 4, or 5) at the beginning of the treatment regimen as a "loading dose", followed by subsequent doses that are given on a less frequent basis (eg, "maintenance dose").

According to exemplary embodiments of the present invention, each secondary and / or tertiary dose is administered 1 to 26 (e.g., 1, 1 /, 2, 2 /, 3, 31/2, 4, 41/2, 5, 51/2, 6, 61/2, 7, 71/2, 8, 81/2, 9, 91/2, 10, 101/2, 11, 11 /, 12, 12 /, 13, 1 3 /, 14, 14 /, 15, 15 /, 16, 16 /, 17, 17 /, 18, 18 /, 19, 19 /, 20, 20 /, 21, 21 /, 22, 22 /, 23, 23 /, 24, 24 /, 25, 25 /, 26, 26 /, or more) weeks after the immediately preceding dose. The term "the immediately preceding dose" as used herein means, in a sequence of multiple administrations, the dose of antigen-binding molecule that is administered to a patient prior to administration of the next dose in the sequence without intermediate doses.

The uses according to this aspect of the invention may comprise administering to a high cardiovascular risk patient any number of secondary and / or tertiary doses of a PCSK9 inhibitor. For example, in certain embodiments, only a single secondary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8, or more) secondary doses are administered to the patient. Also, in certain embodiments, only a single tertiary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8, or more) tertiary doses are administered to the patient.

In embodiments involving multiple secondary doses, each secondary dose can be administered at the same frequency as the other secondary doses. For example, each secondary dose can be administered to the high cardiovascular risk patient 1 to 2, 4, 6, 8, or more weeks after the immediately preceding dose. Similarly, in embodiments involving multiple tertiary doses, each tertiary dose can be administered at the same frequency as the other tertiary doses. For example, each tertiary dose can be administered to the patient 1 to 2, 4, 6, 8, or more weeks after the immediately preceding dose. Alternatively, the frequency at which secondary and / or tertiary doses are administered to a patient may vary over the course of the treatment regimen. The frequency of administration can also be adjusted during the course of treatment by a physician depending on the needs of the individual patient following the clinical examination.

The present invention includes administration regimens that comprise an upward titration option (also referred to herein as "dose modification"). As used herein, an "up-titration option" means that, after receiving a particular number of doses of a PCSK9 inhibitor, if a patient has not achieved a specified reduction in one or more therapeutic parameters defined, the dose of the PCSK9 inhibitor is increased thereafter. For example, in the case of a therapeutic regimen that comprises the administration of 75 mg doses of an anti-PCSK9 antibody to a patient at high cardiovascular risk at a frequency of once every two weeks, if after 8 weeks (i.e. , 5 doses administered in Week 0, Week 2 and Week 4, Week 6 and Week 8), the patient has not reached a serum LDL-C concentration lower than 70 mg / dL, then the dose of anti-PCSK9 antibody it is increased to, for example, 150 mg given once every two weeks thereafter (for example, starting at week 12, or after).

In certain embodiments, the anti-PCSK9 antibody is administered to a subject in a dose of about 150 mg every two weeks, for example, for at least six doses.

In certain embodiments, the anti-PCSK9 antibody is administered to a subject in a dose of about 75 mg every two weeks, for example, for at least six doses.

In some embodiments, the antibody is administered to a subject at a dose of approximately 75 mg every two weeks for 12 weeks, and the dose remains 75 mg every two weeks if, at week 8, the LDL-C value of the subject was less than 70 mg / dL.

In other embodiments, the antibody is administered to a subject at a dose of about 75 mg every two weeks for 12 weeks, and the dose is adjusted up to about 150 mg every two weeks if, at week 8, the value of Subject's LDL-C was greater than or equal to 70 mg / dL.

Examples

The following examples are intended to provide those of ordinary skill in the art with a full disclosure and description of how to prepare and use the methods and compositions of the invention, and are not intended to limit the scope of what the inventors consider to be his invention. Efforts have been made to ensure accuracy with respect to the numbers used (eg quantities, temperature, etc.), but some experimental errors and deviations must be taken into account. Unless otherwise indicated, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees centigrade, and pressure is atmospheric or near atmospheric.

Example 1. Generation of human antibodies against human PCSK9

Human anti-PCSK9 antibodies were generated as described in US Patent No. 8,062,640. The exemplary PCSK9 inhibitor used in the following example is the designated human anti-PCSK9 antibody "mAb316P", also known as "alirocumab." mAb316P has the following amino acid sequence characteristics: heavy chain variable region (HCVR) comprising SEQ ID NO: 1; light chain variable domain (LCVR) comprising SEQ ID NO: 6; heavy chain complementarity determining region 1 (HCDR1) comprising SEQ ID NO: 2; HCDR2 comprising SEQ ID NO: 3; HCDR3 comprising SEQ ID NO: 4; light chain complementarity determining region 1 (LCDR1) comprising SEQ ID NO: 7; LCDR2 comprising SEQ ID NO: 8; and LCDR3 comprising SEQ ID NO: 10.

Example 2: Efficacy and safety of alirocumab, a monoclonal antibody against fully human PCSK9 ("mAb316P"), in high cardiovascular risk patients with uncontrolled hypercholesterolemia with maximum tolerated doses of statins

INTRODUCTION

The objective of the COMBO I and II studies was to evaluate the efficacy and safety of alirocumab ("mAb316P") as adjunctive therapy to stable maximum tolerated daily statin therapy with or without other lipid-lowering therapy, in patients with high cardiovascular risk hypercholesterolemia. . COMBO I was placebo controlled and patients were able to receive other lipid-lowering therapies in addition to statin therapy; COMBO II compared alirocumab with ezetimibe in patients receiving statin therapy (but not other lipid-lowering therapies). Each of the COMBO studies was randomized, double-blind, and placebo-controlled. Both studies used a starting dose of alirocumab 75 mg every 2 weeks (every 2 weeks; administered as a 1 mL solution per autoinjector). The dose of patients with LDL-C levels> 70 mg / dL after 8 weeks of treatment was adjusted upward in a blinded fashion at week 12 to alirocumab 150 mg q / 2 wk (also 1 mL of autoinjector).

OBJECTIVES OF THE STUDY

The primary efficacy endpoint for each study was the difference between treatment groups in percent change in LDL-C from baseline to Week 24.

The primary secondary endpoints for each study were: percent change in LDL-C calculated from baseline to week 24 in the treatment population, using all low-density lipoprotein cholesterol (LDL-C) values. during the period of efficacy of the treatment (estimating from ITT); percent change in LDL-C calculated from baseline to week 12 (estimating from ITT); percent change in LDL-C calculated from baseline to week 12 (estimating during treatment); change in percentage in apolipoprotein (Apo) B from baseline to week 24 (estimating from ITT); percentage change in Apo B from baseline to week 24 (estimating during treatment); change in percentage of non-high-density lipoprotein (non-HDL-C) cholesterol from baseline to week 24 (estimating from ITT); change in percentage in non-HDL-C from baseline to week 24 (estimating during treatment); change in percentage of total cholesterol from baseline to week 24 (estimating from ITT); percentage change in Apo B from baseline to week 12 (estimating from ITT); change in percentage in non-HDL-C from baseline to week 12 (estimating from ITT); change in percentage of total cholesterol from baseline to week 12 (estimating from ITT); percent change in LDL-C calculated from baseline to week 52 (estimating from ITT); proportion of patients achieving calculated LDL-C <70 mg / dL (1.81 mmol / L) at week 24 (estimating from ITT); proportion of patients achieving calculated LDL-C <70 mg / dL (1.81 mmol / L) at week 24 (estimating during treatment); change in percentage in lipoprotein (a) (Lp (a)) from baseline to week 24 (estimating from ITT); percent change in HDL-C from baseline to week 24 (estimating from ITT); change in fasting triglyceride (TG) percentage from baseline to week 24 (ITT estimate); percentage change in Apo A1 from baseline to week 24 (estimating from ITT); percentage change in Lp (a) from baseline to week 12 (estimating from ITT); percent change in HDL-C from baseline to week 12 (estimating from ITT); change in percentage in fasting TG from baseline to week 12 (estimating from ITT); and percentage change in Apo A1 from baseline to week 12 (estimating ITT). Apo, apolipoprotein; HDL-C, high-density lipoprotein cholesterol; ITT, intention to treat; LDL-C, low-density lipoprotein cholesterol; Lp (a), lipoprotein (a); TG, triglycerides.

STUDY DESIGN

COMBO I was a phase 3, randomized, double-blind, placebo-controlled, parallel-group, multicenter, 52-week study. This study evaluated the efficacy and safety of alirocumab as adjunctive therapy at stable maximum tolerated doses of daily statin, with or without other stable lipid-lowering therapies, in high-risk patients with uncontrolled hypercholesterolemia (Figure 1A).

COMBO II was a phase 3, randomized, double-blind, active-controlled, parallel-group, multinational, 104-week study. The study recruited high-risk patients with uncontrolled hypercholesterolaemia on stable maximum tolerated daily statin therapy. Unlike COMBO I, with a placebo group, COMBO II incorporated a treatment group with active product (ezetimibe) with a double simulation design (Figure 1B) and no the patients were allowed to receive no other lipid-lowering therapy in addition to the statin and its randomized treatment.

PATIENT SELECTION

All patients in COMBO I and II had hypercholesterolemia and established CHD or CHD risk equivalents, with LDL-C insufficiently controlled with a maximum tolerated daily dose of statin. In COMBO I alone, patients were also allowed to receive other lipid-lowering therapies in addition to the statin, provided that both the statin and the other lipid-lowering therapies were dose stable for at least 4 weeks (6 weeks for fenofibrate) prior to the visit of selection; in COMBO II, the statin dose was required to be stable for at least 4 weeks prior to the screening visit and no other lipid-lowering therapies were allowed. At screening, patients either had LDL-C> 70 mg / dL (> 1.81 mmol / L) with documented CVD or LDL-C> 100 mg / dL (> 2.59 mmol / L) with no medical records. ECV.

The 'maximum tolerated dose' of a statin was defined as either rosuvastatin 20 mg or 40 mg daily, atorvastatin 40 mg or 80 mg daily, or simvastatin 80 mg daily (if already on this dose for> 1 year). However, patients unable to tolerate the above statin dose remained eligible for inclusion if they received a lower dose of atorvastatin, rosuvastatin, or simvastatin daily provided the investigator had a documented reason for not using the higher dose.

COMBO I

The inclusion criteria for the COMBO I study were as follows. Patients with hypercholesterolaemia and established coronary heart disease (CHD) or CHD risk equivalents (see below for definitions) who are not sufficiently controlled with a maximum tolerated daily dose of statin with or without other lipid-lowering therapy (LTT), both in stable dose for at least 4 weeks prior to screening visit (and 6 weeks for fenofibrate prior to screening visit).

Definition of maximum tolerated dose (any of the following is acceptable): rosuvastatin 20 mg or 40 mg per day, atorvastatin 40 mg or 80 mg per day, or simvastatin 80 mg per day (if already on this dose for> 1 year ). Patients who are unable to be on any of the above statin doses were treated with the daily dose of atorvastatin, rosuvastatin, or simvastatin deemed appropriate for the patient based on the discretion or concerns of the investigator. Some examples of acceptable reasons for a patient to take a lower statin dose include: adverse effects with higher doses, older age, low body mass index (BMI), regional practices, local prescribing information, concurrent medications, and medical conditions. associated such as impaired fasting glucose / glucose intolerance.

Established CHD is defined as a documented history of CHD, which includes one or more of the following: acute myocardial infarction (MI), silent MI, unstable angina, coronary revascularization procedure (for example, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CVR]) and clinically significant CHD diagnosed by invasive or non-invasive tests (such as coronary arteriography, treadmill stress test, stress echocardiography, or nuclear imaging).

Risk equivalents for CHD include one or more of the following 4 criteria: 1) documented peripheral arterial disease (PAD) (one of the following criteria [a, b, or c] must be met): a) current intermittent claudication (discomfort muscle in the lower limb produced by exercise that is both reproducible and relieved by 10-minute rest) of presumed atherosclerotic origin together with an ankle-brachial index equal to or less than 0.90 in any leg at rest, or b) a history of intermittent claudication together with endovascular procedure or surgery on one or both legs due to atherosclerotic disease, or c) history of critical limb ischemia together with thrombolysis, endovascular procedure or surgery on one or both legs due to atherosclerotic disease; 2) Documented ischemic stroke with a focal ischemic neurological deficit that persisted for more than 24 hours, which was considered to be of atherothrombotic origin. Computed tomography (CT) or magnetic resonance imaging (MRI) must have been performed to rule out hemorrhage and non-ischemic neurological disease; 3) documented chronic kidney disease (CKD) as defined by estimated glomerular filtration rate (eGFR) of> 30- <60 mL / min / 1.73 m2 for 3 months or longer, including screening visit; and / or 4) unknown history of diabetes mellitus and 2 or more additional risk factors, including: a) history of hypertension (established with antihypertensive medication), b) documented history of ankle-brachial index <0.90, c) documented history of microalbuminuria or macroalbuminuria or dipstick urinalysis at screening visit (week -2) with> 2+ protein, d) documented history of preproliferative or proliferative retinopathy or laser treatment for retinopathy, e) known family history of Premature CHD (CHD in father or brother before 55 years; CHD in mother or sister before 65 years).

Patients who met all of the above inclusion criteria were selected for the following exclusion criteria.

The exclusion criteria related to the study methodology were the following: Patients without established CHD or equivalent risk of CHD; LDL-C <70 mg / dL (<1.81 mmol / L) at screening visit in patients with a history of documented cardiovascular disease [CVD]); LDL-C <100 mg / dL (<2.59 mmol / L) at visit selection in patients with no documented history of CVD); those who are not on a stable dose of lipid-lowering therapy (including statin) for at least 4 weeks and / or fenofibrate for at least 6 weeks, as applicable, prior to the screening visit and from screening to randomization; currently taking a statin other than simvastatin, atorvastatin, or rosuvastatin; simvastatin, atorvastatin, or rosuvastatin is not taken daily or is not taken at a recorded dose; daily doses greater than atorvastatin 80 mg, rosuvastatin 40 mg, or simvastatin 40 mg (except for patients taking simvastatin 80 mg for> 1 year, who are eligible); use of fibrates, other than fenofibrate within 6 weeks of the screening visit or between screening and randomization visits; use of nutraceuticals or over-the-counter therapies that may affect lipids that have not been taken in a stable dose / amount for at least 4 weeks prior to the screening visit or between screening and randomization visits; use of red yeast rice products within 4 weeks of the screening visit or between screening and randomization visits; patients who have received plasmapheresis treatment within 2 months before the screening visit (week -2), or plan to receive it during the study; Recent MI (within 3 months before screening visit or between screening and randomization visits), unstable angina leading to hospitalization, PCI, CVR, uncontrolled cardiac arrhythmia, stroke, transient ischemic attack, carotid revascularization , endovascular procedure or surgical intervention for peripheral vascular disease; plans to undergo elective PCI, RVC, carotid or peripheral revascularization during the study; systolic BP> 160 mmHg or diastolic BP> 100 mmHg at screening visit or randomization visit; a history of New York Heart Association (NYHA) class III or IV heart failure in the past 12 months; unknown history of hemorrhagic stroke; age <18 years or legal age of majority at the screening visit, whichever is older; patients who have not been previously counseled on a lipid-lowering diet before the screening visit; recently diagnosed diabetes (within 3 months before randomization visit) or poorly controlled (glycated hemoglobin [HbA1c]> 8.5% at screening visit); presence of any uncontrolled clinically significant endocrine disease known to influence serum lipids and lipoproteins (note: patients taking thyroid replacement therapy may be included if the dose has been stable for at least 12 weeks prior to screening and between the screening and randomization visits, and the thyroid stimulating hormone (TSH) level is within the normal range of the central laboratory at the screening visit); history of bariatric surgery within 12 months prior to screening visit; unstable weight defined by a variation> 5 kg within 2 months before screening visit; unknown history of homozygous or heterozygous familial hypercholesterolemia (FH); unknown history of loss of function of proprotein convertase subtilisin kexin 9 (PCSK9) (ie, gene mutation or sequence variation); use of systemic corticosteroids, unless used as replacement therapy for pituitary / adrenal disease with a stable regimen for at least 6 weeks prior to the randomization visit (note: topical, intra-articular, nasal, inhaled, and ophthalmic therapies with steroids are not considered 'systemic' and are allowed); use of continuous hormone replacement therapy with estrogen or testosterone unless the regimen has been stable in the last 6 weeks prior to the screening visit (week -2) and no regimen change is planned during the study; a history of cancer in the past 5 years, except for sufficiently treated basal cell skin cancer, squamous cell skin cancer, or cervical cancer in situ; unknown history of HIV positivity; patients who have taken any investigational drug other than alirocumab placebo training kits within 1 month or 5 half-lives, whichever is longer; patients who have previously participated in any clinical trial of alirocumab or any other anti-PCSK9 therapy; patients who withdrew consent during the selection period (patients who do not wish to continue or who stop returning).

Additional exclusion criteria were conditions / situations such as: any clinically significant abnormalities identified at the time of selection that in the judgment of the investigator or any sub-investigator would rule out safe study completion or limit the evaluation of endpoints such as systemic diseases important or patients with a short life expectancy; deemed by the investigator or any sub-investigator as inappropriate for this study for any reason, for example, deemed unable to meet the specific requirements of the protocol, such as scheduled visits; deemed unable to administer or tolerate long-term injections based on the opinion of the patient or investigator; researcher or any sub-investigator, pharmacist, study coordinator, other study personnel, or relative of the study directly involved in the implementation of the protocol, etc .; presence of any other real or anticipated (eg geographic, social) condition that the investigator feels would restrict or limit patient participation for the duration of the study.

Laboratory results during the selection period (not including randomization evaluations): positive test for Hepatitis B surface antigen or Hepatitis C antibody (confirmed by reflex testing); positive serum human chorionic beta-gonadotropin (hCG) or urine pregnancy test (including week 0) in women of childbearing potential; triglycerides> 400 mg / dL (> 4.52 mmol / L) (1 repeat test allowed); EGFR <30 mL / min / 1.73 m2; alanine aminotransferase (ALT) or aspartate aminotransferase (AST)> 3 x upper limit of normal (ULN) (1 repeat assessment allowed); creatine phosphokinase (CPK)> 3 x ULN (1 repeat assessment allowed); thyroid stimulating hormone (TSH) <lower limit of normal (LLN) or> ULN.

Exclusion criteria related to prior treatment were as follows. All contraindications to previous therapies or warning / precaution for use (where appropriate) as presented in the respective national product labeling.

Exclusion criteria related to alirocumab were as follows. Known hypersensitivity to monoclonal antibody therapeutics; pregnant or lactating women; women of childbearing potential without effective birth control contraception and / or unwilling or unable to take a pregnancy test. Women of childbearing potential must have a confirmed negative pregnancy test at screening and randomization visits. They must use effective contraception throughout the study, and agree to repeat the urine pregnancy test at designated visits. The contraceptive methods applied have to meet the criteria for a highly effective method of birth control according to the Guidance Note on Non-clinical Safety Studies for Human Clinical Trials and Marketing Authorization for Pharmaceutical Products. Postmenopausal women must be amenorrheic for at least 12 months.

COMBO II

The inclusion criteria for the COMBO II study were as follows. Patients with hypercholesterolaemia and established CHD or CHD risk equivalents (see below for definitions) who are not sufficiently controlled with a stable maximum tolerated daily dose of statin for at least 4 weeks prior to the screening visit.

The definition of the maximum tolerated dose (any of the following is acceptable): rosuvastatin 20 mg or 40 mg per day, atorvastatin 40 mg or 80 mg per day, and simvastatin 80 mg per day (if already on this dose for> 1 year - see exclusion criteria). Patients who are unable to be on any of the above statin doses should be treated with the daily dose of atorvastatin, rosuvastatin, or simvastatin that is deemed appropriate for the patient based on the discretion or concerns of the investigator. Some examples of acceptable reasons for a patient to take a lower statin dose include: adverse effects with higher doses, older age, low BMI, regional practices, local prescribing information, concurrent medications, and associated conditions such as intolerance to statin. impaired fasting glucose / glucose.

Established CHD includes one or more of the following: acute MI; Silent IM; unstable angina; coronary revascularization procedure (eg, PCI or RVC); Clinically significant CHD diagnosed by invasive or non-invasive tests (such as coronary arteriography, stress test using a treadmill, stress echocardiography, or nuclear imaging).

The risk equivalents of CHD include one or more of the following 4 criteria: 1) Documented PAD (one of the following criteria must be met [a, b, or c]): a) current intermittent claudication of presumed atherosclerotic origin along with index ankle-arm equal to or less than 0.90 in any resting leg, or b) a history of intermittent claudication in conjunction with endovascular procedure or surgery on one or both legs due to atherosclerotic disease, or c) a history of critical limb ischemia along with thrombolysis, endovascular procedure, or surgery on one or both legs due to atherosclerotic disease; 2) Documented prior ischemic stroke with focal ischemic neurological deficit that persisted for more than 24 hours, which was considered to be of atherothrombotic origin. CT or MRI must have been performed to rule out hemorrhage and non-ischemic neurological disease; 3) Documented CKD as defined by eGFR> 30- <60 mL / min / 1.73 m2 for 3 months or more, including screening visit; and / or 4) unknown history of diabetes mellitus and 2 or more additional risk factors: a) history of hypertension (established with antihypertensive medication), b) documented history of ankle-brachial index <0.90, c) documented history of microalbuminuria or macroalbuminuria or dipstick urinalysis at screening visit (week -3) with> 2+ protein, d) documented history of preproliferative or proliferative retinopathy or laser treatment for retinopathy, e) known family history of premature CHD ( ECC in father or brother before 55 years; ECC in mother or sister before 65 years).

Patients who met all of the above inclusion criteria were selected for the following exclusion criteria.

The exclusion criteria related to the study methodology were the following. Patients without established CHD or equivalent risk of CHD; LDL-C <70 mg / dL (<1.81 mmol / L) at the screening visit in patients with a documented history of CVD; LDL-C <100 mg / dL (<2.59 mmol / L) at screening visit in patients with no documented history of CVD; change in statin dose or regimen from screening to randomization; currently taking a statin other than simvastatin, atorvastatin, or rosuvastatin; simvastatin, atorvastatin or rosuvastatin is not taken daily or is not taken at a recorded dose; daily doses greater than atorvastatin 80 mg, rosuvastatin 40 mg, or simvastatin 40 mg (except for patients taking simvastatin 80 mg for> 1 year, who are eligible); use of cholesterol absorption inhibitor (i.e. ezetimibe), omega-3 fatty acid (at doses> 1000 mg per day), nicotinic acid, bile acid binding sequestrant, or red yeast rice products in the Last 4 weeks before screening visit or between screening and randomization visits; use of fibrates in the last 6 weeks before the screening visit; use of nutraceutical products or over-the-counter therapies that may affect lipids that have not been taken in a stable dose / amount for at least 4 weeks before the screening visit or between screening and randomization visits; patients who have received plasmapheresis treatment within 2 months prior to the screening visit, or plan to receive it during the study; Recent MI (within 3 months before screening visit or between screening and randomization visits), unstable angina leading to hospitalization, PCI, CVR, uncontrolled cardiac arrhythmia, stroke, transient ischemic attack, carotid revascularization , endovascular procedure or surgical intervention for peripheral vascular disease; plans to undergo elective PCI, RVC, carotid or peripheral revascularization during the study; Systolic BP> 160 mmHg or diastolic BP> 100 mmHg at screening visit or randomization visit; History of NYHA Class III or IV heart failure in the past 12 months; unknown history of hemorrhagic stroke; age <18 years or legal age of majority at the screening visit, whichever is older; patients who have not been previously counseled on a lipid-lowering diet before the screening visit; recently diagnosed diabetes (within 3 months before the randomization visit) or poorly controlled (HbA1c> 9% at the screening visit); presence of any uncontrolled clinically significant endocrine disease known to influence serum lipids and lipoproteins (note: patients taking thyroid replacement therapy may be included if the dose has been stable for at least 12 weeks prior to screening and between screening and randomization visits, and the TSH level is within the normal range of the central laboratory at the screening visit); history of bariatric surgery within 12 months prior to screening visit; unstable weight defined by a variation> 5 kg within 2 months before screening visit; unknown history of homozygous or heterozygous FH; unknown history of PCSK9 loss of function (ie, genetic mutation or sequence variation); use of systemic corticosteroids, unless used as replacement therapy for pituitary / adrenal disease with a stable regimen for at least 6 weeks prior to the randomization visit (note: topical, intra-articular, nasal, inhaled and ophthalmic therapies with steroids are not considered 'systemic' and are allowed); use of continuous hormone replacement therapy with estrogen or testosterone unless the regimen has been stable in the last 6 weeks prior to the screening visit and no regimen change is planned during the study; a history of cancer in the past 5 years, except for sufficiently treated basal cell skin cancer, squamous cell skin cancer, or cervical cancer in situ; unknown history of a positive test for HIV; patients who have taken any investigational drug other than alirocumab placebo training kits within 1 month or 5 half-lives, whichever is longer; patients who have previously been treated with at least 1 dose of alirocumab or any other anti-PCSK9 monoclonal antibody in other clinical trials; patients who withdrew consent during the selection period (patients who do not wish to continue or who stop returning).

Additional exclusion criteria were conditions / situations such as any clinically significant abnormalities identified at the time of selection that in the discretion of the investigator or any sub-investigator would rule out safe study completion or limit the evaluation of endpoints such as major systemic diseases. ; patients with a short life expectancy; deemed by the investigator or any sub-investigator as inappropriate for this study for any reason, for example deemed unable to meet specific protocol requirements such as scheduled visits; deemed unable to administer or tolerate long-term injections by patient or investigator; researcher or any sub-investigator, pharmacist, study coordinator, other study personnel or relative of the study directly involved in the implementation of the protocol, etc .; presence of any other real or anticipated (eg geographic, social) condition that the investigator feels would restrict or limit patient participation for the duration of the study.

Laboratory results during the screening period (not including randomization evaluations): positive test for Hepatitis B surface antigen or Hepatitis C antibody; positive serum beta-hCG or urine pregnancy test (including week 0) in women of childbearing potential; triglycerides> 400 mg / dL (> 4.52 mmol / L) (1 repeat test allowed); EGFR <30 mL / min / 1.73 m2; ALT or AST> 3 x ULN (1 repeat assessment allowed); CPK> 3 x ULN (repeat evaluation allowed); TSH <LLN or> ULN (one repeat assessment is allowed).

Exclusion criteria related to active comparator and mandatory prior treatment were as follows. All ezetimibe contraindications or warnings / precautions for use (where appropriate) as presented in the respective national product labeling; all previous statin contraindications or use warning / precaution (where appropriate) as presented in the respective national product labeling.

Exclusion criteria related to alirocumab were as follows. Known hypersensitivity to monoclonal antibody or any component of the drug; pregnant or lactating women; women of childbearing potential who do not use highly effective birth control method (s) and / or who are neither willing nor able to take a pregnancy test. Women of childbearing potential must have a confirmed negative pregnancy test at screening and randomization visits. They must use effective contraception for the entire duration of study treatment, and for 10 weeks after the last dose of study medication (injection or capsule, whichever occurs last), and agree to repeat the pregnancy test in urinate at designated visits. (The contraception methods applied have to meet the criteria for a highly effective method of birth control according to the "Guidance note on non-clinical safety studies for conducting of human clinical trials and authorization for the commercialization of pharmaceutical products. Postmenopausal women must be amenorrheic for at least 12 months).

STUDY PROCEDURES

Patients meeting the inclusion criteria entered a screening period of up to 2 (COMBO I) or 3 (COMBO II) weeks prior to randomization. During selection, patients completed informed consent, inclusion / exclusion criteria were further assessed, patient information was collected, and patients were taught the use of the autoinjector device. In addition, vital signs were measured, a 12-lead electrocardiogram was performed, and fasting urine and blood tests were performed for analysis. AE were assessed from the screening visit throughout the study.

COMBO I

Eligible patients were randomized (2: 1 alirocumab: placebo), stratified by 1) history of myocardial infarction (MI) or ischemic stroke, and 2) intensity of statin treatment to ensure balance between groups for these factors. After randomization, the patients entered a 52-week double-blind treatment period. In addition to existing statin therapies and other existing lipid-lowering therapies, if appropriate, patients randomized to alirocumab received a subcutaneous (SC) dose of 75 mg every 2 weeks (every 2 weeks), administered as a single 1 mL injection using one autoinjector, from randomization to week 12. Patients randomized to placebo received a 1 mL SC injection of placebo from an identical autoinjector.

At week 12, the dose of randomized patients to alirocumab was adjusted up to 150 mg every 2 weeks if LDL-C at week 8 was> 70 mg / dL (1.81 mmol / L). To maintain masking, neither the patient nor the investigator was informed of the LDL-C levels at week 8 (nor of any lipid values after randomization); continuation or upward titration of the dose occurred in an automatic and masked fashion. The 150 mg dose of alirocumab was also administered as a 1 mL solution in an autoinjector.

On-site assessments of patients during the treatment period were scheduled at randomization and then at weeks 4, 8, 12, 16, 24, 36, and 52 (end-of-treatment visit) (Figure 1A). After the treatment period, there was a follow-up period of 8 weeks.

COMBO II

Eligible patients were randomized (2: 1 to alirocumab: ezetimibe), stratified for 1) history of MI or ischemic stroke, 2) intensity of statin treatment, and 3) geographic region, to ensure balance between groups in these factors. After randomization, patients entered a double-blind, double-dummy treatment period of 104 weeks. Patients were randomized to either alirocumab 75 mg SC w / 2 wks plus placebo for ezetimibe orally (PO) per day or placebo for alirocumab SC w / 2 wks plus ezetimibe 10 mg PO per day. At week 12, the dose of randomized patients to alirocumab was adjusted up to 150 mg every 2 weeks if LDL-C at week 8 was> 70 mg / dL (1.81 mmol / L).

On-site patient evaluations were scheduled at regular intervals from randomization to week 104 (end-of-treatment visit) (Figure 1B). After the treatment period, there was a follow-up period of 8 weeks.

COMBO I and II

In both studies, patients were asked to maintain a stable diet (therapeutic lifestyle change diet or equivalent from Panel III adult treatment of the national cholesterol education program) and the daily statin dose should be stable for the entire duration of the study from selection to follow-up visit. Statin modification (and in the case of COMBO I, other prior lipid-lowering therapy) was only allowed in special circumstances.

SAFETY ASSESSMENTS

The safety assessments for these two studies were as follows. Safety was assessed by reporting adverse events (AE) (including adjudicated cardiovascular events), laboratory tests, and measurement of vital signs. Since the LDL-C lowering effects of PCSK9 inhibition, in addition to a statin, are unknown, several AE were defined and monitored as being of particular interest, including alanine aminotransferase abnormalities, allergic events, hemolytic anemia, pregnancy , study drug overdose, neurological events, ophthalmic events, and local injection site reactions. EAs were determined to be of particular interest based on a review of previous clinical trials, correspondence with health authorities and the data monitoring committee, the use of a monoclonal antibody in this study, and the route of drug administration.

The safety analyzes were as follows. AE (including adjudicated cardiovascular events), laboratory parameters, and vital signs were reported descriptively, based on the safety population (all randomized patients receiving at least 1 dose or partial dose of study treatment). Safety analyzes focused on the defined period of treatment-emergent AE as the time from the first double-blind dose to the last double-blind dose of the investigational product 70 days (10 weeks).

Safety: Manifestation of treatment emergent adverse events (TEAEs) reported by the patient or observed by the investigator, serious adverse events (SAEs), TEAEs leading to treatment discontinuation, AE of special concern (local injection site reactions, allergic events, selected neurological events and cardiovascular events with adjudication outcome), manifestation of PCSA (potentially clinically significant abnormalities) in laboratory parameters, specific tests for diabetes or impaired glucose control and patients with 2 LDL-C followed <25 mg / dL (0.65 mmol / L).

COMBO I: STATISTICAL METHODS

Determination of sample size

The final total sample size was 306, with a randomization ratio of 2: 1 (alirocumab 204: placebo 102).

Combo I: Analysis Populations

The primary efficacy analysis population was the intention-to-treat (ITT) population, defined as all randomized patients who had an evaluable primary endpoint, that is, those with an available baseline calculated LDL-C value, and at least one calculated LDL-C value available within one of the analysis windows up to week 24 (including all calculated LDL-C during treatment and without treatment).

The secondary efficacy analysis population was the modified intention-to-treat (mITT) population, defined as all randomized patients who took at least one dose or part of a dose of the double-blind investigational medicinal product (IMP) and had a calculated LDL-C value available at baseline and at least one within one of the analysis windows up to week 24 during the treatment efficacy period. The treatment efficacy period was defined as the time from the first double-blind IMP administration to 21 days after the last double-blind injection.

The safety population included all randomized patients who received at least one dose or part of a dose of the double-blind IMP.

Combo I: Efficacy Analysis

Key efficacy endpoint analyzes were performed using an ITT approach (based on the ITT population defined above), including all lipid data, regardless of whether the patient continued therapy or not. This corresponds to ITT estimates, defined for primary and secondary key endpoints. In addition, analyzes were also performed using an during treatment approach (based on the ITTm population defined above), which includes lipid data collected during the treatment efficacy period. This corresponds to estimates during the treatment of key secondary endpoints.

The ITT approach analyzed all patients, regardless of their adherence to treatment; assessed the benefit of the treatment strategy and reflected the effect as far as possible in a patient population. The during treatment approach looked at the effect of treatment, restricted to the period during which the patient actually received the treatment. It evaluated the benefit that a treatment would achieve in patients adhering to the treatment until the moment of time considered.

Efficacy analyzes were performed by treatment as randomized.

All measurements, scheduled or unscheduled, fasting or non-fasting, were assigned to analysis windows to provide an assessment for time points from week 4 to week 52.

Regarding the main efficacy analysis (ITT approach), the percentage change in LDL-C calculated from baseline to week 24 was analyzed using a mixed effects model with repeated measures (MMRM) approach. All available post-baseline data from the Week 4 to Week 52 analysis window were used and the MMRM accounted for missing data. The model included the fixed categorical effects of treatment group (placebo vs alirocumab), randomization strata (according to IVRS), moment of time (week 4 to week 52), interaction of treatment by moment of time and interaction of strata by moment time, as well as the continuous fixed covariates of the baseline LDL-C value and the interaction of baseline value by moment of time. This model provided mean least squares estimates adjusted to baseline (mean by MC) at week 24 for both treatment groups with their corresponding 95% confidence interval. To compare the alirocumab group with the placebo group, an appropriate statement was used to test for differences in these estimates at the 5% alpha level.

A hierarchical procedure has been defined to test the key secondary endpoints while controlling for multiplicity (using the previous order of the key secondary endpoints). The first key secondary endpoint was the percent change in LDL-C calculated from baseline to week 24 using an on-treatment approach.

Continuous secondary variables that were anticipated to have a normal distribution (ie lipids other than TG and Lp (a) were analyzed) were analyzed using the same MMRM model as for the primary endpoint. Continuous endpoints that were anticipated to have a non-normal distribution (i.e. TG and Lp (a)) were analyzed using the multiple imputation approach for manipulating missing values, followed by the robust endpoint regression model. of interest as a response variable using the estimation of M (using the SAS ROBUSTREG procedure) with treatment group, randomization strata (according to IVRS) and corresponding baseline value (s) as effects to compare the effects of the treatment. Pooled estimates were provided for the mean in both treatment groups, as well as the differences in these estimates, with their corresponding SE, 95% CI, and p-value (using the SAS MIANALYZE procedure).

Binary endpoints of secondary efficacy were analyzed using the multiple imputation approach for handling missing values, followed by stratified logistic regression with treatment group as the main effect and corresponding baseline value (s). as a covariate, stratified by randomization factors (according to IVRS). Pooled estimates of relative chance versus placebo, 95% CI, and p-value (using SAS MIANALYZE procedure) were provided.

Combo I: Security Analysis

The safety analyzes were descriptive, they were carried out in the safety population according to the treatment actually received. For the TEAE and PCSA analysis, the safety analysis focused on the TEAE period defined as the time from the first double-blind IMP dose to 70 days after the last double-blind injection. Analyzes of laboratory results and vital signs were performed over time in the period up to 21 days after the last IMP injection.

COMBO I: RESULTS

Liability of patients

Of the 316 randomized patients, two patients in the alirocumab group were not treated and therefore were not included in the safety population. Five of the randomized patients were not included in the ITT population (no LDL-C value within an analysis window until week 24). Seven of the randomized patients were excluded from the ITTm population (patients excluded from the ITT population and patients with no LDL-C value within one of the analysis windows up to week 24 during the efficacy treatment period).

Table 1 - Analysis populations

Placebo Alirocumab 75 every 2 weeks / up to 150 every 2 weeks All

Randomized population 107 (100%) 209 (100%) 316 (100%)

Efficacy populations

Intention to Treat (ITT) 106 (99.1%) 205 (98.1%) 311

(98.4%)

Modified intention to treat 105 (98.1%) 204 (97.6%) 309 (ITTm) (97.8%)

Security population 107 207 314

Note: Patients in the safety population are tabulated based on the treatment actually received (as treated). For the other populations, patients are tabulated according to their randomized treatment.

In the alirocumab group, among the 191 patients who received at least one injection after week 12, 32 (16.8%) patients received upward automatic dose titration at week 12 from alirocumab 75 mg every 2 weeks to 150 mg every 2 weeks in a blinded mode.

COMBO I: Study layout

Of the 640 patients selected for eligibility, 316 were subsequently randomized to alirocumab (209) or placebo (107). Of the 316 randomized patients, 2 (alirocumab) were untreated; 231 patients (73.1%) completed the 52-week study treatment (75 placebo; 156 alirocumab); 311 (98.4%) comprised the ITT population (106 placebo; 205 alirocumab, 5 patients with absent LDL-C levels); 309 patients comprised the treatment population (105 placebo; 204 alirocumab) and 314 patients comprised the safety population (107 placebo; 207 alirocumab).

During the 52-week double-blind period, compliance with study medication (receipt of> 80% of scheduled injections) was similar between treatment groups (98% alirocumab; 99% placebo). Based on week 8 LDL-C levels> 70 mg / dL, the alirocumab dose was increased in 32/191 patients (16.8%) to 150 mg subcutaneously every 2 weeks at week 12 (between patients with at least 1 injection after week 12).

Double-blind IMP was discontinued prematurely before week 52 for 32 (29.9%) randomized patients in the placebo group and 51 (24.4%) randomized patients in the alirocumab group. The main reasons for discontinuation of study treatment were "other reasons" and adverse events. These 'other reasons' included the following: patient did not meet criteria for termination due to or missed 50 week injection / out of window or 52 week out of window visit (17 patients), withdrawal subject not otherwise specified (8 patients), site closure (4 patients), sudden death / death (3 patients) (no investigator decision to stop treatment before death), miscellaneous (2 patients) .

COMBO I: Summary of Population Characteristics

Demographic characteristics, disease characteristics, and lipid parameters at baseline were similar in the alirocumab group compared to the placebo group. Baseline demographic characteristics are shown in Table 2. Baseline lipid and lipid medication levels are shown in Table 3. The definition of CHD included acute myocardial infarction (MI), silent MI, unstable angina, coronary revascularization or Clinically significant CHD diagnosed by invasive or non-invasive tests. CHD risk equivalents included peripheral arterial disease, ischemic stroke, chronic kidney disease (estimated glomerular filtration rate> 30 to <60 mL / min / 1.73 m2 for> 3 months), or diabetes mellitus in combination with 2 or more factors. risk factors (hypertension, ankle-brachial index <0.90, micro- or macroalbuminuria, dipstick urinalysis with> 2+ protein, retinopathy, or family history of premature CHD [<55 years in parent / child or <65 years in mother / sister]).

There were numerically higher proportions of female patients and patients with type 2 diabetes in the alirocumab group. Similarly, a higher percentage of patients in the placebo group were using other LTTs in addition to statins (49.5% vs 38.3% in the alirocumab group). However, these differences between the treatment groups were not found to be statistically significant.

All patients except one were treated with a statin, receiving 57.6% high intensity statin (atorvastatin 40 to 80 mg per day or rosuvastatin 20 to 40 mg per day) and receiving 8.2% ezetimibe, in addition to the statin. Mean calculated LDL-C (SD) at baseline was 102.2 (31.6) mg / dL (2.646 (0.820) mmol / L). Approximately 78% of the randomized population had a history of coronary heart disease (CHD) (Table 5).

Injection exposure was similar in treatment groups with a mean exposure of 46 weeks. In the alirocumab group, among the 191 patients who received at least one injection after week 12, 32 (16.8%) patients received upward automatic dose titration at week 12 from alirocumab 75 mg every 2 weeks to 150 mg every 2 weeks in a blinded mode.

Table 2 - Baseline demographic characteristics

All patients took the previous maximum tolerated statin ± other LTT. ^ e provide p-values comparing baseline data between treatment groups for descriptive purposes, as a selection tool, using Fisher's exact test for qualitative data and the one-sided asymptotic ANOVA test for Wilcoxon scores (Kruskal-Wallis test) for continuous data.

Table 3 - Baseline lipid and lipid medication levels

Table 4 - Characteristics of the disease and other relevant baseline data - Randomized population Alirocumab 75 c / 2 weeks / until

Placebo (N = 107) 150 c / 2 weeks (N = 209) All (N = 316) Time since diagnosis of

hypercholesterolemia (years)

Number 107 209 316 Mean (SD) 10.60 (7.98) 11.20 (8.01) 10.99 (7.99) Median 9.70 10.05 9.84 Min: Max 0.2: 42 .4 0.4: 46.1 0.2: 46.1

Fredrickson's classification of

hyperlipoproteinemia

Number 99 188 287 11 a 42 (39.3%) 83 (39.7%) 125 (39.6%) 11 b 56 (52.3%) 96 (45.9%) 152 (48.1%)

IV 1 (0.9%) 9 (4.3%) 10 (3.2%)

There were 4 patients without fully documented CHD or equivalent risk of CHD.

Table 5 - Medical history of specific interest: cardiovascular history and risk factors -Randomized population

Alirocumab 75

every 2 weeks / until

Placebo 150 every 2 weeks

(N = 107) (N = 209) All (N = 316) Any cardiovascular history / risk factors 106

(99.1%) 206 (98.6%) 312 (98.7%)

Coronary heart disease a 83 (77.6%) 164 (78.5%) 247 (78.2%) Acute myocardial infarction 47 (43.9%) 83 (39.7%) 130 (41.1%) Silent myocardial infarction 2 (1.9%) 12 (5.7%) 14 (4.4%) Unstable angina 20 (18.7%) 34 (16.3%) 54 (17.1%) 193 Procedures coronary revascularization 60 (56.1%) 133 (63.6%) (61.1%) Other clinically significant CHDb 14 (13.1%) 38 (18.2%) 52 (16.5%) Associated CHD to 1 or more associated diseases (between

hypertension, diabetes or moderate CKD) and / or associated with

other CVD (ischemic stroke, PAD) 76 (71.0%) 150 (71.8%) 226 (71.5%) Coronary heart disease risk equivalents3 51 (47.7%) 85 (40.7% ) 136 (43.0%) Ischemic stroke 6 (5.6%) 21 (10.0%) 27 (8.5%) Peripheral arterial disease 8 (7.5%) 3 (1.4%) 11 (3.5%) Moderate chronic kidney disease 24 (22.4%) 37 (17.7%) 61 (19.3%) Alirocumab 75

every 2 weeks / until

Placebo 150 every 2 weeks

(N = 107) (N = 209) All (N = 316) Unknown history of diabetes mellitus AND 2nd

plus additional risk factors 25 (23.4%) 42 (20.1%) 67 (21.2%) At least 2 CHD risk equivalents or 1 CHD

Equivalent risk associated with hypertension or diabetes 50 (46.7%) 82 (39.2%) 132 (41.8%) Note: A patient can be counted in several categories.

a according to the points previously listed in the e-CRF.

b diagnosed by invasive or non-invasive tests.

PAD defined as intermittent claudication TOGETHER WITH ankle-brachial index <0.90 or TOGETHER with peripheral revascularization procedure / surgery or critical limb ischemia TOGETHER WITH peripheral revascularization procedure / surgery or thrombolysis.

Table 6 - Medical history of specific interest: other medical history of special interest -Randomized population

Alirocumab 75

Placebo every 2 weeks / up to 150 every 2 weeks All (N = 107) (N = 209) (N = 316) Other medical history of special interest 102

(95.3%) 202 (96.7%) 304 (96.2%) Hypertension at 95

(88.8%) 185 (88.5%) 280 (88.6%) Type 1 diabetes to 0 0 0 Type 2 diabetes to 42

(39.3%) 94 (45.0%) 136 (43.0%) Family history of heart disease 37

premature coronary artery a (34.6%) 72 (34.4%) 109 (34.5%) Family history of type 2 diabetes to 31

(29.0%) 60 (28.7%) 91 (28.8%) Menopause (women) a 23

(21.5%) 67 (32.1%) 90 (28.5%) a according to the points previously listed in the e-CRF.

Note: A patient can be counted in several categories.

Table 7 - Previous TML at Randomization - Randomized Population

Alirocumab 75

Placebo every 2 weeks / up to 150 every 2 weeks All (N = 107) (N = 209) (N = 316) Any statin 107 (100%) 208 (99.5%) 315 (99.7%)

Taking high intensity statin 60 (56.1%) 122 (58.4%) 182 (57.6%) Daily dose of atorvastatin (mg) 34 (31.8%) 70 (33.5%) 104 (32 , 9%) Alirocumab 75

Placebo every 2 weeks / up to 150 every 2 weeks All (N = 107) (N = 209) (N = 316)

10 0 2 (1.0%) 2 (0.6%)

20 5 (4.7%) 4 (1.9%) 9 (2.8%)

40 17 (15.9%) 40 (19.1%) 57 (18.0%)

80 12 (11.2%) 24 (11.5%) 36 (11.4%)

Other doses 0 0 0 Rosuvastatin daily dose (mg) 34 (31.8%) 66 (31.6%) 100 (31.6%)

5 1 (0.9%) 3 (1.4%) 4 (1.3%)

10 1 (0.9%) 5 (2.4%) 6 (1.9%)

20 16 (15.0%) 33 (15.8%) 49 (15.5%)

40 15 (14.0%) 25 (12.0%) 40 (12.7%)

Other doses 1 (0.9%) 0 1 (0.3%) Simvastatin daily dose (mg) 39 (36.4%) 71 (34.0%) 110 (34.8%)

10 0 1 (0.5%) 1 (0.3%)

20 9 (8.4%) 16 (7.7%) 25 (7.9%)

40 21 (19.6%) 45 (21.5%) 66 (20.9%)

80 9 (8.4%) 8 (3.8%) 17 (5.4%)

Other doses 0 1 (0.5%) 1 (0.3%)

Any TML other than statins3 53 (49.5%) 80 (38.3%) 133 (42.1%) Any TML other than nutraceuticals 46 (43.0%) 68 (32.5%) 114 (36.1 %) Ezetimibe 11 (10.3%) 15 (7.2%) 26 (8.2%) Nutraceuticals 9 (8.4%) 15 (7.2%) 24 (7.6%) a in combination with statins or not.

High intensity statin corresponds to atorvastatin 40 to 80 mg per day or rosuvastatin 20 to 40 mg per day.

Table 8 - Baseline Lipid Efficacy Parameters - Quantitative Summary in Conventional Units - Randomized Population

Alirocumab 75

every 2 weeks / up to 150 every 2 weeks

Placebo (N = 107) (N = 209) All (N = 316) Calculated LDL-C (mg / dL)

Number 107 209 316 Mean (SD) 106.0 (35.3) 100.2 (29.5) 102.2 (31.6) Median 97.0 98.0 97.0

Q1: Q3 86.0: 120.0 81.0: 114.0 82.0: 115.0 Alirocumab 75

every 2 weeks / up to 150 every 2 weeks

Placebo (N = 107) (N = 209) All (N = 316) Min: Max 61: 256 33: 240 33: 256

LDL-C measured (mg / dL)

Number 70 138 208 Mean (SD) 100.2 (34.4) 94.8 (29.3) 96.6 (31.2) Median 92.0 91.0 91.5

Q1: Q3 75.0: 119.0 76.0: 109.0 75.5: 110.0

Min: Max 53: 238 28: 239 28: 239

No HDL-C (mg / dL)

Number 107 209 316 Mean (SD) 133.4 (39.8) 130.0 (34.0) 131.1 (36.0) Median 125.0 125.0 125.0

Q1: Q3 106.0: 147.0 103.0: 149.0 104.5: 148.5

Min: Max 79: 304 61: 270 61: 304

Total C (mg / dL)

Number 107 209 316 Mean (SD) 182.3 (39.6) 178.3 (35.7) 179.7 (37.0) Median 176.0 173.0 174.0

Q1: Q3 156.0: 204.0 151.0: 199.0 154.0: 200.5

Min: Max 119: 348 119: 316 119: 348

HDL-C (mg / dL)

Number 107 209 316 Mean (SD) 48.8 (12.7) 48.3 (14.4) 48.5 (13.8) Median 47.0 46.0 46.0

Q1: Q3 40.0: 55.0 39.0: 56.0 39.0: 55.0

Min: Max 26: 98 17: 109 17: 109

Fasting TG (mg / dL)

Number 106 209 315 Mean (SD) 140.3 (64.3) 151.2 (93.2) 147.5 (84.6) Median 123.0 130.0 127.0 Alirocumab 75

every 2 weeks / up to 150 every 2 weeks

Placebo (N = 107) (N = 209) All (N = 316)

Q1: Q3 95.0: 177.0 92.0: 189.0 92.0: 186.0

Min: Max 52: 431 35: 999 35: 999

Lipoprotein- (a) (mg / dL)

Number 101 191 292 Mean (SD) 49.4 (48.3) 49.6 (51.0) 49.5 (50.0) Median 38.0 31.0 33.0

Q1: Q3 10.0: 70.0 8.0: 81.0 9.5: 79.5

Min: Max 2: 184 2: 248 2: 248

Apo-B (mg / dL)

Number 101 191 292 Mean (SD) 91.4 (24.1) 90.8 (21.4) 91.0 (22.3) Median 88.0 87.0 87.5

Q1: Q3 76.0: 103.0 75.0: 105.0 76.0: 105.0

Min: Max 50: 194 51: 166 50: 194

Apo-A1 (mg / dL)

Number 101 191 292 Mean (SD) 145.1 (23.7) 143.1 (25.0) 143.8 (24.5) Median 141.0 142.0 141.5

Q1: Q3 129.0: 161.0 125.0: 157.0 128.0: 158.0

Min: Max 96: 217 69: 262 69: 262

Apo-B / Apo-A1 (ratio)

Number 101 191 292 Mean (SD) 0.647 (0.207) 0.653 (0.192) 0.651 (0.197) Median 0.620 0.620 0.620

Q1: Q3 0.520: 0.720 0.520: 0.760 0.520: 0.740

Min: Max 0.30: 1.52 0.30: 1.70 0.30: 1.70

Total C / HDL-C (ratio)

Number 107 209 316 Mean (SD) 3,934 (1,199) 3,931 (1,211) 3,932 (1,205) Alirocumab 75

every 2 weeks / up to 150 every 2 weeks

Placebo (N = 107) (N = 209) All (N = 316)

Median 3,711 3,750 3,750

Q1: Q3 3,052: 4,474 3,096: 4,500 3,076: 4,474

Min: Max 2.05: 7.91 1.87: 10.59 1.87: 10.59

The LDL-C pool measured was not planned in the initial protocol and was added in a modification. Therefore, the measured LDL-C values are available for fewer patients compared to the calculated LDL-C values.

COMBO I: Administration and duration

Injection exposure was similar in the treatment groups with a mean exposure of approximately 46 weeks. In the alirocumab group, among the 191 patients who received at least one injection after week 12, 32 (16.8%) patients received upward automatic dose titration at week 12 from alirocumab 75 mg every 2 weeks to 150 mg every 2 weeks in a blinded mode.

COMBO I: Primary Efficacy Endpoint

The ITT analysis includes all LDL-C values collected during treatment and without treatment up to week 52. Analysis of the primary endpoint is provided (percent change in LDL-C calculated from baseline to week 24 ) based on a model of MMRM in the ITT population, using mean estimates by MC at week 24. Sixteen (7.8%) patients in the alirocumab group and 9 (8.5%) patients in the non-placebo group. had an LDL-C value calculated at week 24. The MMRM model accounted for these missing values.

Results of the primary endpoint analysis are presented in Table 9, in mmol / L and mg / dL.

A statistically significant decrease in the percentage change in LDL-C from baseline to week 24 was observed in the alirocumab group (mean by MC vs. baseline -48.2%) compared to the placebo group. (mean by MC vs. baseline level -2.3%) (mean difference by MC vs. placebo of -45.9%, p <0.0001).

In the alirocumab group, a reduction in LDL-C was observed from baseline from week 4 to week 52.

A slight decrease in LDL-C reduction over time was observed in the alirocumab group (mean by MC vs. baseline at week 52 of -42.5 vs. -48.2 at week 24) probably due to the greater number of treatment interruptions at week 52 compared to week 24 and, as a result, a greater number of post-treatment LDL-C was included at week 52 (8.8% at week 52 vs. 3.9% in week 24).

In fact, the treatment effect is stable from week 24 to week 52 when only LDL-C was considered during treatment (see Figure 3), while a slight decrease is observed when post-treatment LDL-C is also included ( see Figure 2).

Table 9 - Percentage change from baseline in calculated LDL-C and other lipid parameters at week 24 (ITT analysis or during treatment as indicated)

Table 10 - LDL-C calculated over time - ITT analysis - ITT population

Alirocumab 75 every 2 weeks / up to 150 Placebo (N = 106) every 2 weeks (N = 205)

Change in Percentage Change LDL-C Percent Change Change from from level from from calculated level Baseline baseline level value Baseline baseline level value

Average per MC

(EE) (mmol / L)

Baseline at 2,709 2,597

(0.081) NA NA (0.054) NA NA

Week 4 2,524 1,327

(0.062) -0.112 (0.062) -2.3 (2.4) (0.045) -1.308 (0.045) -50.6 (1.7)

Week 8 2,592 1,264

(0.060) -0.043 (0.060) -0.4 (2.4) (0.043) -1.372 (0.043) -51.6 (1.7)

Week 12 2,643 1,428

(0.071) 0.007 (0.071) 1.1 (2.5) (0.051) -1.207 (0.051) -46.3 (1.8)

Week 16 2,595 1,291

(0.069) -0.041 (0.069) 0.6 (2.6) (0.049) -1.345 (0.049) -50.5 (1.9)

Week 24 2,533 1,332

(0.073) -0.102 (0.073) -2.3 (2.7) (0.052) -1.303 (0.052) -48.2 (1.9)

Week 36 2,464 1,411

(0.078) -0.172 (0.078) -5.3 (3.4) (0.057) -1.225 (0.057) -44.8 (2.5)

Week 52 2,586 1,483

(0.090) -0.049 (0.090) 0.5 (3.6) (0.063) -1.153 (0.063) -42.5 (2.5)

Average per MC

(EE) (mg / dL)

Basal level at 100.3

104.6 (3.1) NA NA (2.1) NA NA

Week 4 51.2

97.5 (2.4) -4.3 (2.4) -2.3 (2.4) (1.7) -50.5 (1.7) -50.6 (1.7)

Week 8 100.1 48.8

(2.3) -1.7 (2.3) -0.4 (2.4) (1.7) -53.0 (1.7) -51.6 (1.7) Alirocumab 75 every 2 weeks / up to 150 Placebo (N = 106) every 2 weeks (N = 205)

Change in Percentage Change LDL-C Percent Change Change from from level from from calculated level Baseline baseline level value Baseline baseline level value

Week 12 102.0 55.1

(2.8) 0.3 (2.8) 1.1 (2.5) (2.0) -46.6 (2.0) -46.3 (1.8)

Week 16 100.2 49.8

(2.7) -1.6 (2.7) 0.6 (2.6) (1.9) -51.9 (1.9) -50.5 (1.9)

Week 24 51.4

97.8 (2.8) -3.9 (2.8) -2.3 (2.7) (2.0) -50.3 (2.0) -48.2 (1.9)

Week 36 54.5

95.1 (3.0) -6.6 (3.0) -5.3 (3.4) (2.2) -47.3 (2.2) -44.8 (2.5)

Week 52 57.2

99.9 (3.5) -1.9 (3.5) 0.5 (3.6) (2.4) -44.5 (2.4) -42.5 (2.5)

a The baseline level is described using means and standard errors.

Note: Least squares means (LC), standard errors (SE) and p-value taken from MMRM analysis (mixed effects model with repeated measures). The model includes fixed categorical effects of treatment group, randomization strata according to IVRS, moment of time, interaction of treatment by moment of time, interaction of strata by moment of time, as well as the continuous fixed covariates of the LDL-C value. baseline and the interaction of the baseline LDL-C value by moment of time

MMRM model and baseline description performed in patients with a baseline value and a post-baseline value in at least one of the analysis windows used in the model.

COMBO I: Secondary Key Efficacy Endpoints

Table 11 summarizes the results of the analysis on the key secondary endpoints in the hierarchical order. All key secondary endpoints are statistically significant by hierarchical testing procedure up to and including the HDL-C endpoint at week 24 (ITT estimate) included. Statistical significance was not reached for the fasting TG endpoint at week 24 (ITT estimate).

Table 11 - Key Secondary Efficacy Endpoints

Endpoint Analysis Results P value

Calculated LDL-C - Percent Change During Mean Difference by MC vs <0.0001 from Baseline to Week 24 Placebo Treatment of -49.9%

Calculated LDL-C - ITT Percent Change Mean Difference by MC vs <0.0001 from Baseline to Week 12 Placebo of -47.4%

Calculated LDL-C - Percent Change During Mean Difference by MC vs <0.0001 from Baseline to Week 12 Placebo Treatment of -49.3%

Apo-B - Percentage change from ITT Mean difference by MC vs <0.0001 baseline to week 24 placebo of -35.8%

Apo-B - Percentage change from During the Mean Difference by MC vs <0.0001 baseline level to week 24 placebo treatment of -37.5%

No HDL-C - Percentage change from ITT Mean difference by MC vs <0.0001 from baseline to week 24 placebo of -37.5%

No HDL-C - Percentage change from During Mean Difference by MC vs <0.0001 baseline to Week 24 placebo treatment of -40.4%

Endpoint Analysis Results P value

Total C - Percentage change from ITT Mean difference by MC vs <0.0001 baseline to week 24 placebo of -25%

Apo-B - Percentage change from ITT Mean difference by MC vs. <0.0001 baseline to week 12 placebo of -38.2%

No HDL-C - Percentage change from ITT Mean difference by MC vs <0.0001 from baseline to week 12 placebo of -40.1%

Total C - Percentage change from ITT Mean difference by MC vs <0.0001 baseline to week 12 placebo of -26.4%

Calculated LDL-C - ITT Percent Change Mean Difference by MC vs <0.0001 from baseline to Week 52 placebo of -43%

Proportion of patients achieving LDL-ITT Pooled estimate for <0.0001 C calculated <70 mg / dL (1.81 mmol / L) at relative opportunity versus placebo

week 24 of 38.5

Proportion of Patients Achieving LDL- During Pooled Estimate for <0.0001 C calculated <70 mg / dL (1.81 mmol / L) at Treatment Relative Chance vs. Placebo

week 24 of 50

Lp (a) - Percent Change from ITT Pooled Estimate for Difference <0.0001 Baseline to Week 24 Adjusted Mean vs. Placebo of -

14.6%

HDL-C - Percentage change from ITT Mean difference by MC vs. 0.0001 baseline to Week 24 placebo of 7.3%

Fasting TG - ITT Percent Change Estimated Pooled for Difference 0.7597 from Baseline to Week 24 Adjusted Mean vs. Placebo of -

1.2%

The analysis during treatment of the change in the percentage of LDL-C from baseline to week 24 shows results consistent with the ITT analysis with a mean difference by MC vs placebo of -49.9% in the analysis during treatment vs. -45.9% in the ITT analysis. In fact, some patients had LDL-C values collected after treatment (that is, more than 21 days after the last injection) at week 24: 5 patients (4.7%) in the placebo group and 8 patients (3.9%) in the alirocumab group.

A statistically significant decrease in the percentage change in LDL-C from baseline to week 12 (i.e., before possible upward dose adjustment) was observed in the ITT analysis in the alirocumab group (mean by MC vs. baseline -46.3%) compared to placebo group (mean by MC vs. baseline 1.1%) (mean difference by MC vs. placebo of -47.4%, p <0.0001 ). The results obtained with the analysis during the treatment were similar.

Thirty-nine (19.5%) patients had two consecutive calculated LDL-C values <25 mg / dL. No particular safety concern has been observed in these 39 patients.

Table 12 - Number (%) of patients with 2 LDL-C in a row <25 mg / dL (<0.65 mmol / L) during the treatment period - Safety population

Alirocumab 75 Placebo every 2 weeks / up to 150 every 2 weeks (N = 107) (N = 207)

Patients with 2 consecutive values of calculated LDL-C <25 mg / dL

1 0/104 39/200 (19.5%)

Time to first calculated LDL-C value <25 mg / dL

(weeks) 2

Number 0 39

Alirocumab 75

Placebo every 2 weeks / up to 150 every 2 weeks (N = 107) (N = 207)

Mean (SD) 11.48 (9.72)

Median 8.00

Min: Max 3.9: 36.3

Patients with 2 consecutive values of calculated LDL-C <15 mg / dL

1 0/104 9/200 (4.5%)

Time to first calculated LDL-C value <15 mg / dL

(weeks) 2

Number 0 9

Mean (SD) 12.51 (6.83)

Median 13.57

Min: Max 4.1: 23.9

The number (n) represents the subset of the total number of patients who met the criteria

The denominator (/ N) within a treatment group is the number of patients for the treatment group who had at least two calculated LDL-C values evaluated at least 21 days apart in the efficacy period.

1 2 values are considered in a row if they are separated by at least 21 days

2 First calculated LDL-C value <25 or <15 mg / dL among the first 2 values in a row of calculated LDL-C <25 or <15 mg / dL per patient

COMBO I: Summary of efficacy results

At week 24, the percentage change from baseline in LDL-C calculated in the ITT population was significantly greater in the alirocumab group (mean by MC vs. baseline -48.2%) compared to the group placebo (mean by MC vs. baseline -2.3%) (mean difference by MC vs. placebo of -45.9%, p <0.0001) (see Table 9). The analysis during treatment of the change in the percentage of LDL-C from baseline to week 24 shows results consistent with the ITT analysis with a mean difference by MC vs placebo of -49.9% in the analysis during treatment (p <0.0001) (see Table 9).

At week 12, before the possible upward adjustment of the dose from 75 mg to 150 mg, statistical significance was also reached in the ITT population (mean by MC vs. baseline level -46.3% and 1.1%, for patients alirocumab and placebo groups, respectively, mean difference by MC vs. placebo of -47.4%; p <0.0001) (see Table 11).

In the alirocumab group, LDL-C reduction from baseline was observed from week 4 to week 52 (see Table 10). A slight decrease in LDL-C reduction over time was observed in the alirocumab group (mean by MC vs. baseline at week 52 of -42.5% vs. -48.2% at week 24) probably due to the higher number of treatment interruptions at week 52 compared to week 24 and, as a result, the higher number of LDL-C was included after baseline at week 52 (8.8% at week 52 vs. to 3.9% at week 24). The results for measured LDL-C (beta quantification) were in agreement with those for calculated LDL-C. The results of a sensitivity analysis of the primary endpoint, using a pattern mix model, were in agreement with the ITT analysis. Specifically, in the ITT group, the pooled estimate for the mean change by MC (SE) from baseline at week 24 (%) was -44.2 (2.1 for the alirocumab group and -1.5 ( 3.0) for the placebo group The mean difference by MC (SE) in% for alirocumab vs placebo was -42.7 (3.7) (95% CI from -49.9 to -35.4 ; p <0.0001). Sensitivity analysis was performed to further assess the impact of missing data on the primary endpoint. In this analysis, the calculated LDL cholesterol values absent during the "during treatment" period were imputed multiply using a model that assumed absent LDL cholesterol values at randomization and Calculated absent during the post-treatment period were imputed multiple times using random extractions from a normal distribution, with a mean equal to the subject's own baseline value.

Figure 4 shows LDL-C levels over time for patients treated with alirocumab with / without dose escalation at week 12. In patients with dose escalation, LDL-C decreased by an additional mean 22.8% (SD 27.1) at week 24 compared to week 12. Among the 32 patients (16.8%) with increased dose of alirocumab at week 12 (based on LDL-C at week 8> 70 mg / dL ), the LDL-C achieved was comparable at weeks 24, 36 and 52 to that observed among patients in whom no dose increase was performed (LDL-C at week 8 <70 mg / dL).

The relative proportions of patients achieving LDL-C <70 mg / dL (<1.81 mmol / L) at week 24 among ITT populations (75.0%) and during treatment (77.5%) were significantly higher with alirocumab than with placebo (9.0% and 8.0%, respectively, p <0.0001).

All key secondary endpoints including Apo B, non-HDL-C, total C, Lp (a), HDL-C at various time points were statistically significant according to the hierarchical test procedure, except the TG endpoint fasting at week 24 (ITT estimate) (see Table 11). Significant reductions from baseline through week 24 after alirocumab therapy (vs placebo) were seen in non-HDL-C (-39.1 [1.8]% alirocumab, -1.6 [2.5 ]% of placebo), apolipoprotein B (-36.7 [1.6]% of alirocumab, -0.9 [2.3]% of placebo), total cholesterol (-27.9 [1.3]% of alirocumab, -2.9 [1.8]% placebo) and lipoprotein (a) (-20.5 [2.0]% alirocumab, -5.9 [2.8]% placebo) (all p <0.0001 alirocumab vs placebo). No significant change in triglyceride levels was observed, although a significant and directionally divergent increase in HDL-C (apolipoprotein A1) was observed in the alirocumab group; 3.5 (1.1)% vs. -3.8 (1.5)% for placebo (p <0.0001; see Table 9).

The percentage of changes from baseline in LDL-C at week 24 by demographic characteristics and patient subgroups for alirocumab versus placebo is shown in Figure 5. All 95% confidence intervals for differences in percentage reduction of LDL-C between alirocumab and placebo within each subgroup level defined by age, sex, race, ethnicity, intensity of previous statin therapy, other THL therapy (in addition to statin), and history of myocardial infarction or ischemic stroke they are completely to the left of the line of no effect. The treatment effect was observed at each level within each subgroup. In addition, the evidence for interaction by age, sex, race, ethnicity, intensity of previous statin therapy did not reach significance at the 5% level and thus demonstrate consistency of treatment effect within these subgroups. However, patients with other THL therapy (in addition to statin) and those with a history of myocardial infarction or ischemic stroke demonstrated a relatively greater effect of treatment (p-value for interaction 0.012 and 0.018 respectively; see Figure 5). .

Two consecutive values of calculated LDL-C <25 mg / dL (<0.65 mmol / L) were observed in 39 (19.5%) patients. No particular safety concern has been observed in these patients.

COMBO I: Summary of Safety Results

The percentages of patients experiencing treatment emergent adverse events (TEAE), serious TEAE, TEAE leading to death, and TEAE leading to treatment discontinuation were similar between treatment groups. The safety data collected up to the last patient visit at week 52 are shown in Table 13.

Of the 209 patients originally randomized to alirocumab, 2 did not receive the treatment, which means that the safety population comprised 207 patients to alirocumab. All randomized patients in the placebo group received their assigned treatment, therefore the safety population was 107 patients for placebo.

Table 13 - Adverse Events and Laboratory Values to Assess Safety (Safety Population)

N ° (%) of patients Alirocumab (n = Placebo (n =

207) 107) All patients taking maximum tolerated statin ± other LTL

TEAE 157 (75.8) 81 (75.7)

Treatment-emergent SAE 26 (12.6) 14 (13.1)

TEAE leading to death 2 (1.0) 3 (2.8)

TEAE leading to interruption 13 (6.3) 8 (7.5)

TEAE by preferred term occurring in> 5% of patients in any group

Upper respiratory infection 16 (7.7) 11 (10.3) N ° (%) of patients Alirocumab (n = Placebo (n =

207) 107) All patients taking maximum tolerated statin ± other LTL

Arthralgia 8 (3.9) 8 (7.5) Nasopharyngitis 15 (7.2) 5 (4.7) Urinary tract infection 13 (6.3) 4 (3.7) Dizziness 11 (5.3) 6 (5.6) Non-cardiac chest pain 2 (1.0) 7 (6.5) Sinusitis 11 (5.3) 4 (3.7) Injection site reaction 11 (5.3) 3 (2, 8) AE of special interest *

Local injection site reactions 11 (5.3) 3 (2.8) Possible general allergic reaction events 18 (8.7) 7 (6.5) Neurological events 5 (2.4) 2 (1.9) Neurocognitive disorders 0 (0) 1 (0.9) Cardiovascular TEAE confirmed by adjudication

Any patient with emerging cardiovascular events

of treatment confirmed by adjudication ** ^{- 6 (2.9) 3 (2.8)} Death from coronary heart disease (including cause

indeterminate) ^{1 (0.5) 1 (0.9)} Non-fatal myocardial infarction 1 (0.5) 1 (0.9) Fatal and non-fatal ischemic stroke (including

stroke not otherwise specified) ^{- 2 (1.0) 0} Unstable angina requiring hospitalization 0 0 Congestive heart failure requiring hospitalization 0 1 (0.9) Ischemia-guided coronary revascularization procedure 3 (1.4) 1 (0.9) * Company MedDRA Searches (CMQ). ** One patient in the placebo group and 1 patient in the alirocumab group each had 2 events that were positively adjudicated: non-fatal myocardial infarction and ischemia-guided coronary revascularization procedure. TEAEs are adverse events that developed, worsened, or aggravated during the TEAE period (time from first to last injection of study treatment 70 days). SAE = serious adverse events; TEAE = treatment emergent adverse events; ULN = upper limit of normality.

The most frequently reported and notable SOCs with a higher frequency in the alirocumab group compared to the placebo group were: "Infections and infestations": 37.2% in the alirocumab group vs 27.1% in the alirocumab group. placebo; "Metabolism and nutrition disorders": 10.1% in the alirocumab group vs 5.6% in the placebo; and "Cardiac disorders": 8.2% in the alirocumab group vs 4.7% in the placebo group, although no striking imbalance was observed for a particular event, it is considerable that 9 ischemic events occurred in the group of alirocumab versus 3 in the placebo group. When it comes to adjudication results, 5 patients had cardiovascular events that were adjudicated positively (2.4%) compared to 2 patients in the placebo group (1.9%).

Among the SOCs with a lower frequency, the SOC "Eye disorders" was seen in 4.3% of patients in the alirocumab group versus 0.9% in the placebo group with no imbalance for a particular event. Two (1.0%) and 3 (2.8%) deaths occurred during the treatment period in the alirocumab (myocardial infarction and pulmonary embolism) and placebo (esophageal adenocarcinoma, dementia, and sudden cardiac death) groups, respectively. In addition, one death occurred after death treatment (worsening of coronary artery disease) in alirocumab group.

Awarded CV events include all positively awarded CV AE. The award categories are as follows: death from CHD, non-fatal MI, fatal and non-fatal ischemic stroke, unstable angina requiring hospitalization, congestive heart failure requiring hospitalization, and ischemia-guided coronary revascularization procedure [PCI, RVC] .

SAEs were reported by 12.6% patients on alirocumab and 13.1% on placebo during the TEAE period. There is no particular clinical pattern among the preferred terms for SAE that were individually reported with low frequency.

No specific pattern was observed among TEAEs that led to permanent treatment discontinuation.

Among the events of interest, no particular signal was detected for TEAEs related to neurological events and neurocognitive disorders.

Fourteen patients, 11 (5.3%) in the alirocumab group and 3 (2.8%) in the placebo group, had a local treatment-emergent reaction at the injection site. Among general allergic reactions, an imbalance for asthma was observed with 5 (2.4%) cases including 2 severe cases in the alirocumab group versus no cases in the placebo group.

Five (7.4%) patients in the alirocumab group and 1 (2.7%) patient in the placebo group who reported impaired glucose control at baseline were classified as diabetic in the period of TEAE. . No patient classified as normal at baseline became diabetic.

The imbalance for PCSA values was observed for the decrease in hemoglobin from baseline> 20 g / L (6.3% in the alirocumab group vs 3.9% in the placebo group) and for new cases of erythrocyte values> 6 Tera / L (2.5% in the alirocumab group vs no cases in the placebo group). No other anomalies relevant to PCSA were observed.

LDL-C levels <25 mg / dL (in 2 consecutive measurements> 21 days apart) were observed in 39 patients treated with alirocumab, of which 9 had LDL-C <15 mg / dL. The overall adverse event profile appeared similar to patients without such low LDL-C levels, although there were slightly higher rates of myalgia (7.7% in patients with LDL-C <25 mg / dL vs 3.4%). in the alirocumab group as a whole, 3.7% with placebo), osteoarthritis (7.7% vs 3.9% and 4.7%), arthralgia (5.1% vs 3.9% and 7, 5%) and herniated invertebral disc (5.1% vs 1.0% and 0%).

Antibodies against alirocumab were detected in a total of 18 patients (of the 296 evaluable patients; 6.1%), with antibodies against alirocumab detected at baseline in five total patients subsequently randomized to alirocumab (3/197; 1.5 %) or placebo (2/99; 2.0%). Low treatment-emergent antibody positivity was observed in 13/197 (6.6%) alirocumab-treated patients without titers above 240. In seven of these patients, the antibodies were transient and resolved despite continued alirocumab treatment. The median time to detection of antibodies to alirocumab was 12 weeks; no specific clinical events were observed in antibody positive patients. However, the presence of anti-alirocumab antibodies had no observed effect on safety and efficacy.

COMBO I: Overall Results

In this patient population, with heHF and high baseline LDL-C levels despite the maximum tolerated statin (with or without another LTT), the following observations were made: 1) Self-administered alirocumab produced significantly greater LDL-C reductions vs placebo at week 24; 2) the mean absolute decrease from baseline in LDL-C was -90.8 mg / dL at week 24 with alirocumab versus -15.5 mg / dL with placebo; 3) mean LDL-C levels achieved were 107 mg / dL at week 24 with alirocumab versus 182 mg / dL with placebo; 4) 32% of patients with alirocumab achieved LDL-C <70 mg / dL despite baseline LDL-C> 190 mg / dL; 5) 57% of patients with alirocumab reached LDL-C <100 mg / dL at week 24; and 6) alirocumab was generally well tolerated and TEAEs were generally comparable with the placebo group.

COMBO II: STATISTICAL METHODS

Determination of sample size

The final total sample size was 660 with a randomization ratio of 2: 1 (alirocumab 440: ezetimibe 220).

Combo II: Chronological development of the analyzes

The first-stage analysis included efficacy endpoints up to week 52 (final efficacy analysis) and interim safety analysis, which was performed on all safety data up to the cut-off date. common study (last visit of week 52 of the patient). Analyzes of lipid data beyond week 52 were descriptive. These results are presented in this document.

The second (final) stage analysis will be performed at the end of the study and will consist of the final analysis of the efficacy endpoints up to week 104 and the final safety analysis.

Combo II: Analysis Populations

The primary efficacy analysis population was the intention-to-treat (ITT) population, defined as all randomized patients who had an evaluable primary endpoint, that is, those with an available baseline calculated LDL-C value, and at least one calculated LDL-C value available within one of the analysis windows up to week 24 (including all calculated LDL-C during treatment and without treatment).

The secondary efficacy analysis population was the modified intention-to-treat (mITT) population, defined as all randomized patients who took at least one dose or part of a dose of the double-blind investigational medicinal product (IMP) and had a calculated LDL-C value available at baseline and at least one within one of the analysis windows up to week 24 during the treatment efficacy period. The period of treatment efficacy was defined as the period of time from the first administration of double-blind IMP (capsule or injection, whichever occurs first) to the day of the last injection 21 days or the day of the last dose of the capsule 3 days, whichever occurs first.

The safety population included all randomized patients who received at least one dose or part of a dose of the double-blind IMP.

Combo II: Efficacy Analysis

Key efficacy endpoint analyzes were performed using an ITT approach (based on the ITT population defined above), including all lipid data, regardless of whether the patient continued therapy or not. This corresponds to ITT estimates, defined for primary and secondary key endpoints. In addition, analyzes were also performed using an during treatment approach (based on the ITTm population defined above), which includes lipid data collected during the treatment efficacy period. This corresponds to estimates during treatment of the key secondary endpoints.

The ITT approach analyzed all patients, regardless of their adherence to treatment; assessed the benefit of the treatment strategy and reflected the effect as far as possible in a patient population. The during treatment approach looked at the effect of treatment, restricted to the period during which the patient actually received the treatment. It evaluated the benefit that a treatment would achieve in patients adhering to the treatment until the moment of time considered.

Efficacy analyzes were performed by treatment as randomized.

All measurements, scheduled or unscheduled, fasting or non-fasting, were assigned to analysis windows to provide an assessment for time points from week 4 to week 104.

Regarding the main efficacy analysis (ITT approach), the percentage change in LDL-C calculated from baseline to week 24 was analyzed using a mixed effects model with repeated measures (MMRM) approach. All available post-baseline data from the Week 4 to Week 52 analysis window were used and the MMRM accounted for missing data. The model included the fixed categorical effects of treatment group (ezetimibe vs alirocumab), randomization strata (according to IVRS), moment of time (week 4 to week 52), interaction of treatment by moment of time and interaction of strata by moment time, as well as the continuous fixed covariates of the baseline LDL-C value and the interaction of baseline value by moment of time. This model provided mean least squares estimates adjusted to baseline (mean by MC) at week 24 for both treatment groups with their corresponding 95% confidence interval. To compare the alirocumab group with the ezetimibe group, an appropriate statement was used to test for differences in these estimates at the 5% alpha level.

A hierarchical procedure has been defined to test the key secondary endpoints while controlling for multiplicity (using the previous order of the key secondary endpoints). The first key secondary endpoint was the percent change in LDL-C calculated from baseline to week 24 using an on-treatment approach.

Continuous secondary variables that were anticipated to have a normal distribution (ie lipids other than TG and Lp (a)) were analyzed using the same MMRM model as for the primary endpoint. Continuous endpoints that were anticipated to have a non-normal distribution (i.e. TG and Lp (a)) were analyzed using the multiple imputation approach for manipulating missing values, followed by the robust endpoint regression model. of interest as a response variable using the estimation of M (using the SAS ROBUSTREG procedure) with treatment group, randomization strata (according to IVRS) and corresponding baseline value (s) as effects to compare the effects of the treatment. Estimates were provided combined for the mean in both treatment groups, as well as the differences in these estimates, with their corresponding SE, 95% CI, and p-value (using the SAS MIANALYZE procedure).

Binary endpoints of secondary efficacy were analyzed using the multiple imputation approach for handling missing values, followed by stratified logistic regression with treatment group as the main effect and corresponding baseline value (s). as a covariate, stratified by randomization factors (according to IVRS). Pooled estimates of relative chance versus ezetimibe, 95% CI, and p-value (using SAS MIANALYZE procedure) were provided.

Combo II: Security Analysis

The safety analyzes were descriptive, they were carried out in the safety population according to the treatment actually received. For the TEAE and PCSA analysis, the safety analysis focused on the TEAE period defined as the time from the first dose of double-blind IMP administration (capsule or injection, whichever occurs first) to 70 days after administration. last double-blind injection. Analyzes of laboratory results and vital signs were performed over time in the period up to 21 days after the last IMP injection. COMBO II: RESULTS

Liability of patients

Of the 720 randomized patients, all patients were treated and therefore included in the safety population.

Thirteen of the randomized patients (12 in the alirocumab group and 1 in the ezetimibe group) were not included in the ITT population (non-LDL-C value within one of the analysis windows up to week 24).

Twenty-one of the randomized patients were excluded from the ITTm population (patients excluded from the ITT population and patients with no LDL-C value within one of the analysis windows up to week 24 during the treatment efficacy period).

In the alirocumab group, among the 446 patients who received at least one injection after week 12, 82 (18.4%) patients received upward automatic dose titration at week 12 from alirocumab 75 mg every 2 weeks to 150 mg every 2 weeks in a blinded mode.

Table 14 - Analysis populations

Combo II: Study layout

Study distribution, exposure, and safety analysis were assessed using all data up to the common study cutoff date (defined as the date of the patient's last 52 week visit). Therefore, this analysis of the first stage includes data beyond week 52 for some patients. The results presented in this document are from this first stage analysis, and include efficacy data up to week 52, safety data up to week 52-102 (including all data collected up to the patient's last visit in SEM52). .

None of the randomized patients completed the 104-week double-blind study treatment period and 612 (85.0%) randomized patients (N = 406 in the alirocumab group and N = 206 in the ezetimibe group) were on treatment. at the time of the first stage analysis deadline.

Double-blind IMP was discontinued prematurely before week 104 for 73 (15.2%) randomized patients in the alirocumab group (including 71 patients who discontinued before week 52) and 35 (14.5%) patients randomized to the ezetimibe group (including 33 patients who discontinued before week 52).

The main reasons for discontinuation of study treatment were adverse events and other reasons. The category "others" represented the most frequently reported and included the following: the patient did not meet the inclusion / exclusion criteria of the protocol (3 patients), withdrawal of the subject for personal reasons (14 patients), sudden death / death (5 patients ) (there was no investigator decision to stop treatment before death), lost of sight to follow-up (1 patient). In this first stage analysis, final results are available for the primary efficacy endpoint at week 24 and the secondary key efficacy endpoints assessed at week 12, week 24, and week 52. At week 24 Week 24, the primary efficacy endpoint was available for 428 (91.6%) in the alirocumab groups and 221 (92.1%) in the ezetimibe groups. At week 52, the primary efficacy endpoint was available for 414 (88.7%) in the alirocumab groups and 211 (87.9%) in the ezetimibe groups.

The primary endpoint was absent for 58 patients (39 patients (8.4%) in the alirocumab groups and 19 patients (7.9%) in the ezetimibe groups). At the 24 week visit, the reasons for the absence were as follows: 29 samples were not collected due to premature discontinuation of the study; 8 samples were taken outside the analysis window time; 9 samples absent during the 24 week visit; 12 samples were taken but the measurement could not be made (lipemia, insufficient amount, TG> 400 mg / dL [> 4.52 mmol / L], loss of sample).

COMBO II: Demographic and Baseline Characteristics

Demographic characteristics, disease characteristics, and lipid parameters at baseline were generally similar in the alirocumab group compared to the ezetimibe group. For the alirocumab group (N = 479), the age (mean age (SD)) was 61.7 (9.4), the percentage of males was 75.2% (N = 360), the percentage of white race was 84.3% (N = 404), the percentage of black or African American race was 4.4% (N = 21), the percentage of other races was 11.3% (N = 54) and the iMc (mean kg / m2 (SD)) was 30.0 (5.4). For the ezetimibe group (N = 241), the age (mean age (Sd)) was 61.3 (9.2), the percentage of males was 70.5% (N = 170), the percentage of white race was 85.5% (N = 206), the percentage of black or African American was 2.9% (N = 7), the percentage of other races was 11.6% (N = 28) and the BMI (mean kg / m2 (SD)) was 30.3 (5.1).

The baseline characteristics of the alirocumab and ezetimibe groups are shown in Tables 15-19. Mean baseline LDL-C (SD) was 107.3 (35.7) mg / dL (2.778 (0.926) mmol / L). HbA1c (mean (SD),%) was 6.05 (0.75) for the alirocumab group and 6.07 (0.77) for the ezetimibe group. Approximately 90% of the randomized population had a history of CHD (that is, at least one of the 5 subcategories below for CHD) and the remaining patients had CHD risk equivalents (Table 16), except for 2 patients, in the alirocumab group, who had no fully documented CHD or CHD risk equivalents. Globally, 30% had a history of diabetes. All patients except one were treated with a statin, receiving 66.7% high intensity statin (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily) and 2.1% receiving simvastatin 80 mg up to date.

In summary, 1112 high cardiovascular risk patients were selected, 720 of whom were eligible and wished to participate in the study. Of these, 479 were randomized to alirocumab and 241 to ezetimibe. The mean age (SD) was 61.6 (9.3) years, 73.6% of the participants were men, 90.1% had coronary heart disease, 30.7% had type 2 diabetes, Mean baseline calculated LDL-C concentration (SD) was 107.3 (35.7) mg / dL and 66.7% were taking high-intensity statin therapy (i.e., atorvastatin 40/80 mg / day or rosuvastatin 20 / 40 mg / day). Fifteen patients were taking simvastatin 80 mg. Baseline characteristics were balanced between the two groups.

Table 15 - Characteristics of the disease and other relevant baseline data - Randomized population Alirocumab 75

Ezetimibe 10 every 2 weeks / up to 150 every 2 weeks All (N = 241) (N = 479) (N = 720) Time since diagnosis of the

hypercholesterolemia (years)

Number 240 479 719 Mean (SD) 8.81 (7.62) 9.43 (7.23) 9.22 (7.36) Median 7.48 7.89 7.85

Min: Max 0.1: 53.9 0.1: 46.8 0.1: 53.9

Fredrickson's classification of

hyperlipoproteinemia

Number 185 369 554

IIa 113 (46.9%) 232 (48.4%) 345 (47.9%) I Ib 72 (29.9%) 137 (28.6%) 209 (29.0%) IV 0 0 0

Table 16 - Medical history of specific interest: cardiovascular history and risk factors -Randomized population

Alirocumab 75

Ezetimibe 10 every 2 weeks / up to 150 All (N = 241) every 2 weeks (N = 479) (N = 720) Any cardiovascular history / risk factors 241 (100%) 477 (99.6%) 718

(99.7%)

Coronary heart disease a 212 (88.0%) 437 (91.2%) 649

(90.1%) Acute myocardial infarction 139 (57.7%) 277 (57.8%) 416

(57.8%) Silent myocardial infarction 4 (1.7%) 11 (2.3%) 15

(2.1%) Unstable angina 46 (19.1%) 106 (22.1%) 152

(21.1%) Coronary revascularization procedures 165 (68.5%) 330 (68.9%) 495

(68.8%) Other clinically significant CCT b 82 (34.0%) 184 (38.4%) 266

(36.9%) CHD associated with 1 or more associated disease (among 178 (73.9%) 366 (76.4%) 544 moderate hypertension, diabetes or CKD) and / or associated with (75.6%) other CVD (ischemic stroke, PAD)

Coronary heart disease risk equivalents 72 (29.9%) 151 (31.5%) 223 a (31.0%) Ischemic stroke 20 (8.3%) 40 (8.4%) 60

(8.3%) Peripheral arterial disease 11 (4.6%) 24 (5.0%) 35

(4.9%) Moderate chronic kidney disease 23 (9.5%) 61 (12.7%) 84

(11.7%) Unknown history of diabetes mellitus AND 2 or 31 (12.9%) 59 (12.3%) 90 plus additional risk factors (12.5%) At least 2 CHD risk equivalents or 1 equivalent 67 (27.8%) 141 (29.4%) 208 risk of CHD associated with hypertension or diabetes (28.9%) Note: A patient can be counted in several categories.

a according to the points previously listed in the e-CRF.

b diagnosed by invasive or non-invasive tests.

PAD defined as intermittent claudication TOGETHER WITH ankle-brachial index <0.90 or TOGETHER with peripheral revascularization procedure / surgery or critical limb ischemia TOGETHER WITH peripheral revascularization procedure / surgery or thrombolysis.

Table 17 - Medical history of specific interest: other medical history of special interest -Randomized population

Ezetimibe 10 Alirocumab 75 All (N = 241) every 2 weeks / up to 150 every 2 weeks (N = 720)

(N = 479)

Other medical history of special interest 219 (90.9%) 424 (88.5%) 643 (89.3%) Hypertension a 198 (82.2%) 382 (79.7%) 580 (80.6%) Type 1 to 0 diabetes 2 (0.4%) 2 (0.3%) Type 2 to 76 diabetes (31.5%) 145 (30.3%) 221 (30.7%) Family history of disease 59 (24.5%) 94 (19.6%) 153 premature coronary heart a (21.3%) Family history of type 2 diabetes a 38 (15.8%) 60 (12.5%) 98 (13 , 6%) Menopause (women) a 65 (27.0%) 106 (22.1%) 171 (23.8%) according to the points previously listed in the e-CRF.

Note: A patient can be counted in several categories.

Table 18 - Previous TML at Randomization - Randomized Population

Ezetimibe 10 Alirocumab 75 All (N = 241) every 2 weeks / up to 150 every 2 weeks (N = 720)

(N = 479)

Any statin 241 (100%) 478 (99.8%) 719 (99.9%)

Taking high intensity statin 160 (66.4%) 320 (66.8%) 480 (66.7%) Daily dose of atorvastatin (mg) 118 (49.0%) 237 (49.5%) 355 (49 ,3 %)

10 6 (2.5%) 5 (1.0%) 11 (1.5%)

20 11 (4.6%) 26 (5.4%) 37 (5.1%)

40 55 (22.8%) 115 (24.0%) 170 (23.6%)

80 46 (19.1%) 90 (18.8%) 136 (18.9%)

Other doses 0 1 (0.2%) 1 (0.1%) Rosuvastatin daily dose (mg) 75 (31.1%) 137 (28.6%) 212 (29.4%)

5 2 (0.8%) 9 (1.9%) 11 (1.5%)

10 14 (5.8%) 12 (2.5%) 26 (3.6%)

20 41 (17.0%) 80 (16.7%) 121 (16.8%)

40 17 (7.1%) 34 (7.1%) 51 (7.1%)

Other doses 1 (0.4%) 2 (0.4%) 3 (0.4%) Simvastatin daily dose (mg) 49 (20.3%) 105 (21.9%) 154 (21.4% )

10 4 (1.7%) 5 (1.0%) 9 (1.3%)

20 16 (6.6%) 28 (5.8%) 44 (6.1%)

40 22 (9.1%) 61 (12.7%) 83 (11.5%)

80 5 (2.1%) 10 (2.1%) 15 (2.1%)

Other doses 2 (0.8%) 1 (0.2%) 3 (0.4%)

Any TML other than statins3 12 (5.0%) 29 (6.1%) 41 (5.7%) Any TML other than nutraceuticals 4 (1.7%) 13 (2.7%) 17 (2.4 %) Nutraceuticals 8 (3.3%) 16 (3.3%) 24 (3.3%) a in combination with statins or not.

High intensity statin corresponds to atorvastatin 40 to 80 mg per day or rosuvastatin 20 to 40 mg per day.

Table 19 - Baseline Lipid Efficacy Parameters - Quantitative Summary in Conventional Units - Randomized Population

Ezetimibe 10 Alirocumab 75 q / 2 wk / until All (N = 241) 150 q / 2 w (N = 479) (N = 720) Calculated LDL-C (mg / dL)

Number 241 479 720 Mean (SD) 104.6 (34.1) 108.6 (36.5) 107.3 (35.7) Median 98.0 100.0 99.0

Q1: Q3 81.0: 122.0 83.0: 126.0 83.0: 124.0

Min: Max 38: 243 22: 303 22: 303

LDL-C measured (mg / dL)

Number 213 429 642 Mean (SD) 101.1 (35.0) 103.8 (34.8) 102.9 (34.9) Median 93.0 96.0 95.0

Q1: Q3 75.0: 118.0 79.0: 120.0 78.0: 119.0

Min: Max 47: 237 26: 284 26: 284

No HDL-C (mg / dL)

Number 241 479 720 Mean (SD) 136.8 (40.4) 139.1 (40.4) 138.3 (40.4) Median 128.0 129.0 128.0

Q1: Q3 109.0: 154.0 110.0: 161.0 110.0: 158.0

Min: Max 65: 317 61: 322 61: 322

Total C (mg / dL)

Number 241 479 720 Mean (SD) 183.9 (41.8) 186.5 (41.2) 185.6 (41.4) Median 175.0 178.0 177.0

Q1: Q3 156.0: 201.0 159.0: 209.0 157.0: 206.5

Min: Max 117: 347 90: 411 90: 411

HDL-C (mg / dL)

Number 241 479 720 Mean (SD) 47.2 (13.5) 47.4 (13.3) 47.3 (13.4) Median 44.0 45.0 45.0

Q1: Q3 37.0: 56.0 38.0: 54.0 38.0: 54.0 Ezetimibe 10 Alirocumab 75 every 2 weeks / until All (N = 241) 150 every 2 weeks (N = 479) (N = 720) Min: Max 21: 112 16: 117 16: 117

Fasting TG (mg / dL)

Number 241 479 720 Mean (SD) 159.2 (77.5) 153.9 (77.0) 155.7 (77.1) Median 141.0 133.0 137.0

Q1: Q3 106.0: 198.0 98.0: 193.0 100.0: 195.0

Min: Max 47: 456 46: 532 46: 532

Lipoprotein- (a) (mg / dL)

Number 234 470 704 Mean (SD) 40.5 (45.0) 45.2 (46.3) 43.6 (45.9) Median 23.0 28.0 25.0

Q1: Q3 8.0: 56.0 8.0: 70.0 8.0: 66.0

Min: Max 2: 233 2: 245 2: 245

Apo-B (mg / dL)

Number 234 470 704 Mean (SD) 93.5 (23.1) 94.3 (23.2) 94.0 (23.1) Median 89.0 90.0 90.0

Q1: Q3 78.0: 105.0 78.0: 108.0 78.0: 107.0

Min: Max 43: 193 45: 180 43: 193

Apo-A1 (mg / dL)

Number 234 470 704 Mean (SD) 140.2 (25.5) 140.7 (23.6) 140.5 (24.2) Median 137.0 139.0 139.0

Q1: Q3 121.0: 159.0 124.0: 155.0 123.0: 156.0

Min: Max 87: 248 89: 237 87: 248

Apo-B / Apo-A1 (ratio)

Number 234 470 704 Mean (SD) 0.688 (0.213) 0.689 (0.206) 0.689 (0.208) Median 0.650 0.660 0.655 Ezetimibe 10 Alirocumab 75 every 2 weeks / up to All (N = 241) 150 every 2 weeks (N = 479) (N = 720)

Q1: Q3 0.540: 0.790 0.540: 0.810 0.540: 0.800

Min: Max 0.33: 1.65 0.30: 1.79 0.30: 1.79

Total C / HDL-C (ratio)

Number 241 479 720

Mean (SD) 4,155 (1,436) 4,188 (1,342) 4,177 (1,373)

Median 3,864 3,914 3,902

Q1: Q3 3,228: 4,761 3,254: 4,818 3,249: 4,815

Min: Max 2.10: 11.57 1.87: 9.40 1.87: 11.57

The LDL-C pool measured was not planned in the initial protocol and was added in a modification. Therefore, the measured LDL-C values are available for fewer patients compared to the calculated LDL-C values.

COMBO II: Administration and duration

Exposure to injections (alirocumab or placebo) and capsules (ezetimibe or placebo) was similar in the treatment groups, with a mean exposure of approximately 57 weeks.

In the alirocumab group, among the 446 patients who received at least one injection after week 12, 82 (18.4%) patients received upward automatic dose titration at week 12 from alirocumab 75 mg every 2 weeks to 150 mg every 2 weeks in a blinded mode.

The mean duration (SD) of injection exposures was 58.0 (18.7) weeks (with a mean [SD] of 26.6 [8.8] injections) in the alirocumab group and 57.7 ( 19.0) weeks (26.6 [9.0] injections) in the ezetimibe group. At the time of this analysis, 84.8% of patients in the alirocumab group and 85.5% in the ezetimibe group were on treatment (active or placebo). The dose of eighty-two (18.4%) patients in the alirocumab group was increased at week 12 to the 150 mg twice weekly regimen because their LDL-C at week 8 was> 70 mg / dL.

COMBO II: Primary Efficacy Endpoint

The ITT analysis includes all calculated LDL-C values collected during treatment and without treatment up to week 52. Analysis of the primary endpoint (percent change in calculated LDL-C from baseline to week 52) is provided. 24) based on a model of MMRM in the ITT population, using mean estimates by CM at week 24. Thirty-nine (8.4%) patients in the alirocumab group and 19 (7.9%) patients in the alirocumab group. of ezetimibe did not have a calculated LDL-C value at week 24. The MMRM model accounted for these missing values.

Results of the primary endpoint analysis are presented in Table 20, in mmol / L and mg / dL.

There was a statistically significant decrease in the percentage change in LDL-C from baseline to week 24 in the alirocumab group (mean by MC vs. baseline -50.6%) compared to the ezetimibe group. (mean by MC vs. baseline level -20.7%) (mean difference by MC vs. ezetimibe -29.8%, p <0.0001).

In the alirocumab group, a reduction in LDL-C was observed from baseline from week 4 to week 52 (see Figure 6 and Table 20). The LDL-C reduction was maintained until week 52 in the alirocumab group (mean by MC vs. baseline at week 52 of -49.5% vs. -50.6% at week 24).

Table 20 - Percentage change from baseline in LDL-C calculated at week 24: MMRM - ⁱ T ^t analysis - ITT population and treatment population

ITT POPULATION

Ezetimibe 10 Alirocumab 75 every 2 weeks / up to 150 Calculated LDL cholesterol (N = 240) every 2 weeks (N = 467) Baseline level (mmol / L)

Number 240 467

Mean (SD) 2.706 (0.884) 2.805 (0.946) Median 2.538 2.590

Min: Max 0.98: 6.29 0.57: 7.85

Baseline level (mg / dL)

Number 240 467

Mean (SD) 104.5 (34.1) 108.3 (36.5) Median 98.0 100.0

Min: Max 38: 243 22: 303

Week 24 percentage change from

baseline level (%)

Mean by MC (SE) -20.7 (1.9) -50.6 (1.4) Mean difference by MC (SE) vs -29.8 (2.3) ezetimibe

95% CI (-34.4 to -25.3) P value vs ezetimibe <0.0001 *

Table 21 - LDL-C calculated over time - ITT analysis - ITT population Alirocumab 75 c / 2 weeks / up to 150 c / 2 weeks Ezetimibe 10 (N = 240) (N = 467)

Change Change in Change Change in LDL-C from percentage from from percentage from calculated Baseline value baseline level Baseline value baseline level Mean by MC

(EE) (mmol / L)

Baseline at 2.706 NA NA 2.805 NA NA (0.057) (0.044)

Week 4 2,002 -0.770 -25.3 (1.6) 1.254 -1.518 -54.7 (1.1)

(0.044) (0.044) (0.031) (0.031)

Week 8 2,047 -0.725 -24.3 (1.7) 1.259 -1.512 -54.3 (1.2)

(0.045) (0.045) (0.032) (0.032)

Week 12 2.102 -0.670 -21.8 (1.8) 1.350 -1.422 -51.2 (1.3)

(0.049) (0.049) (0.035) (0.035)

Week 16 2,069 -0,702 -23.0 (1.8) 1,194 -1,578 -56.4 (1.3)

(0.048) (0.048) (0.035) (0.035)

Alirocumab 75 c / 2 weeks / up to 150 c / 2 weeks Ezetimibe 10 (N = 240) (N = 467)

Change Change in Change Change in LDL-C from percentage from from percentage from calculated Baseline value baseline level Baseline level value baseline level

Week 24 2,138 -0,634 -20.7 (1.9) 1,337 -1,435 -50.6 (1.4)

(0.051) (0.051) (0.036) (0.036)

Week 36 2,187 -0,585 -19.3 (2.0) 1,337 -1,434 -51.2 (1.4)

(0.058) (0.058) (0.041) (0.041)

Week 52 2,210 -0.562 -18.3 (2.1) 1.381 -1.390 -49.5 (1.5)

(0.061) (0.061) (0.044) (0.044)

Average per MC

(EE) (mg / dL)

Alirocumab 75 c / 2 weeks / up to 150 c / 2 weeks Ezetimibe 10 (N = 240) (N = 467)

Change Change in Change Change in LDL-C from percentage from from percentage from calculated Baseline value baseline level Baseline level value baseline level

Baseline level at 104.5 NA NA 108.3 NA NA (2.2) (1.7)

Week 4 77.3 -29.7 (1.7) -25.3 (1.6) 48.4 -58.6 (1.2) -54.7 (1.1) (1.7) ( 1,2)

Week 8 79.0 -28.0 (1.7) -24.3 (1.7) 48.6 -58.4 (1.2) -54.3 (1.2) (1.7) ( 1,2)

Week 12 81.1 -25.9 (1.9) -21.8 (1.8) 52.1 -54.9 (1.4) -51.2 (1.3) (1.9) ( 1.4)

Week 16 79.9 -27.1 (1.9) -23.0 (1.8) 46.1 -60.9 (1.3) -56.4 (1.3) (1.9) ( 1.3)

Week 24 82.5 -24.5 (2.0) -20.7 (1.9) 51.6 -55.4 (1.4) -50.6 (1.4) (2.0) ( 1.4)

Week 36 84.4 -22.6 (2.2) -19.3 (2.0) 51.6 -55.4 (1.6) -51.2 (1.4) (2.2) ( 1.6)

Week 52 85.3 -21.7 (2.4) -18.3 (2.1) 53.3 -53.7 (1.7) -49.5 (1.5) (2.4) ( 1.7)

a The baseline level is described using means and standard errors.

Note: Least squares means (LC), standard errors (SE) and p-value taken from MMRM analysis (mixed effects model with repeated measures). The model includes fixed categorical effects of treatment group, randomization strata according to IVRS, moment of time, interaction of treatment by moment of time, interaction of strata by moment of time, as well as the continuous fixed covariates of the LDL-C value. baseline and the interaction of the baseline LDL-C value by moment of time

MMRM model and baseline description performed in patients with a baseline value and a post-baseline value in at least one of the analysis windows used in the model.

COMBO II: Secondary Key Efficacy Endpoints and Additional Analyzes

The following table summarizes the results of the analysis on the key secondary endpoints in the hierarchical order. All key secondary endpoints are statistically significant by hierarchical testing procedure up to and including the HDL-C endpoint at week 24 (ITT estimate) included.

Statistical significance for fasting TG was not reached at week 24 (estimating from ITT) and thus the test procedure was stopped, p-values are only provided from this endpoint for descriptive purposes.

Table 22

Endpoint Analysis Results Results p-value

Calculated LDL-C - Change in During the Mean Difference by MC Mean difference by <0.0001 percentage from baseline treatment vs ezetimibe de - MC vs level up to week 24 30.6% baseline of - 52.4 %

Calculated LDL-C - Change in ITT Mean difference by MC Mean difference by <0.0001 percent from baseline vs ezetimibe de - MC vs level up to week 24, 29.7% baseline method of - 47, 7% beta quantification

Calculated LDL-C - Change in ITT Mean difference by MC Mean difference by <0.0001 percent from baseline vs ezetimibe of - MC vs level up to week 12 29.4% baseline of -51.2%

Calculated LDL-C - Change in During the Mean Difference by MC Mean difference by <0.0001 percentage from baseline treatment vs ezetimibe de - MC vs level up to week 12 29.7% baseline of -52.4

Apo-B - Change in ITT percentage Mean difference by MC Mean difference by <0.0001 from baseline to forehead to ezetimibe de - MC vs. week 24 level 22.4% baseline of -40.7

Apo-B - Percentage change During the Mean difference by MC Mean difference by <0.0001 from baseline to treatment vs ezetimibe de - MC vs week 24 level 23% baseline of -42.1

No HDL-C - Change in ITT Mean difference by MC Mean difference by <0.0001 percentage from baseline vs ezetimibe de - MC vs level up to week 24 22.9% baseline of -42.1

No HDL-C - Change in the During the Mean difference by MC Mean difference by <0.0001 percentage from baseline treatment vs ezetimibe de - MC vs level until week 24 23.5% baseline of -43.7

Total C - Change in ITT percentage Mean difference by MC Mean difference by <0.0001 from baseline to forehead to ezetimibe from - MC vs. week 24 level 14.7% baseline of -29.3

Apo-B - Change in ITT percentage Mean difference by MC Mean difference by <0.0001 from baseline to forehead to ezetimibe de - MC vs. week 12 level 22.5% baseline of -39.7

No HDL-C - Change in ITT Mean difference by MC Mean difference by <0.0001 percentage from baseline vs. ezetimibe de - MC vs. level up to week 12 22% baseline of -42.6

Total C - Change in ITT percentage Mean difference by MC Mean difference by <0.0001 from baseline to face-to-face to ezetimibe from - MC to week 12 level 14.3% baseline of -29.4

Calculated LDL-C - Change in ITT Mean difference by MC Mean difference by <0.0001 percent from baseline vs ezetimibe of - MC vs level up to week 52 31.2% baseline of -49.5

Proportion of Patients Who Estimated Combined ITT for <0.0001 Achieve LDL-C Calculated Relative Chance

<70 mg / dL (1.81 mmol / L) in the face to ezetimibe of 5.4

week 24

Endpoint Analysis Results Results p-value

Proportion of patients who during the combined estimate for <0.0001 reach calculated LDL-C treatment the relative opportunity

<70 mg / dL (1.81 mmol / L) in the face to ezetimibe of 5.9

week 24

Lp (a) - Change in ITT percentage Combined estimate for Mean difference by <0.0001 from baseline to the mean difference MC vs week 24 adjusted vs baseline of -27.8

-21.7% ezetimibe

HDL-C - Change in ITT percentage Mean difference by MC Mean difference by <0.0001 from baseline to MC ezetimibe vs. week 24 level 8.1% baseline of _ + 8.6

Fasting TG - Change in ITT Combined estimate for 0.9117 percent from baseline mean difference

up to week 24 adjusted against

ezetimibe of -0.3%

Apolipoprotein A-1 ITT Mean difference by MC Mean difference by <0.0001 vs ezetimibe from MC vs MC level

6.3% baseline of 5.0

The analysis during treatment of the change in the percentage of LDL-C from baseline to week 24 shows results very consistent with the ITT analysis (mean difference by MC vs ezetimibe of -30.6% in the analysis during treatment vs -29.8% in ITT analysis).

The following key secondary endpoints including Apo B, no HDL-C, Total C, Lp (a), HDL-C at various time points, as well as the proportion of patients reaching their LDL-C goals on the week 24, were statistically significant according to the hierarchical test procedure.

Most of the high cardiovascular risk patients who received alirocumab with prior statin achieved their LDL-C goal. The proportion of patients achieving calculated LDL-C <70 mg / dL (1.81 mmol / L) at week 24 was significantly higher in the alirocumab group than in the ezetimibe group (pooled estimate for ratio of 77, 0% in the alirocumab group vs 45.6% in the ezetimibe group, p <0.0001).

The difference in percentage change in fasting TG from baseline to week 24 in the ITT analysis was not statistically significant. The mean by CM versus baseline was -13.0% in the alirocumab group and -12.8% in the ezetimibe group (mean difference by CM versus ezetimibe of - 0.3%, p = 0.9117 ).

One hundred and five (22.8%) patients presented two consecutive values of calculated LDL-C <25 mg / dL. No particular safety concern has been observed in these 105 patients.

Table 23 - Number (%) of patients with 2 LDL-C in a row <25 mg / dL (<0.65 mmol / L) during the treatment period - Safety population

Ezetimibe 10 Alirocumab 75 (N = 241) every 2 weeks / up to 150 every 2 weeks (N = 479)

Patients with 2 consecutive values of calculated LDL-C <25 mg / dL 1 0/230 105/460 (22.8%)

Time to first calculated LDL-C value <25 mg / dL

(weeks) 2

Number 0 105

Mean (SD) 12.56 (12.31)

Median 5.14

Ezetimibe 10 Alirocumab 75

(N = 241) every 2 weeks / up to 150 every 2 weeks (N = 479)

Min: Max 3.1: 64.1

Patients with 2 consecutive values of calculated LDL-C <15 mg / dL 1 0/230 31/460 (6.7%)

Time to first calculated LDL-C value <15 mg / dL

(weeks) 2

Number 0 31

Mean (SD) 15.07 (13.15)

Median 9.14

Min: Max 3.1: 52.1

The number (n) represents the subset of the total number of patients who met the criteria

The denominator (/ N) within a treatment group is the number of patients for the treatment group who had at least two calculated LDL-C values evaluated at least 21 days apart in the efficacy period.

12 values are considered in a row if they are separated by at least 21 days

2 First calculated LDL-C value <25 or <15 mg / dL among the first 2 values in a row of calculated LDL-C <25 or <15 mg / dL per patient

Table 24 - Percentage change from baseline to week 24 in LDL-C and secondary lipid parameters (analysis during treatment)

COMBO II: Summary of efficacy results

At week 24, the percentage change from baseline in LDL-C calculated in the ITT population was significantly greater in the alirocumab group (mean by MC vs. baseline -50.6%) compared to the group of ezetimibe (mean by MC vs. baseline level -20.7%) (mean difference by MC vs. ezetimibe of -29.8%, p <0.0001) (Table 20). The analysis during treatment of the change in the percentage of LDL-C from baseline to week 24 shows results consistent with the ITT analysis with a mean difference by MC vs ezetimibe of -30.6% in the analysis during treatment (p <0.0001) (Table 24).

The time course of changes in LDL-C concentrations in the alirocumab and ezetimibe groups from baseline to 52 weeks is shown in Figure 6. Mean LDL-C concentrations decreased rapidly in the first 4 weeks. , but to a greater degree in the alirocumab group. In the alirocumab group, the LDL-C reduction from baseline was observed from week 4 and was maintained until week 52 (mean by MC vs. baseline at week 52 of -49.5% vs. - 50.6% at week 24) (Table 21).

The distribution of baseline and achieved LDL-C values at 24 weeks is shown in Figure 7. The median was 40 mg / dL for alirocumab compared to and 70 mg / dL for ezetimibe. Mean LDL-C reached at week 24 was 51.6 (1.4) mg / dL with alirocumab and 82.5 (2.0) mg / dL with ezetimibe; these differences were maintained until week 52.

The temporal evolution of the changes in LDL-C concentrations according to the dose increase status in the alirocumab group is shown in Figure 8. Only 18% percent of the patients in the alirocumab group had an increase of the dose up to 150 mg SC every 2 weeks. These patients had much higher baseline LDL-C values compared to patients who did not require a dose increase (140.4 [47.4] mg / dL vs 101.1 [29.7] mg / dL), and the percentage of reductions in LDL-C achieved at weeks 12 and 24 was lower. The dose increase at 12 weeks led to a further reduction of 12.4%. Furthermore, the absolute reduction in LDL-C by week 24 was slightly greater in the dose escalation group (63.5 vs 56.9 mg / dL) compared to the rest of the alirocumab group.

For key secondary efficacy endpoints, statistically significant reductions were observed for Apo B (22.4%), Lp (a) (21.7%), and non-HDL-C (22.9%) (all p <0.0001), and there was an 8.1% increase in HDL-C at week 24 in the alirocumab group compared with ezetimibe (p <0.0001) (Table 22). The statistically significant difference was not reached with fasting TG at week 24 (decreased from baseline by 13.5% in the alirocumab group and 13.3% in the ezetimibe group) and therefore the test procedure for this endpoint. The efficacy of alirocumab versus ezetimibe was consistent across several subgroups in the ITT population (Figure 9). In Table 22, the beta quantification method for determining the percent change in LDL-C from baseline to week 24 was a sensitivity analysis performed on 180 patients in the ezetimibe group and 361 patients in the ezetimibe group. alirocumab.

COMBO II: Summary of Safety Results

Treatment emergent adverse event (TEAE) rates are shown in Table 25 relative to a mean of 58 (19) weeks of follow-up. The total percentage of patients who had at least one TEAE was 71.2% in the alirocumab group and 67.2% in the ezetimibe group. A TEAE occurred leading to death in 2 (0.4%) patients in the alirocumab group (both of cardiac origin) and in 4 (1.7%) patients in the ezetimibe group (two of cardiac origin). Percentages of similar subjects in both groups had a serious adverse event (18.8% for alirocumab vs 17.8% for ezetimibe). A higher proportion of patients in the alirocumab group had TEAE that led to treatment discontinuation (7.5% vs 5.4%), with no specific pattern at the preferred term level (Table 25).

There was no indication of imbalance in TEAE at the organ system class level, with the exception of slightly higher rates with alirocumab for infections and infestations (27.1% vs 25.3% for ezetimibe), musculoskeletal disorders, and connective tissue (19.6% vs. 17.0%) and gastrointestinal disorders (15.0% vs. 13.7%) (Table 25). Awarded cardiovascular events were also more frequent in the alirocumab group (4.8%, n = 23; vs 3.7%, n = 9) due to higher rates of non-fatal myocardial infarctions and coronary revascularizations.

Treatment-emergent local injection site reaction rates appeared slightly higher in the alirocumab group (2.5% vs 0.8% for ezetimibe) (Table 25). The reactions were mild in intensity, except for one of moderate intensity, and none were severe. Two events led to discontinuation in the alirocumab group. A low percentage of patients in both groups developed myalgia.

Laboratory abnormalities were rare and occurred at similar rates in both groups, with the exception of alanine aminotransferase and aspartate aminotransferase, which were more common in the alirocumab group, and impaired glucose control, which was less common. in the alirocumab group (Table 25).

One hundred five (22.8% of 460) patients in the alirocumab group and none in the ezetimibe group had two consecutive LDL-C values of <25 mg / dL during the treatment period. The rates of TEAE in this group were similar to those in the ezetimibe group, with the exception of nasopharyngitis, which was more frequent in the alirocumab group (Table 25).

Table 25 - TEAE and laboratory parameters (safety population) at 52 weeks by system and organ class and preferred term (including those occurring in patients with two LDL-C values <25 mg / dL of alirocumab treatment)

COMBO II: Overall Results

In this population of high CV-risk patients who had poorly controlled LDL-C on maximally tolerated statin therapy, the following observations were made: 1) Self-administered alirocumab produced significantly greater LDL-C reductions than ezetimibe after 24 weeks ( mean difference by MC -29.8%); 2) self-administered alirocumab had good compliance and was well tolerated; 3) 77% of patients with alirocumab reached the LDL-C goal of <0.81 mmol / L (70 mg / dL) at week 24; LDL-C reductions of -50% versus baseline were maintained until week 52 with alirocumab; 4) mean LDL-C levels of 1.4 mmol / L (53.3 mg / dL) were reached at week 52 with alirocumab; 5) approximately 80% of the patients did not require an upward adjustment of the dose until alirocumab 150 mg every 2 weeks, which suggests that 75 mg every 2 weeks may be sufficient for the majority of patients; and 6) TEAEs occurred at a similar frequency in the alirocumab and ezetimibe groups.

Example 3: The long-term safety and tolerability of alirocumab in high-risk cardiovascular patients with hypercholesterolemia who are not sufficiently controlled with their lipid-modifying therapy: a randomized, double-blind, placebo-controlled study

INTRODUCTION

This study was conducted to evaluate the long-term safety and tolerability of alirocumab in high cardiovascular risk patients who are not on target for LDL-C. This non-target LDL-C population with optimized TML represents the highest risk group with a well-identified unmet medical need that can be treated by adding alirocumab to their LDL-C modifying therapy. Two sets of results are reported: (1) a pre-specified interim analysis was performed when all patients reached one year and approximately 25 percent of patients reached 18 months of treatment; and (2) the final analysis of the safety population, when all patients completed the study.

OBJECTIVES OF THE STUDY

The main objective of the study was to evaluate the long-term safety and tolerability of alirocumab in high cardiovascular risk patients with hypercholesterolemia who are not sufficiently controlled with their lipid modifying therapy.

The secondary objectives of the study were: 1) to evaluate the effect of alirocumab on low-density lipoprotein cholesterol (LDL-C) levels after 24 weeks of treatment compared to placebo; 2) evaluate the efficacy of alirocumab on LDL-C levels at other moments of time; 3) evaluate the effect of alirocumab on apolipoprotein B (Apo B), non-high-density lipoprotein cholesterol (not HDL-C), total cholesterol (total C), lipoprotein a (Lp [a]), lipoprotein cholesterol high density (HDL-C), triglyceride (TG) and apolipoprotein A-1 (Apo A-1) levels after 24 weeks of treatment and at other time points compared to placebo; 4) evaluate the development of anti-alirocumab antibodies; and 5) evaluate the pharmacokinetics (PK) of alirocumab.

STUDY DESIGN

This was a randomized, double-blind, placebo-controlled, unbalanced (2: 1, alirocumab: placebo), parallel-group, multicenter, multinational study that evaluated the long-term safety and tolerability of alirocumab in high-risk patients. cardiovascular disease with hypercholesterolemia that were not sufficiently controlled with maximum daily recorded tolerated dose of a statin with or without other lipid modifying therapy. See Figure 10. Patients were stratified by heFH population, history of MI or ischemic stroke, statin treatment, and geographic region. High cardiovascular risk patients were defined as 1) who have heHF (which may or may not have CHD / CHD risk equivalents) or 2) not before the diagnosis of heHF but who have hypercholesterolaemia together with established CHD or equivalent of CHD risk. Patients must be hypercholesterolemic and sufficiently controlled (ie, LDL-C> 70 mg / dL [> 1.81 mmol / L]) despite therapy with the maximum daily tolerated dose of a statin with or without other therapy. lipid modifier at a stable dose for at least 4 weeks (6 weeks for fenofibrate) before selection.

Protocol description

Patients randomized to alirocumab received 150 mg every 2 weeks. The treatment schedule could be adjusted, if necessary, during the course of the study, by modifying the protocol, to introduce a lower dose with a dose adjustment schedule.

The study consisted of 3 periods: screening, double-blind treatment, and follow-up. The selection period was up to 3 weeks in length, which included an intermediate visit during which the patient (or other designated person such as spouse, relative, etc.) was taught to self-inject / inject with placebo. Eligibility assessments were conducted to allow for randomization of patients into the study. The double-blind treatment period was a double-blind, randomized study treatment period of 18 months. The first injection during the double-blind period was made at the site on the day of randomization and as soon as possible after randomization in the study. The patient made subsequent injections (self-injection), or another designated person (such as spouse, relative, etc.) in a location preferred by the patient (home ...). The follow-up period was a period of 8 weeks after the end of the double-blind treatment period.

Patients who achieved 2 levels in a row of calculated LDL-C <25 mg / dL (0.65 mmol / L) during the study were monitored and managed.

Statin and other lipid-modifying therapy (if applicable) should be stable (including dose) for the first 24 weeks of the double-blind treatment period, except in exceptional circumstances where major concerns (including, but not limited to) a, the triglyceride alert registered by the central laboratory) guarantee such changes, at the discretion of the investigator. From week 24 onward, previous lipid modifying therapy could only be modified under certain conditions.

Patients were on a stable diet (NCEP-ATPIII TLC diet or equivalent) for the entire duration of the study from selection. The dietitian or appropriately trained site staff reviewed the patient's diet at the screening visit and periodically throughout the study. Table 26 provides a summary of the TLC diet for high cholesterol.

Table 26

Total fat 25% - 35% of total calories * Saturated fat * <7% of total calories

Polyunsaturated fat up to 10% of total calories Monounsaturated fat up to 20% of total calories Carbohydrates of 50% - 60% of total calories * Protein -15% of total calories Cholesterol <200 mg / day (5,172 mmol / day) Plant sterols 2 g

Soluble fiber such as psyllium 10 g - 25 g

* ATP III allows an increase in total fat up to 35 percent of total calories and a reduction in carbohydrate up to 50 percent for people with metabolic syndrome. Any increase in fat intake should be in the form of either polyunsaturated or monounsaturated fat. Trans fatty acids are another LDL-raising fat that should be kept low.

f Carbohydrate should be derived predominantly from foods rich in complex carbohydrates including grains, especially whole grain fruits, and vegetables.

Patients with cardiovascular events from randomization to the final follow-up visit had an adjudication packet prepared and referred to the independent clinical events committee.

The patients were periodically tested for color vision throughout the study. An ophthalmologic substudy was performed in a subset of the study population.

Duration of study participation

Study duration included up to a 3-week screening period, 18-month double-blind study treatment period, and 8-week follow-up period. Thus, the duration of the study per patient was approximately 20 months. Study end per patient was the last planned protocol visit or resolution / stabilization of all SAEs, and AESI, whichever was the latter. The end of the study was defined as the last visit of the follow-up period for each patient.

PATIENT SELECTION

The study was designed to randomize approximately 2,100 patients in a 2: 1 randomization ratio to the following: Alirocumab - approximately 1,400 patients; placebo - approximately 700 patients.

Patients who fulfilled the following criteria were considered for enrollment in the study: 1) patients with heterozygous familial hypercholesterolaemia (heFH) * with or without established coronary heart disease (CHD) or CHD risk equivalents that are not sufficiently controlled with a dose maximum tolerated daily stable statin ** for at least 4 weeks prior to screening visit (week -3) with or without other lipid modifying therapy (TML); or 2) patients with hypercholesterolaemia and established CHD or CHD risk equivalents (see below for definitions) who are not sufficiently controlled with a stable maximum tolerated daily dose of statin ** for at least 4 weeks prior to screening visit (week -3) with or without other lipid modifying therapy (TML).

* The diagnosis of heFH must be made either by genotyping or by clinical criteria. For non-genotyped patients, clinical diagnosis can be based on either the WHO criteria / Dutch Lipid Clinical Network criteria with a score> 8 points or the Simon Broome registry diagnostic criteria with a defined HF criteria.

** Definition of maximum tolerated dose (any of the following is acceptable): 1) rosuvastatin 20 mg or 40 mg daily; 2) atorvastatin 40 mg or 80 mg daily; 3) simvastatin 80 mg per day (if already on this dose for> 1 year); 4) Patients who are unable to be on any of the above statin doses should be treated with the daily dose of atorvastatin, rosuvastatin, or simvastatin that is deemed appropriate for the patient based on the judgment or concerns of the investigator. Some examples of acceptable reasons for a patient to take a lower statin dose include, but are not limited to: adverse effects with higher doses, older age, low body mass index, regional practices, local prescribing information, medications concurrent, associated conditions such as impaired fasting glucose / glucose intolerance. The reason (s) had to be documented.

A documented history of CHD includes one or more of the following: i) acute myocardial infarction (MI); ii) silent myocardial infarction; iii) unstable angina; iv) coronary revascularization procedure (eg, percutaneous coronary intervention [PCI] or surgery for coronary revascularization [CVR]); and / or v) Clinically significant CHD diagnosed by invasive or non-invasive tests (such as coronary arteriography, stress test using a treadmill, stress echocardiography, or nuclear imaging).

CHD risk equivalents include one or more of the following 4 criteria: i) documented peripheral arterial disease (one of the following criteria must be met [a, b, or c]): current intermittent claudication (lower extremity muscle discomfort which is both reproducible and produced by exercise and relieved by rest for 10 minutes) of presumed atherosclerotic origin together with an ankle-brachial index <0.90 in any leg at rest, or b) a history of intermittent claudication (muscular discomfort in the lower limb that is both reproducible and produced by exercise and relieved by 10-minute rest) in conjunction with endovascular procedure or surgery on one or both legs due to atherosclerotic disease or c) history of critical limb ischemia along with thrombolysis, endovascular procedure or surgical intervention in one or both legs due to atherosclerotic disease; ii) Documented prior ischemic stroke with a focal ischemic neurological deficit that persisted for more than 24 hours, which was considered to be of atherothrombotic origin. CT or MRI must have been performed to rule out hemorrhage and non-ischemic neurological disease; iii) documented moderate chronic kidney disease (CKD) as defined by 30 <eGFR <60 mL / min / 1.73 m2 for 3 months or longer, including screening visit; iv) unknown history of diabetes mellitus AND 2 or more additional risk factors (as listed below): a History of hypertension (established with antihypertensive medication), b documented history of ankle-brachial index <0.90, c documented history of microalbuminuria or macroalbuminuria or dipstick urinalysis at screening visit (week -3) with> 2+ protein, d documented history of pre-proliferative or proliferative retinopathy or laser treatment for retinopathy, e Known family history of premature CHD (ECC in father or brother before 55 years; ECC in mother or sister before 65 years).

According to the diagnostic criteria of the Simon Broome registry for heterozygous familial hypercholesterolemia, defined familial hypercholesterolemia is defined as: total C> 6.7 mmol / L (260 mg / dL) or LDL cholesterol above 4.0 mmol / L ( 155 mg / dL) in a child <16 years or total C> 7.5 mmol / L (290 mg / dL) or LDL cholesterol above 4.9 mmol / L (190 mg / dL) in an adult. (Levels or pre-treatment or highest during treatment) PLUS xanthomas in the tendons in the patient, or in a first-degree relative (parents, siblings, descendants), or in a second-degree relative (grandparents, uncle, aunt ) or DNA-based evidence of a familial defective LDL or apo B-100 receptor mutation.

According to the diagnostic criteria of the Simon Broome registry for heterozygous familial hypercholesterolemia, possible familial hypercholesterolemia is defined as: total C> 6.7 mmol / L (260 mg / dL) or LDL cholesterol above 4.0 mmol / L ( 155 mg / dL) in a child <16 years or total C> 7.5 mmol / L (290 mg / dL) or LDL cholesterol above 4.9 mmol / L (190 mg / dL) in an adult. (Levels or pre-treatment or highest during treatment) and at least one of the following: Family history of myocardial infarction below 50 years of age in 2nd degree relative or below 60 years of age in 1st degree relative, or family history of elevated cholesterol> 7.5 mmol / L (290 mg / dL) in adult 1st or second degree relatives or> 6.7 mmol / L (260 mg / dL) in offspring or sibling under 16 years old.

The WHO criteria (Dutch Lipid NetWork clinical criteria) for diagnosing heterozygous familial hypercholesterolemia (HeFH) are listed in Table 27.

Table 27

Patients who met all of the above inclusion criteria were selected for the following exclusion criteria.

The exclusion criteria related to the study methodology were: 1) No history of established CHD or equivalent risk of CHD or without a diagnosis of heHF based on genotyping or clinical criteria; 2) LDL-C <70 mg / dL (<1.81 mmol / L) at the screening visit (week-3); 3) are not on a stable dose of TML (including statin) for at least 4 weeks and / or fenofibrate for at least 6 weeks, as applicable, prior to the screening visit (week -3) and from screening to screening randomization; 4) currently taking a statin other than simvastatin, atorvastatin, or rosuvastatin; 5) simvastatin, atorvastatin or rosuvastatin is not taken daily or is not taken in a recorded dose; 6) daily doses greater than atorvastatin 80 mg, rosuvastatin 40 mg or simvastatin 40 mg (except for patients taking simvastatin 80 mg for more than one year, who are eligible); 7) Use of fibrates other than fenofibrate 6 weeks before the screening visit (week -3) or between screening and randomization visits; 8) Use of nutraceutical products or over-the-counter therapies that may affect lipids that have not been at a stable dose for at least 4 weeks prior to the screening visit (week -3) or between screening and randomization visits ; 9) use of red yeast rice products within 4 weeks of the screening visit (week -3) or between screening and randomization visits; 10) patient who has received plasmapheresis treatment 2 months before the screening visit (week -3), or plans to receive it; 11) Recent MI (within 3 months before screening visit [week -3] or between screening and randomization visits), unstable angina leading to hospitalization, uncontrolled cardiac arrhythmia, CVR, PCI, carotid surgery or stent implantation, stroke, transient ischemic attack (TIA), endovascular procedure, or surgical intervention for peripheral vascular disease; 12) plans to undergo elective PCI, RVC, carotid or peripheral revascularization during the study; 13) history of New York Heart Association (NYHA) class III or IV heart failure in the past 12 months; 14) systolic blood pressure> 180 mmHg or diastolic blood pressure> 110 mmHg at screening visit or randomization visit; 15) unknown history of hemorrhagic stroke; 16) age <18 years or legal age of majority at the screening visit (week -3), whichever is older; 17) unknown history of active optic nerve disease; 18) patients who have not previously been advised on a lipid-lowering diet before the screening visit (week -3); 19) unknown history of homozygous FH; 20) unknown history of PCSK9 loss of function (ie, genetic mutation or sequence variation); 21) use of systemic corticosteroids, unless used as replacement therapy for pituitary / adrenal disease with a stable regimen for at least 6 weeks prior to randomization. Note: Topical, intra-articular, nasal, inhaled, and ophthalmic steroid therapies are not considered "systemic" and are allowed; 22) use of continuous hormone replacement therapy unless the regimen has been stable in the last 6 weeks prior to the screening visit (week -3) and no regimen change is planned during the study; 23) history of cancer in the last 5 years, except sufficiently treated basal cell skin cancer, squamous cell skin cancer, or cervical cancer in situ; 24) unknown history of HIV positivity; 25) conditions / situations such as: a) Any clinically significant abnormality identified at the time of selection that in the judgment of the investigator or any sub-investigator would rule out safe study completion or limit evaluation of endpoints such as major systemic diseases, patients with a short life expectancy, b) patients considered by the investigator or any sub-investigator as inappropriate for this study for any reason, for example, i) those considered unable to meet the specific requirements of the protocol, such as scheduled visits; ii) those considered incapable of administering or tolerating long-term injections according to the patient or the investigator; iii) investigator or any sub-investigator, pharmacist, study coordinator, other study personnel or relative of the study directly involved in the implementation of the protocol, etc .; iv) presence of any other current or anticipated condition (eg geographic, social ...) that the investigator feels would restrict or limit the patient's participation for the duration of the study; 26) patient who has previously been treated with at least one dose of alirocumab or any other monoclonal anti-PCSK9 antibody in other clinical trials; 27) patient who has taken any investigational drug other than alirocumab placebo training kits within 1 month or 5 half-lives, whichever is longer; 28) patient withdrawing consent during the selection period (patient who does not wish to continue or who stops returning); 29) Laboratory results during the selection period (not including randomization laboratories): A) Positive test for Hepatitis B surface antigen and / or Hepatitis C antibody (confirmed by reflex test), B) Triglycerides (TG)> 400 mg / dL (> 4.52 mmol / L) (1 repeat laboratory allowed); C) positive serum or urine pregnancy test in women of childbearing potential; D) eGFR <30 mL / min / 1.73 m2 according to the 4-variable MDRD equation; E) HbA1c>10%; F) ALT or AST> 3 x ULN (1 repeat lab allowed); G) CPK> 3 x ULN (1 repeat lab is allowed).

Doctors frequently evaluate the stage of heart failure according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to daily activities and the patient's quality of life, as shown in Table 28.

Table 28

Exclusion criteria related to the active comparator and / or mandatory prior therapies were: 30) All contraindications to prior therapies or warning / precaution for use (when appropriate) as presented in the respective national product labeling.

Exclusion criteria related to current knowledge of alirocumab were: 31) Known hypersensitivity to monoclonal antibody therapeutics; 32) pregnant or lactating women; 33) women of childbearing potential who do not use highly effective birth control method (s) and / or who are neither willing nor able to take a pregnancy test. Note: Women of childbearing potential must have a confirmed negative pregnancy test at screening and a urine pregnancy test at the randomization visit. You must use effective contraception throughout the study and agree to repeat the urine pregnancy test at designated visits. The contraceptive methods applied have to meet the criteria for a highly effective method of birth control according to the "Guidance Note on Non-clinical Safety Studies for Human Clinical Trials for Pharmaceutical Products (CPMP / ICH / 286/95 ) ". Postmenopausal women must be amenorrheic for at least 12 months.

STUDY TREATMENTS

The sterile drug (IMP) alirocumab was supplied at a concentration of 150 mg / mL as 1 mL of volume loaded into a syringe. During the double-blind treatment period, alirocumab or placebo was administered subcutaneously as a 1 mL injection every 2 weeks, starting at week 0 and continuing until the last injection (i.e., week 76) which was 2 weeks prior to the end of double-blind treatment period. The IMP should ideally have been administered every two weeks subcutaneously at approximately the same time of day, however, having a window period of ± 3 days was acceptable.

The following drug classes were identified as uninvestigated medications (NIMP) because the medication was either a prior therapy or a possible rescue medication: statins (rosuvastatin, atorvastatin, simvastatin); cholesterol absorption inhibitors (ezetimibe); bile acid binding sequestrants (such as cholestyramine, colestipol, colesevelam); nicotinic acid; fenofibrate; omega-3 fatty acids (> 1000 mg per day).

Patients were randomized to receive either placebo or alirocumab during the treatment period of the double-blind study. The alirocumab: placebo randomization ratio was 2: 1. Randomization was stratified by HeFH population (Yes, No), history of acute or silent MI or ischemic stroke (Yes, No), statin therapy (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily, versus simvastatin whatever the daily dose, atorvastatin less than 40 mg per day or rosuvastatin less than 20 mg per day) and region (North America, Western Europe, Eastern Europe and rest of the world).

A concurrent medication was any treatment received by the patient concurrent with the study (up to the follow-up visit). Concurrent medications had to be kept to a minimum during the study. Without However, if these were considered necessary for the well-being of the patient and unlikely to interfere with IMP, they could be administered at the investigator's discretion, at a stable dose (where possible). In addition to the specific information related to concurrent medications provided in this section, any other concurrent medications will be allowed and will need to be recorded. If the patient had an LDL-C> 160 mg / dL (4.14 mmol / L) at the screening visit (week -3) and was treated with a statin alone, that is, without additional TML, the investigator had to report the reason why the patient was not on a second TML. Nutraceuticals or over-the-counter therapies that could affect lipids were allowed only if they were used at a stable dose for at least 4 weeks prior to the screening visit, during the screening period and were maintained for the first 24 weeks of the screening period. double-blind treatment. After the 24 week visit, modification of these nutraceuticals or over-the-counter therapies was allowed, but should generally be avoided. Examples of such nutraceutical products or OTC therapies included omega-3 fatty acids in doses <1000 mg, plant stanols such as those found in Benecol, flax seed oil, and psyllium.

Patients took the maximum daily recorded tolerated dose of statins with or without other lipid-modifying therapy during the study. From the screening visit (week -3) to the first 24 weeks of the double-blind treatment period (week 24), previous lipid-modifying therapy should not be changed. No dose adjustment, interruption, or initiation of other statins or other lipid-modifying therapy should take place during this time, except in exceptional circumstances where major concerns (including, but not limited to, laboratory-recorded triglyceride alert central) ensure such changes, at the discretion of the researcher.

The following therapies were not allowed during the study (including the screening period until the follow-up visit): fibrates other than fenofibrate; red yeast rice products; and statin other than simvastatin, atorvastatin, or rosuvastatin.

SAFETY ASSESSMENT

Safety was assessed by the following parameters: recording of adverse events (including adjudicated cardiovascular events); routine analytical tests (hematology, chemistry, and urinalysis); liver function tests (ALT, AST, alkaline phosphatase [ALP] and total bilirubin); creatine phosphokinase (CPK); Hepatitis C antibody (if positive, then reflex test confirmed); vitamin E (alpha-tocopherol) and other fat-soluble vitamins; cortisol (with reflex ACTH levels, as needed, followed by ACTH stimulation test, as needed); gonadal hormone evaluations; electrocardiogram (ECG); vital signs (systolic and diastolic blood pressure and heart rate); physical examination (including neurological examination); color vision test (as a screening test for a more comprehensive eye test, as needed). Safety parameters (adverse events [including adjudicated cardiovascular events], laboratory results, vital signs, and ECG) were evaluated throughout the study.

Patients who reach 2 calculated LDL-C in a row <25 mg / dL (0.65 mmol / L) will be monitored.

Antibody samples will be collected from patients who have an anti-alirocumab antibody titer of or above 240 at the follow-up visit 6 to 12 months after the last dose and approximately every 3 to 6 months thereafter. until the title returns below 240.

The safety endpoints evaluated in this trial were: cardiovascular events; allergic events; local tolerability at the injection site; other adverse events (including hemolytic anemia); Laboratory tests: urinalysis, hematology (number of red blood cells, red blood cell distribution width (RDW), reticulocyte count, hemoglobin, hematocrit, platelets, number of leukocytes with leukocyte formula), standard chemistry (sodium, potassium, chloride , bicarbonate, calcium, phosphorus, urea nitrogen, creatinine, uric acid, total protein, albumin, LDH, Y-glutamyl transferase [yGT]), vitamin E (alpha-tocopherol) and other fat-soluble vitamins, cortisol (and reflective ACTH levels , as needed, followed by ACTH stimulation test, as needed), gonadal hormone evaluations, hepatitis C antibody, liver function tests (ALT, AST, ALP, and total bilirubin), and CPK; vital signs including heart rate and blood pressure; and 12-lead ECG.

STUDY PROCEDURES

For all visits after day 1 / week 0 (randomization visit), a time period of a certain number of days was allowed. The window period for visits at weeks 12 and 24 was ± 3 days, at week 52 it was ± 5 days, and for all other site visits it was ± 7 days during the double-blind treatment period, and the follow-up period. A window period of 3 days was allowed for the randomization visit (day 1 / week 0) and ± 7 days were allowed for the screening visit for injection training (week -1). A window period of ± 7 days was allowed for all telephone visits. For all visits after day 1 / randomization visit, if the date of one visit was changed, then the next visit occurred according to the original schedule.

OPHTHALMOLOGICAL SUBSTUDY

Despite evidence that the ocular abnormalities observed during toxicology studies in rats were not due to alirocumab administration, comprehensive ophthalmic evaluations were performed in a subset of patients in the protocol to verify the ophthalmic safety of alirocumab.

The primary objective was to evaluate the clinical ophthalmic safety of alirocumab in high cardiovascular risk patients with hypercholesterolaemia who are not sufficiently controlled with their TML.

Patients underwent ophthalmologic evaluations by ophthalmologists / optometrists in the screening period. If patients were deemed eligible for the main study trial and met additional eligibility criteria for the substudy, then patients underwent ophthalmologic evaluations every 6 months during the 18-month double-blind treatment period.

The primary endpoint was adverse events related to ophthalmologic abnormalities (using SMQ "optic nerve disorders", "retinal disorders" and "corneal disorders") for the duration of the study.

Approximately 270 patients were expected to participate in this substudy. All subjects must meet the eligibility criteria for the main study and the additional eligibility criteria set out for this substudy to be eligible for this substudy.

The only additional inclusion criterion was signed written informed consent.

Additional exclusion criteria for the substudy were: patient who withdrew consent for the ophthalmologic substudy during the selection period (patient who did not wish to continue); patient unable to complete all ophthalmologic evaluations during the screening period; patient with active optic nerve disease (eg optic neuritis) detected during ophthalmologic evaluations in the screening period. Note - The patient with controlled open-angle glaucoma may be eligible for the study; and the patient with active chorioretinal disease detected during ophthalmological evaluations in the screening period.

Statistical methods:

Determination of sample size:

For safety assessment, a sample size of 2,100 patients (randomization ratio 2: 1, i.e. alirocumab: 1,400 and placebo: 700) allows the collection of long-term safety data in a large database (at least 1000 patients exposed to alirocumab for a minimum of 12 months, of which approximately 900 patients were exposed to alirocumab for 18 months).

With this sample size and the following assumptions: duration of recruitment of 16 months, 44% of patients were recruited in the first 9 months and a withdrawal rate of 25% and 35% at 12 months and 18 months, respectively. The expected number of patients exposed to alirocumab for a minimum of 12 months and 18 months of treatment is given below:

Number of patients exposed to alirocumab according to the chronological development of the analysis:

Furthermore, a sample size of 1400 patients treated with alirocumab allows detecting adverse events with a rate> 0.002 with 95% confidence in the alirocumab group. It was anticipated that between 122 and 142 patients exposed to alirocumab would be evaluated in the ophthalmological substudy for at least 12 months considering a sample size of 270 patients and assuming a 25% discontinuation rate for 12 months. This would allow the detection of an ophthalmological event with a true manifestation between 0.021 and 0.024 in the alirocumab group, with 95% confidence.

Chronological development of the analyzes:

The first-stage analysis included the final efficacy endpoints through week 52 (including the primary efficacy endpoint at week 24) and interim safety analysis, which was performed in all safety data up to the common study cutoff date (date when approximately 600 of the randomized patients had completed 18 months of the double-blind treatment period). Analyzes of lipid data beyond week 52 were descriptive. The results are presented in this document.

The second (final) stage analysis will be performed at the end of the study and will consist of the final analysis of efficacy data at time points beyond the time points analyzed in the first stage analysis and safety analysis. final.

Analysis populations:

The primary efficacy analysis population was the intention-to-treat (ITT) population, defined as all randomized patients who had an evaluable primary efficacy endpoint, that is, those with a baseline calculated LDL-C value. available, and at least one calculated LDL-C value available within one of the analysis windows up to week 24 (including all calculated LDL-C during treatment and without treatment).

The secondary efficacy analysis population was the modified intention-to-treat (mITT) population, defined as all randomized patients who took at least one dose or part of a dose of the double-blind investigational medicinal product (IMP) and had a calculated LDL-C value available at baseline and at least one calculated LDL-C value available within one of the analysis windows up to week 24 during the treatment efficacy period. The treatment efficacy period was defined as the time from the first double-blind IMP administration to 21 days after the last double-blind injection.

The safety population included all randomized patients who received at least one dose or part of a dose of the double-blind IMP.

Efficacy analysis:

Key efficacy endpoint analyzes were performed using an ITT approach (based on the ITT population defined above), including all lipid data, regardless of whether the patient continued therapy or not. This corresponds to ITT estimates, defined for primary and secondary key endpoints. In addition, analyzes were also performed using an during treatment approach (based on the ITTm population defined above), which includes lipid data collected during the treatment efficacy period. This corresponds to estimates during treatment of the key secondary endpoints.

The ITT approach analyzed all patients, regardless of their adherence to treatment; assessed the benefit of the treatment strategy and reflected the effect as far as possible in a patient population. The during treatment approach looked at the effect of treatment, restricted to the period during which the patient actually received the treatment. It evaluated the benefit that a treatment would achieve in patients adhering to the treatment until the moment of time considered.

Efficacy analyzes were performed by treatment as randomized.

All measurements, scheduled or unscheduled, fasting or non-fasting, were assigned to analysis windows to provide an assessment for time points from week 4 to week 78.

Regarding the main efficacy analysis (ITT approach), the percentage change in LDL-C calculated from baseline to week 24 was analyzed using a mixed effects model with repeated measures (MMRM) approach. All available post-baseline data from the Week 4 to Week 52 analysis window were used and the MMRM accounted for missing data. The model included the fixed categorical effects of treatment group (placebo vs alirocumab), randomization strata (according to IVRS), moment of time (week 4 to week 52), interaction of treatment by moment of time and interaction of strata by moment time, as well as the continuous fixed covariates of the baseline LDL-C value and the interaction of baseline value by moment of time. This model provided mean least squares estimates adjusted to baseline (mean by MC) at week 24 for both treatment groups with their corresponding SEs and 95% confidence intervals. To compare the alirocumab group with the placebo group, an appropriate contrast statement was used to test for differences in these estimates at the 5% alpha level.

A hierarchical procedure has been defined to test the key secondary endpoints while controlling for multiplicity (using the previous order of the key secondary endpoints). The first key secondary endpoint was the percent change in LDL-C calculated from baseline to week 24 using an on-treatment approach.

Continuous secondary variables that were anticipated to have a normal distribution (ie, lipids other than TG and Lp (a)) were analyzed using the same MMRM model as for the primary endpoint. Continuous endpoints that were anticipated to have a non-normal distribution (i.e. TG and Lp (a)) were analyzed using the multiple imputation approach for manipulating missing values, followed by the robust endpoint regression model. of interest as a response variable using the estimate of M (using the SAS ROBUSTREG procedure) with treatment group, randomization strata (according to IVRS) and corresponding baseline value (s) as effects to compare treatment effects. Pooled estimates were provided for the mean in both treatment groups, as well as the differences in these estimates, with their corresponding SE, 95% CI, and p-value (using the SAS MIANALYZE procedure).

Binary endpoints of secondary efficacy were analyzed using the multiple imputation approach for handling missing values, followed by stratified logistic regression with treatment group as the main effect and corresponding baseline value (s). as a covariate, stratified by randomization factors (according to IVRS). Relative chance estimates versus placebo, 95% CI, and p-value (using SAS MIANALYZE procedure) were provided.

Security analysis:

The safety analyzes were descriptive, they were carried out in the safety population according to the treatment actually received. The safety analysis focused on the TEAE period defined as the time from the first double-blind injection dose to 70 days after the last double-blind injection. TEAE that developed, worsened, or aggravated or PCSA that occurred after the patient's first injection in the open-label extension study (LTS13643) were not considered in the TEAE period. The TEAE period was truncated at the common study cut-off date.

RESULTS I - PREVIOUSLY SPECIFIED ANALYSIS

Liability of patients

A pre-specified interim analysis was performed when all patients reached one year and approximately 25 percent of patients reached 18 months of treatment. Of the 2341 randomized patients, three patients were untreated and therefore not included in the safety population.

Thirty-one of the randomized patients were not included in the ITT population (no LDL-C value within one of the analysis windows up to week 24).

Forty-one of the randomized patients were excluded from the ITT m population (patients excluded from the ITT population and patients with no LDL-C value within one of the analysis windows up to week 24 during the treatment efficacy period).

Table 29 - Analysis populations

Placebo Alirocumab 150 every 2 weeks All

Randomized population 788 (100%) 1,553 (100%) 2,341 (100%)

Efficacy populations

Intent to Treat (ITT) 780 (99.0%) 1530 (98.5%) 2310 (98.7%)

Modified intention to treat (ITTm) 777 (98.6%) 1523 (98.1%) 2300 (98.2%)

Security population 788 1550 2338

Note: Patients in the safety population are tabulated based on the treatment actually received (as treated). For the other populations, patients are tabulated according to their randomized treatment.

Study distribution

By the cut-off date in this previously specified analysis, 607 (25.9%) patients had completed the 18-month double-blind treatment period (defined as an exposure of at least 76 weeks and had a visit at week 78), which includes at least 400 patients in the alirocumab group, as agreed with the health authorities during the consultation meeting of the "End of Phase 2": 405 patients (26.1%) in the alirocumab group and 202 patients (25 , 6%) in the placebo group.

In the alirocumab group, 1,550 of the 1,553 actually received alirocumab. 23% (n = 349) of these patients completed 78 weeks, 20% (n = 311) discontinued treatment, and 57% (n = 890) are still receiving treatment. The group of alirocumab patients who discontinued treatment did so due to poor protocol compliance (n = 54), an adverse event (n = 98), or another reason (n = 159). ITT security stocks for the alirocumab group were 1530 and 1550 patients, respectively. In the placebo group, 788 received placebo. 22% (n = 176) of these patients completed 78 weeks, 19% (n = 146) discontinued treatment, and 59% (n = 466) are still receiving treatment. Patients in the placebo group who discontinued treatment did so due to poor protocol compliance (n = 34), an adverse event (n = 44), or another reason (n = 67). The ITT safety populations for the alirocumab group were 780 and 788 patients, respectively. Patients in the ITT population were all included in the efficacy endpoints through week 52. Patients in the safety population received either alirocumab or placebo for at least 52 weeks.

Study distribution, exposure, and safety analysis were assessed using all data up to the common study cut-off date and therefore include data beyond week 52 and up to week 78 or up to the follow-up visit. Final results for the primary efficacy endpoint (at week 24) and secondary key efficacy endpoints (assessed through week 52) are provided in this first stage analysis.

There were a total of 525 (22.4%) randomized patients who completed the study treatment period up to the cut-off date in this previously specified analysis, that is, they received the last IMP injection (week 76) and the end-of-study visit. Treatment (week 78) was performed within 21 days after the last IMP injection and at least 525 days after randomization.

Double-blind IMP was discontinued prematurely for 455 (19.4%) randomized patients (310 (20.0%) patients in the alirocumab group and 145 (18.4%) patients in the placebo group). For 1,358 (58.0%) randomized patients, treatment was continuing at the time of the first-stage analysis cut-off date.

Overall, the main reasons for discontinuation of study treatment were "other reasons - other" and "adverse event": These "other reasons" included the following: subject refuses to continue (93 patients), patient did not meet criteria CDR electronic support to end treatment due to or missing week 78 / out-of-window visit (71 patients), death (6 patients) (no investigator decision to stop treatment before death), miscellaneous (5 patients), lost visa for follow-up (4 patients), site closure (3 patients) and the subject moved (2 patients).

Furthermore, among these 455 patients who discontinued prematurely, 219 (14.1%) randomized patients had prematurely discontinued double-blind IMP prior to the 52-week visit in the alirocumab group and 111 (14.1%) in the alirocumab group. placebo group.

Finally, 139 (5.9%) patients participated in the optional ophthalmologic substudy (instead of the planned 270 patients).

In this first stage analysis, the final results are available for the primary efficacy endpoint at week 24 and the secondary key efficacy endpoints assessed at week 12, week 24, and week 52. At week 24, the primary efficacy endpoint was available for 1,384 (90.5%) in the alirocumab group and 708 (90.8%) in the placebo group.

The primary efficacy endpoint was absent for 218 patients. At the 24 week visit, the reasons for the absence were as follows: 108 samples were not collected due to premature discontinuation of the study; 47 samples were taken outside the analysis windows; 10 samples were not taken; 51 samples were taken, but the measurement could not be made (insufficient amount, TG> 400 mg / dL (4.52 mmol / L) ...); and 2 samples were not taken for randomized but untreated patients.

Demographic and baseline characteristics

A total of 2341 patients were randomized to the study (1553 in the alirocumab group vs 788 in the placebo group). Demographic characteristics, disease characteristics, and lipid parameters at baseline were similar in the alirocumab group compared to the placebo group. For the alirocumab group (N = 1553), the age (mean age (SD)) was 60.4 (10.4), the percentage of males was 63.3% (N = 983), the percentage of white race was 92.8% (N = 1441) and the BMI (mean kg / m2 (SD)) was 30.2 (5.7). For the placebo group (N = 788), the age (mean age (SD)) was 60.6 (10.4), the percentage of males was 60.2% (N = 474), the percentage of white race was 92.6% (N = 730) and the BMI (mean kg / m2 (SD)) was 30.5 (5.5).

17.7% of the patients (17.8% (N = 276) of the alirocumab patients and 17.6% (N = 139) of the placebo group) had heFH with or without established CHD or risk equivalents of ECC. 82.3% of the patients were enrolled with non-familial hypercholesterolemia with established CHD or equivalent risk of CHD. The vast majority of the randomized population (90.6%) had a history of coronary heart disease (CHD) or equivalent risk of CHD. CHD was reported for 68.6% of patients. 91.5% of patients were classified as very high risk (see note below).

Demographic characteristics, disease characteristics, and lipid parameters at baseline were similar in the alirocumab group compared to the placebo group. Mean baseline calculated LDL-C (SD) it was 122.4 (42.2) mg / dL (3.171 (1.092) mmol / L). Regarding prior lipid-modifying therapy, 1,032 (44.1%) patients took high-intensity statins at randomization (i.e., atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg daily) and 334 (14.3 %) were receiving ezetimibe in addition to the statin.

A summary of the baseline characteristics of the alirocumab and placebo groups is set forth in Table 34. Exposure to injections was similar in the treatment groups with a median exposure of 68 weeks. By the cutoff date (May 7, 2014), 607 (25.9%) patients had completed the 18-month double-blind treatment period (i.e., completed at least 76 weeks of exposure and the 78-week visit ), which includes at least 400 patients in the alirocumab group, as agreed with the health authorities during the consultation meeting at the End of Phase 2: 405 patients (26.1%) in the alirocumab group and 202 patients (25 , 6%) in the placebo group.

Table 30 - Characteristics of the disease and other relevant baseline data - Randomized population Placebo Alirocumab 150 c / 2 weeks All (N = 788 (N = 1553) (N = 2341) Type of hypercholesterolemia

Heterozygous familial hypercholesterolemia

(HFhe) 139 (17.6%) 276 (17.8%) 415 (17.7%) Non-familial hypercholesterolemia (UFH) 649 (82.4%) 1277 (82.2%) 1926 (82.3% )

Patients with unfamiliar hypercholesterolemia

Time since diagnosis of

hypercholesterolemia (years)

Number 647 1273 1920 Mean (SD) 8.95 (7.29) 9.13 (7.65) 9.07 (7.53) Median 7.36 7.46 7.44 Min: Max -0.0: 42.1 0.0: 49.4 -0.0: 49.4

Fredrickson's classification of

hyperlipoproteinemia

Number 649 1277 1926 11 to 455 (57.7%) 885 (57.0%) 1340 (57.2%) I Ib 194 (24.6%) 392 (25.2%) 586 (25.0%)

IV 0 0 0

Patients with familial hypercholesterolemia

heterozygous

Time since diagnosis of

hypercholesterolemia (years)

Number 139 276 415 Mean (SD) 10.58 (10.66) 11.09 (11.40) 10.92 (11.15) Median 7.37 7.22 7.24 Min: Max -1.4: 44.2 -1.5: 48.2 -1.5: 48.2 Placebo Alirocumab 150 c / 2 weeks All (N = 788 (N = 1553) (N = 2341) Confirmation of diagnosis

By genotyping 56 (7.1%) 111 (7.1%) 167 (7.1%) By WHO / Simon Broomea 83 (10.5%) 165 (10.6%) 248 (10.6%) a for diagnosis of heHF not confirmed by genotyping.

Table 31 - Medical history of specific interest: cardiovascular history and risk factors -Randomized population

Placebo Alirocumab 150 All (N = 788) every 2 weeks (N = 1553) (N = 2341)

Any cardiovascular history / risk factor ⁷¹⁹ 1403 (90, _(91.2%) 3%) 2122 (90.6%)

Coronary heart disease a ⁵⁵²

_(70.1%) 1055 (67.9%) 1607 (68.6%)

Acute myocardial infarction ³⁰⁹

_(39.2%) 563 (36.3%) 872 (37.2%) Silent myocardial infarction 16 (2.0%) 53 (3.4%) 69 (2.9%)

Unstable angina ¹⁰⁸

_(13.7%) 183 (11.8%) 291 (12.4%)

Coronary revascularization procedures ³⁶⁸

_(46.7%) 713 (45.9%) 1081 (46.2%)

233

Another clinically significant CHD b _(29.6%) 445 (28.7%) 678 (29.0%) CHD associated with 1 or more associated diseases (among 449

hypertension, diabetes or moderate CKD) and / or associated with 845 (54.4%) 1,294 (55.3%) other CVD (ischemic stroke, AD ₎

P) _(57.0%

Heart disease risk equivalents 323

coronary _{arterya (41.0%)} 639 (41.1%) 964 (41.2%) Ischemic stroke 74 (9.4%) 158 (10.2%) 232 (9.9%) Peripheral arterial disease 42 ( 5.3%) 80 (5.2%) 122 (5.2%)

Moderate chronic kidney disease ¹⁰³ 223 (14.4%) 326 (13.9%)

(13.1%)

Unknown history of diabetes mellitus Y 2 or 171

plus additional risk factors _(21.7%) 316 (20.3%) 487 (20.8%) At least 2 CHD risk equivalents or 1 CHD 308

equivalent risk of associated with hypertension or diabetes _(39.1%) 592 (38.1%) 900 (38.4%)

CV risk categorization by protocol

Very high CV risk ⁷²⁸

_(92.4%) 1413 (91.0%) 2141 (91.5%) Placebo Alirocumab 150 All (N = 788) every 2 weeks (N = 1553) (N = 2341) High CV risk 60 (7.6%) 140 (9.0%) 200 (8.5%) Note: One patient it can be counted in several categories.

a according to the points previously listed in the e-CRF.

b diagnosed by invasive or non-invasive tests.

PAD defined as intermittent claudication TOGETHER WITH ankle-brachial index <0.90 or TOGETHER with peripheral revascularization procedure / surgery or critical limb ischemia TOGETHER WITH peripheral revascularization procedure / surgery or thrombolysis.

Very high CV risk is defined as heHF patients with CHD or equivalent risk of CHD or patients with UFH. High CV risk is defined as heFH patients without CHD or CHD risk equivalents.

Note: 219 patients had neither a medical history of coronary heart disease nor a medical history of equivalent risk of coronary heart disease. 200 of them are patients with heFH (corresponding to the CV high risk category). The other 19 are UFH with no history of established CHD or CHD risk equivalents (ie, exclusion criterion E01). By convention at the program level, these 19 deviant patients are considered in the very high CV risk category.

The following summarizes the history of lipid modifying therapy (TML) that includes statins in the screening: 1,245 (53.2%) patients did not take atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg, or simvastatin 80 mg daily. The most common motive was regional practice and local labeling. Among the 656 (28.0%) patients who did not take the high intensity statin or simvastatin 80 mg daily due to regional practice / local labeling, 375 (57.2%) patients took simvastatin 40 mg.

Table 32 - Prior TML at Randomization - Randomized Population

Placebo Alirocumab 150 q / 2 weeks All (N = 788) (N = 1553) (N = 2341) Any statin 787 (99.9%) 1552 (> 99.9%) 2339 (> 99.9%)

Taking high intensity statin 342 (43.4%) 690 (44.4%) 1032 (44.1%) Daily dose of atorvastatin (mg) 283 (35.9%) 623 (40.1%) 906 (38 , 7%)

10 33 (4.2%) 67 (4.3%) 100 (4.3%)

20 62 (7.9%) 138 (8.9%) 200 (8.5%)

40 112 (14.2%) 240 (15.5%) 352 (15.0%)

80 73 (9.3%) 174 (11.2%) 247 (10.6%)

Other doses 3 (0.4%) 4 (0.3%) 7 (0.3%) Rosuvastatin daily dose (mg) 199 (25.3%) 362 (23.3%) 561 (24.0% )

5 9 (1.1%) 20 (1.3%) 29 (1.2%)

10 34 (4.3%) 66 (4.2%) 100 (4.3%)

20 74 (9.4%) 134 (8.6%) 208 (8.9%)

40 80 (10.2%) 140 (9.0%) 220 (9.4%)

Other doses 2 (0.3%) 2 (0.1%) 4 (0.2%) Simvastatin daily dose (mg) 306 (38.8%) 567 (36.5%) 873 (37.3% ) Placebo Alirocumab 150 every 2 weeks All (N = 788) (N = 1553) (N = 2341)

10 21 (2.7%) 43 (2.8%) 64 (2.7%)

20 84 (10.7%) 150 (9.7%) 234 (10.0%)

40 166 (21.1%) 323 (20.8%) 489 (20.9%)

80 30 (3.8%) 39 (2.5%) 69 (2.9%)

Other doses 5 (0.6%) 12 (0.8%) 17 (0.7%)

Any TML other than statinase 220 (27.9%) 437 (28.1%) 657 (28.1%) Any TML other than nutraceuticals 176 (22.3%) 337 (21.7%) 513 (21.9 %) Ezetimibe 118 (15.0%) 216 (13.9%) 334 (14.3%) Nutraceuticals 68 (8.6%) 134 (8.6%) 202 (8.6%) a in combination with statins or not.

High intensity statin corresponds to atorvastatin 40 to 80 mg per day or rosuvastatin 20 to 40 mg per day. Note: Two patients, one in each group, received no statin at randomization and received IMP (through week 10 for one patient and through week 74 for the other patient).

Table 33 - Baseline Lipid Efficacy Parameters - Quantitative Summary in Conventional Units - Randomized Population

Alirocumab 150 c / 2sem

Placebo (N = 788) (N = 1553) All (N = 2341) Calculated LDL-C (mg / dL)

Number 788 1553 2341

Mean (SD) 121.9 (41.4) 122.7 (42.6) 122.4 (42.2) Median 112.7 114.7 114.0

Q1: Q3 95.0: 140.9 94.2: 141.0 94.6: 140.9

Min: Max 19: 404 39: 424 19: 424

LDL-C measured (mg / dL)

Number 677 1,322 1999 Mean (SD) 115.6 (38.1) 117.2 (39.0) 116.7 (38.7) Median 108.9 110.4 109.7

Q1: Q3 91.5: 132.0 90.3: 134.0 90.7: 132.8

Min: Max 17: 358 30: 359 17: 359

No HDL-C (mg / dL)

Number 788 1553 2341

Alirocumab 150 c / 2sem

Placebo (N = 788) (N = 1553) All (N = 2341) Mean (SD) 152.0 (45.8) 152.6 (46.6) 152.4 (46.3) Median 142.5 144 .8 144.0

Q1: Q3 122.0: 174.5 121.2: 173.0 121.6: 174.0

Min: Max 31: 420 54: 475 31: 475

Total C (mg / dL)

Number 788 1553 2341 Mean (SD) 201.9 (47.0) 202.4 (47.4) 202.2 (47.3) Median 192.8 194.2 193.8

Q1: Q3 170.3: 225.3 171.0: 223.2 170.7: 224.7

Min: Max 78: 477 108: 521 78: 521

HDL-C (mg / dL)

Number 788 1553 2341 Mean (SD) 50.0 (12.4) 49.8 (12.2) 49.9 (12.3) Median 48.6 48.0 48.3

Q1: Q3 41.7: 56.8 41.3: 56.4 41.3: 56.4

Min: Max 13: 109 14: 113 13: 113

Fasting TG (mg / dL)

Number 787 1553 2340 Mean (SD) 151.5 (79.7) 150.7 (85.3) 150.9 (83.4) Median 135.0 132.0 132.7

Q1: Q3 94.7: 188.5 93.8: 183.2 94.0: 185.0

Min: Max 35: 650 31: 1422 31: 1422

Lipoprotein- (a) (mg / dL)

Number 777 1521 2298 Mean (SD) 42.1 (47.2) 43.5 (48.7) 43.0 (48.2) Median 20.9 22.2 22.0

Q1: Q3 6.5: 66.8 7.6: 66.5 7.3: 66.7

Min: Max 2: 262 2: 363 2: 363

Apo-B (mg / dL)

Alirocumab 150 c / 2sem

Placebo (N = 788) (N = 1553) All (N = 2341) Number 778 1523 2301 Mean (SD) 101.4 (27.3) 101.9 (27.7) 101.7 (27.6) Median 97.0 98.0 98.0

Q1: Q3 84.0: 115.0 83.0: 116.0 83.0: 115.0

Min: Max 18: 247 42: 268 18: 268

Apo-A1 (mg / dL)

Number 778 1523 2301 Mean (SD) 147.3 (27.3) 146.5 (25.1) 146.8 (25.9) Median 145.0 145.0 145.0

Q1: Q3 130.0: 162.0 129.0: 161.0 129.0: 161.0

Min: Max 30: 291 30: 295 30: 295

Apo-B / Apo-A1 (ratio)

Number 778 1523 2301 Mean (SD) 0.713 (0.250) 0.719 (0.267) 0.717 (0.261) Median 0.670 0.680 0.670

Q1: Q3 0.560: 0.830 0.550: 0.830 0.560: 0.830

Min: Max 0.12: 3.17 0.27: 4.80 0.12: 4.80

Total C / HDL-C (ratio)

Number 788 1553 2341 Mean (SD) 4,228 (1,295) 4,252 (1,367) 4,244 (1,343) Median 3,965 4,040 4,020

Q1: Q3 3,355: 4,835 3,350: 4,820 3,350: 4,830

Min: Max 1.66: 12.61 1.81: 16.64 1.66: 16.64 Note: LDL-C was assessed as measured by the beta quantification method.

Table 34 - Summary of baseline characteristics of the alirocumab and placebo groups

Administration and duration

Injection exposure was similar in the treatment groups with a median exposure of 68 weeks. It is noteworthy that 817 (35.0%) patients were treated for at least 76 weeks (543 (35.0%) patients in the alirocumab group and 274 (34.6%) patients in the placebo group). Among the 817 patients, 607 patients also completed the 78 week visit at the time of the first stage analysis cut-off date.

Primary efficacy endpoint

The ITT analysis includes all LDL-C values collected during treatment and without treatment up to week 52. Analysis of the primary endpoint is provided (percent change in LDL-C calculated from baseline to week 24 ) based on a model of MMRM in the ITT population, using mean estimates by MC at week 24. 146 (9.5%) patients in the alirocumab group and 72 (9.2%) patients in the non-placebo group. had an LDL-C value calculated at week 24. The MMRM model accounted for these missing values.

Results of the primary endpoint analysis are presented in Table 35, in mmol / L and mg / dL. There was a statistically significant decrease in the percentage change in LDL-C from baseline to week 24 in the alirocumab group (mean by MC vs. baseline - 61.0%) compared to the placebo group. (mean by MC vs. baseline 0.8%) (mean difference by MC vs. placebo - 61.9%, p <0.0001).

In the alirocumab group, a consistent reduction in LDL-C from baseline was observed from week 4 to week 52. Calculated LDL-C values, change from baseline, and percentage change from baseline for this period are presented in Table 36 and Figure 11 (ITT analysis of all available measurements during the 52 week observation period), and demonstrate a clear difference between the alirocumab and placebo treated groups.

Table 35 - Percentage change from baseline in LDL-C calculated at week 24: MMRM -ITT analysis - ITT population

Calculated LDL cholesterol Placebo (N = 780) Alirocumab 150 c / 2sem (N = 1530)

Baseline level (mmol / L)

Number 780 1530

Mean (SD) 3,159 (1,077) 3,180 (1,106) Median 2,920 2,974

Min: Max 0.49: 10.47 1.01: 10.99

Baseline level (mg / dL)

Number 780 1530

Mean (SD) 122.0 (41.6) 122.8 (42.7) Median 112.7 114.8

Min: Max 19: 404 39: 424

Absolute level at week 24 (mg / dL) 118.9 (1.2) 48.3 (0.9)

Change in percentage at week 24 from

baseline level (%)

Mean by MC (SE) 0.8 (1.0) -61.0 (0.7) Mean difference by MC (SE) vs placebo -61.9 (1.3)

95% CI (-64.3 to -59.4) P-value vs placebo <0.0001 *

Note: Least squares means (LC), standard errors (SE) and p-value taken from MMRM analysis (mixed effects model with repeated measures). The model includes the fixed categorical effects of treatment group, randomization strata according to IVRS, moment of time, treatment by moment of time and interaction of Calculated LDL cholesterol Placebo (N = 780) Alirocumab 150 c / 2sem (N = 1530)

strata by moment of time, as well as the continuous fixed covariates of baseline calculated LDL-C value and interaction by level baseline calculated LDL-C value by moment of time.

MMRM model and baseline description performed on patients with a baseline value and a value after baseline in at least one of the analysis windows used in the model.

The p-value is followed by a '*' if it is statistically significant according to the fixed hierarchical approach used to ensure a strong control for the overall type I error rate at the 0.05 level.

Table 36 - LDL-C calculated over time - ITT analysis - ITT population

Placebo (N = 780) Alirocumab 150 q / 2 weeks (N = 1530)

LDL-C Change Change Change Change in percentage calculated from the percentage from from from basal level _value baseline value baseline level baseline

Average per MC

(EE) (mmol / L)

3,159 3,180

Baseline level a (0.039) NA NA (0.028) NA NA

3,109 -0,064 1,145 -2,028

Week 4 (0.025) (0.025) 1.1 (0.9) (0.018) (0.018) -64.8 (0.6)

3,084 -0,089 1,111 -2,061

Week 8 (0.026) (0.026) 1.0 (0.9) (0.019) (0.019) -65.8 (0.7)

3,112 -0,061 1,184 -1,989

Week 12 (0.029) (0.029) 1.5 (1.0) (0.020) (0.020) -63.3 (0.7)

3,076 -0,097 1,143 -2,030

Week 16 (0.029) (0.029) 0.9 (1.0) (0.021) (0.021) -64.5 (0.7)

3,081 -0,092 1,252 -1,921

Week 24 (0.031) (0.031) 0.8 (1.0) (0.022) (0.022) -61.0 (0.7)

3,066 -0,107 1,278 -1,895

Week 36 (0.032) (0.032) 0.3 (1.1) (0.023) (0.023) -59.5 (0.8)

3,187 0.014 1.376 -1.797

Week 52 (0.036) (0.036) 4.4 (1.2) (0.026) (0.026) -56.8 (0.8)

Average per MC

(EE) (mg / dL)

122.0 122.8

Baseline level a (1.5) NA NA (1.1) NA NA

120.0 44.2

Week 4 (1.0) -2.5 (1.0) 1.1 (0.9) (0.7) -78.3 (0.7) -64.8 (0.6)

119.1 42.9

Week 8 (1.0) -3.4 (1.0) 1.0 (0.9) (0.7) -79.6 (0.7) -65.8 (0.7)

120.1 45.7

Week 12 (1.1) -2.4 (1.1) 1.5 (1.0) (0.8) -76.8 (0.8) -63.3 (0.7)

118.8 44.1

Week 16 (1.1) -3.7 (1.1) 0.9 (1.0) (0.8) -78.4 (0.8) -64.5 (0.7) Placebo (N = 780) Alirocumab 150 q / 2 weeks (N = 1530)

LDL-C Change Change Change Change in percentage calculated from the percentage from from from basal level _value baseline value baseline level baseline

118.9 48.3

Week 24 (1.2) -3.6 (1.2) 0.8 (1.0) (0.9) -74.2 (0.9) -61.0 (0.7)

118.4 49.3

Week 36 (1.2) -4.1 (1.2) 0.3 (1.1) (0.9) -73.2 (0.9) -59.5 (0.8)

123.0 53.1

Week 52 (1.4) 0.5 (1.4) 4.4 (1.2) (1.0) -69.4 (1.0) -56.8 (0.8)

a The baseline level is described using means and standard errors.

Note: Least squares means (LC), standard errors (SE) and p-value taken from MMRM analysis (mixed effects model with repeated measures). The model includes fixed categorical effects of treatment group, randomization strata according to IVRS, moment of time, interaction of treatment by moment of time, interaction of strata by moment of time, as well as the continuous fixed covariates of the LDL-C value. baseline and the interaction of the baseline LDL-C value by moment of time

MMRM model and baseline description performed in patients with a baseline value and a post-baseline value in at least one of the analysis windows used in the model.

It is noteworthy that as part of the testing of the assumptions of the model, the homogeneity of the treatment effect on baseline lipid levels has been evaluated and shows a significant interaction of treatment by baseline LDL-C level (p <0.0001 ). To further explore this interaction, the effect of treatment on the primary efficacy endpoint, based on 4 classes of baseline LDL-C, is presented below. Shows a reduction in treatment effect versus placebo for higher baseline LDL-C levels (from -75.0% for patients with baseline LDL-C <100 mg / dL to -41.3% for patients with LDL-C > 160 mg / dL). This observation appears to be due to changes in the placebo group, where the percentage change in LDL-C from baseline to week 24 decreases with increasing baseline LDL-C categories. In contrast, the percentage change in LDL-C from baseline to week 24 is consistent across the different LDL-C subcategories within the alirocumab group.

Table 37 - Percentage change from baseline in LDL-C calculated at week 24: Subgroup analysis according to LDL-C calculated at baseline - ITT analysis

Subgroup factor

Percentage change from baseline in LDL- Alirocumab 150 Interaction C calculated at week 24 (%) Placebo (N = 780) c / 2 weeks (N = 1530) p-value

Baseline calculated LDL-C <0.0001

<100 mg / dL / <2.59 mmol / L

Number 241 470

Means by CM (SE) 13.6 (1.8) -61.3 (1.3)

Mean difference by MC (SE) vs placebo -75.0 (2.2)

95% CI (-79.3 to -70.6)

Mean absolute LDL-C reduction by

MC, mg / dL 9.5 -51.6

> 100 to <130 mg / dL /> 2.59 to <3.37 mmol / L

Number 285 562

Means by CM (SE) 0.5 (1.7) -62.0 (1.2)

Mean difference by CM (SE) vs placebo -62.5 (2.0)

Subgroup factor

Percentage change from baseline in LDL- Alirocumab 150 Interaction C calculated at week 24 (%) Placebo (N = 780) c / 2 weeks (N = 1530) p-value 95% CI (-66.5 a -58.4)

Mean absolute LDL-C reduction by MC, mg / dL 0.0 -71.2

> 130 to <160 mg / dL /> 3.37 to <4.14 mmol / L

Number 143 271

Means by CM (SE) -5.2 (2.4) -59.8 (1.7)

Mean difference by MC (SE) vs placebo -54.6 (2.9)

95% CI (-60.3 to -48.8)

Mean absolute LDL-C reduction by MC, mg / dL -7.6 -85.3

> 160 mg / dL /> 4.14 mmol / L

Number 111 227

Means by CM (SE) -18.2 (2.8) -59.5 (1.9)

Mean difference by MC (SE) vs placebo -41.3 (3.3)

95% CI (-47.8 to -34.8)

Mean absolute LDL-C reduction by MC, mg / dL -33.7 -115.8

Baseline HDL-C 0.0989

<40 mg / dL / <1.04 mmol / L

Number 151 306

Means by CM (SE) 0.5 (2.3) -65.5 (1.6)

Mean difference by CM (SE) vs placebo -66.1 (2.8)

95% CI (-71.6 to -60.5)

> 40 mg / dL /> 1.04 mmol / L

Number 629 1224

Means by CM (SE) 0.9 (1.1) -59.9 (0.8)

Mean difference by MC (SE) vs placebo -60.8 (1.4)

95% CI (-63.6 to -58.1)

Note: Least squares means (LC), standard errors (SE) and p-value taken from MMRM analysis (mixed effects model with repeated measures).

The model includes the fixed categorical effects of treatment group, randomization strata according to IVRS, subgroup factor, moment of time, and the interactions treatment by moment of time, stratum by moment of time, subgroup factor by moment of time, group treatment by subgroup factor and treatment group by subgroup factor by time point for baseline LDL-C as subgroup factor. For other subgroup factors, the model also includes the continuous fixed covariates of baseline LDL-C value and baseline LDL-C value interaction by moment of time.

The number corresponds to the number of patients with a baseline value and a post-baseline value in at least one of the analysis windows used in the model.

Subgroup factor

Percentage change from baseline in LDL- Alirocumab 150 Interaction C calculated at week 24 (%) Placebo (N = 780) c / 2 weeks (N = 1530) p-value

The p-value is provided for descriptive purposes only

Secondary Key Efficacy Endpoints

Table 38 summarizes the results of the analysis on the key secondary endpoints in the hierarchical order. All key secondary endpoints are statistically significant according to the hierarchical testing procedure.

Table 38

Endpoint Analysis Results P value

Calculated LDL-C - Percentage Change from -63.5% Mean Difference by MC <0.0001 Baseline to Week 24 Treatment vs. Placebo

Calculated LDL-C - Percentage change from ITT Mean difference by MC <0.0001 baseline to week 12 vs placebo of -64.8%

Calculated LDL-C - Percentage change from -65.5% MC mean difference <0.0001 baseline to week 12 treatment vs placebo

Measured LDL-C (by ultracentrifugation) - Change in ITT Mean difference by MC <0.0001 percentage from baseline to week 24 vs placebo of -61.3%

Apo-B - Percentage change from baseline ITT Mean difference by MC <0.0001 through week 24 vs placebo of -54%

Apo-B - Percentage change from baseline During MC mean difference <0.0001 until week 24 treatment vs placebo of -55.5%

No HDL-C - Percentage change from ITT level Mean difference by MC <0.0001 baseline to week 24 vs placebo of -52.3%

Non-HDL-C - Percentage Change from Level During Baseline Mean Difference by MC <0.0001 to Week 24 Treatment vs. Placebo of -53.7%

Total C - Percentage change from baseline ITT Mean difference by MC <0.0001 up to week 24 vs placebo of -37.5%

Apo-B - Percentage change from baseline ITT Mean difference by MC <0.0001 through week 12 vs placebo of -56%

No HDL-C - Percentage change from ITT level Mean difference by MC <0.0001 baseline to week 12 vs placebo of -54.6%

Total C - Percentage change from baseline ITT Mean difference by MC <0.0001 through week 12 vs placebo of -39%

Proportion of very high CV risk patients that estimated combined ITT for <0.0001 reach LDL-C calculated <70 mg / dL (1.81 mmol / L) or the relative chance high CV risk patients who reach LDL-C vs a placebo of 71.5

calculated <100 mg / dL (2.59 mmol / L) at week 24

Endpoint Analysis Results P value

Proportion of very high CV risk patients who During the pooled estimate for <0.0001 reach calculated LDL-C <70 mg / dL (1.81 mmol / L) or treatment the relative opportunity high CV risk patients who reach LDL- C vs placebo of 93.4 calculated <100 mg / dL (2.59 mmol / L) at week 24

Proportion of patients reaching calculated LDL-C ITT Pooled estimate for <0.0001 <70 mg / dL (1.81 mmol / L) at week 24 relative chance

vs placebo 74.6

Proportion of Patients Achieving LDL-C Calculated During Pooled Estimate for <0.0001 <70 mg / dL (1.81 mmol / L) at Week 24 Treatment Relative Chance

vs placebo 97.3

Lp (a) - Percent Change from Baseline ITT Pooled Estimate for <0.0001 through Week 24 Adjusted Mean Difference vs. Placebo of -25.6%

HDL-C - Percentage change from baseline ITT Mean difference by MC <0.0001 through week 24 vs placebo of 4.6%

Fasting TG - Percent Change from ITT Level Estimated Pooled for <0.0001 Baseline through Week 24 Adjusted Mean Difference vs. Placebo of -17.3%

Apolipoprotein A1 - Percentage change from ITT Mean difference by MC <0.0001 baseline to week 24 vs placebo of 2.9%

Lp (a) - Percent Change from Baseline ITT Pooled Estimate for <0.0001 through Week 12 Adjusted Mean Difference vs. Placebo of -25.1%

HDL-C - Percentage change from baseline ITT Mean difference by MC <0.0001 through week 12 vs placebo of 5.6%

Fasting TG - Percent Change from ITT Level Estimated Pooled for <0.0001 Baseline through Week 12 Adjusted Mean Difference vs. Placebo of -17.9%

Apolipoprotein A1 - Percentage change from ITT Mean difference by MC <0.0001 baseline to week 12 vs placebo of 4%

Table 39 - Percentage change from baseline in lipid parameters at week 24 (ITTa population)

Placebo Alirocumab 150 c / 2 weeks Secondary endpoints (N = 780) (N = 1530)

Proportion (%) of patients reaching LDL-C levels

calculated at week 24

<70 mg / dL (very high risk) or <100 mg / dL (high risk) 8.5 80.7

p-value vs placebo <0.0001 *

<70 mg / dL (regardless of risk) 8.0 79.3

p-value vs placebo <0.0001

Percentage change from baseline to week 78 3.6 (1.3) -52.4 (0.9) in calculated LDL-C

Placebo Alirocumab 150 q / 2 wk Secondary endpoints (N = 780) (N = 1530) mean difference by CM (SE) vs placebo -56.0 (1.6) 95% CI -59.1 to -52 .8 p-value vs placebo <0.001

Mean change by MC (SE) from baseline to week

24 (%) in secondary lipid parameters

No HDL-C 0.7 (0.9) -51.6 (0.6) mean difference by MC (SE) vs placebo -52.3 (1.1) 95% CI -54.4 to - 50.2 p-value vs placebo <0.0001 Apo B 1.2 (1.0) -52.8 (0.7) mean difference by MC (SE) vs placebo -54.0 (1.2 ) 95% CI -56.3 to -51.7 p-value vs placebo <0.0001 Total cholesterol -0.3 (0.7) -37.8 (0.5) mean difference by MC (SE ) vs placebo -37.5 (0.8) 95% CI -39.1 to -35.9 p-value vs placebo <0.0001 Lipoprotein (a) b -3.7 (1.0) -29.3 (0.7) mean difference by MC (SE) vs placebo -25.6 (1.3) 95% CI -28.1 to -23.1 p-value vs placebo <0, 0001 Fasting triglyceridesb 1.8 (1.2) -15.6 (0.8) mean difference by CM (SE) vs placebo -17.3 (1.4) 95% CI -20.1 a - 14.6 p-value vs placebo <0.0001

HDL-C -0.6 (0.5) 4.0 (0.4)

mean difference by MC (SE) vs placebo 4.6 (0.7) 95% CI 3.3 to 5.9 p-value vs placebo <0.0001 Apo A1 1.2 (0.6) 4.0 (0.4) mean difference by MC (SE) vs placebo 2.9 (0.7) 95% CI 1.6 to 4.2 p-value vs placebo <0.0001 Placebo Alirocumab 150 c / 2 weeks Secondary endpoints (N = 780) (N = 1530) Number of patients with available LDL-C measured C values 652 1278

Mean change by MC (SE) from baseline to week 3.5 (1.1) -57.8 (0.8) 24 in measured LDL-C,%

mean difference by MC (SE) vs placebo -61.3 (1.4) 95% CI -64.0 to -58.5 p-value vs placebo <0.0001 Abbreviations: CI, confidence intervals; HDL, high-density lipoprotein; ITT, intention to treat; LDL, low-density lipoprotein; MC, least squares; THL, lipid-lowering therapy; SD, standard deviation; SE, standard error.

a Primary and secondary efficacy analyzes were performed using an ITT approach including patients with calculated baseline LDL cholesterol and at least one calculated LDL cholesterol value with or without treatment within one of the analysis windows through week 24 Means were taken for MC, SE and p value from the analysis of the mixed effects model with repeated measures. The p-values are significant according to the hierarchical approach used to ensure control of the overall type 1 error rate at the 0.05 level.

b pooled estimates for the adjusted mean (SE) shown for lipoprotein (a) and triglycerides.

c LDL-cholesterol measured by beta quantification.

Table 40 - Percentage change from baseline in lipid parameters at week 24 -Analysis during treatmenta

Placebo Alirocumab 150 c / 2 weeks (N = 777) (N = 1523) calculated LDL-C

Baseline level, mean (SD) mg / dL 121.9 (41.5) 122.8 (42.7) Range 19-404 39-424 Mean change by CM (SE) from baseline to week

24 (%) 0.7 (1.0) -62.8 (0.7) mean difference by MC (SE) vs placebo -63.5 (1.2) 95% CI -65.9 a - 61.2 p-value vs placebo <0.0001 Mean change by MC (SE) from baseline to week

24 (%) in secondary lipid parameters

No HDL-C 0.6 (0.9) -53.1 (0.6) mean difference by MC (SE) vs placebo -53.7 (1.0) 95% CI -55.7 to - 51.6 p-value vs placebo <0.0001 Apo B 1.2 (0.9) -54.3 (0.7) mean difference by MC (SE) vs placebo -55.5 (1.2 ) 95% CI -57.7 to -53.2 Placebo Alirocumab 150 c / 2 weeks (N = 777) (N = 1523) p-value versus placebo <0.0001 Total cholesterol -0.4 (0.6) -38.8 (0.5) mean difference by MC (SE) vs placebo -38.4 (0.8) 95% CI -39.9 to -36.9 p-value vs placebo <0.0001 Lipoprotein (a) b -3.9 (1, 0) -30.2 (0.7) mean difference by MC (SE) vs placebo -26.3 (1.3) 95% CI -28.8 to -23.8 p-value vs placebo < 0.0001 Triglyceridesb 1.4 (1.2) -15.8 (0.8) mean difference by MC (SE) vs placebo -17.2 (1.4) 95% CI -20.0 a - 14.4 p-value vs placebo <0.0001

HDL-C -0.7 (0.5) 4.2 (0.4)

mean difference by MC (SE) vs placebo 4.9 (0.7) 95% CI 3.6 to 6.1 p-value vs placebo <0.0001 Apo A1 1.2 (0.6) 4 , 2 (0.4) mean difference by MC (SE) vs placebo 2.9 (0.7) 95% CI 1.6 to 4.3 p-value vs placebo <0.0001 Abbreviations: CI, confidence intervals; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MC, least squares; THL, lipid-lowering therapy; SE, standard error.

a Only patients who were receiving study treatment were included in the analysis during treatment. During treatment analysis excludes any patient without a calculated LDL-cholesterol value available between the first dose of study treatment until 21 days after the last injection. b pooled estimates for adjusted mean (SE) shown for lipoprotein (a) and triglycerides.

P values were taken from the analysis of the mixed effects model with repeated measures.

Table 41 - Percentage change from baseline in LDL-C calculated at week 24 (pattern mix model)

Alirocumab 150 c / 2sem Placebo (N = 780) (N = 1523)

Calculated LDL-C

Baseline level, mean (SD) mg / dL 122.0 (41.6) 122.7 (42.7)

Range 19-404 39-424

Mean change by MC (SE) from baseline to

week 24 (%) 0.7 (1.1) -57.8 (0.8)

mean difference by MC (SE) vs placebo -58.5 (1.3)

95% CI -61.1 to -55.8

p-value vs placebo <0.0001

Abbreviations: CI, confidence intervals; LDL, low-density lipoprotein; MC, least squares; THL, lipid-lowering therapy; SE, standard error.

a This sensitivity analysis has been performed to further assess the impact of missing data on the primary endpoint: in this approach, missing LDL-cholesterol values calculated during the "during treatment" period were multiple imputed using a model that assumed LDL cholesterol values absent at randomization and absent values calculated during the post-treatment period were imputed multiply using random draws from a normal distribution, with a mean equal to the subject's own baseline value.

The detailed analysis for each key secondary endpoint is described in this document.

The analysis during treatment of the change in the percentage of LDL-C calculated from baseline to week 24 shows results consistent with the ITT analysis with a mean difference by MC vs placebo of - 63.5% in the analysis during the treatment versus -61.9% in ITT analysis. In fact, LDL-C values were collected from some patients after treatment (that is, more than 21 days after the last injection at week 24: 37 patients (2.4%) in the alirocumab group vs 20 (2.6%) in the placebo group. The change in percentage from baseline in lipid parameters at week 24 in the ITT population and the treatment population can be seen in Table 39 and Table 40, Respectively, the analysis of the pattern mixes model of the change in percentage from baseline in LDL-C calculated at week 24 can be seen in Table 41.

ITT and during treatment analysis of the change in percent LDL-C calculated from baseline to week 12 also shows consistent results.

At week 24, the effect of treatment on measured LDL-C is comparable to the effect on calculated LDL-C. The measured LDL-C results will be further investigated, including the correlation between calculated and measured LDL-C.

ITT analysis was performed on Apo B, not HDL-C and total C at week 12 and 24. Analysis during treatment was also performed at week 24 for Apo B and not HDL-C. The results of the ITT analysis and during treatment are similar for these 2 lipid parameters. The alirocumab group had a significant reduction in non-HDL-C, ApoB and Lp (a) levels compared to placebo in 24 weeks.

In ITT analysis at week 24, 80.7% of very high CV or high CV risk patients achieved calculated LDL-C <70 mg / dL or <100 mg / dL, respectively, in the alirocumab group vs. to 8.5% in the placebo group (p <0.0001). Regarding the analysis during treatment at week 24, 82.8% of patients with very high CV risk or high CV risk achieved calculated LDL-C <70 mg / dL or <100 mg / dL, respectively, in the alirocumab group versus 8.5% in the placebo group.

The proportion of patients achieving calculated LDL-C <70 mg / dL in ITT analysis and during treatment at week 24 was studied. 79.3% of patients in the alirocumab group reached this level in ITT analysis ( 81.2% in the on-treatment analysis) versus 8.0% in the placebo group in the ITT analysis (8.0% in the on-treatment analysis).

Primary Efficacy Endpoint by Subgroup Status

As described below, primary efficacy endpoint comparisons were analyzed in various subgroups, including heFH status, demographic groups, medical history, and patients achieving two LDL-C <25 mg / dL in a row.

A comparison of the percentage change in LDL-C from baseline to week 24 between patients who have heterozygous familial hypercholesterolemia ("HeFH"), and those who do not, is provided in Table 43 and Figures 12A-C. . Figure 12B shows a comparison between the HeFH patient population having baseline LDL-C levels of <160 mg / dL or> 160 mg / dL; Figure 12C shows a comparison between the HeFH patient population who have baseline LDL-C levels of <190 mg / dL or> 190 mg / dL. All patients received prior treatment that included maximally tolerated statins and optional additional lipid-lowering therapies. The decrease in the percentage change in LDL-C from baseline to week 24 was statistically significant in the alirocumab groups compared to the placebo groups regardless of whether the patients had heHF (see Figure 12A). The decrease in the percentage change in LDL-C from baseline to week 24 was also statistically significant in the alirocumab groups compared to the placebo groups regardless of and whether heHF patients had LDL-C> 160 mg / dL or <160 mg / dL (see Figure 12B) or LDL-C> 190 mg / dL or <190 mg / dL (see Figure 12C).

The observed difference between mean percent change by MC (SE) from baseline to week 24 for LDL-C in alirocumab-treated patients (compared to placebo patients) was also consistent in patients with PCSK9 levels that were lower or higher than the median total or free PCSK9 value. Median total PCSK9 levels were 637 ng / mL in the alirocumab group and 640 ng / mL in the placebo group. Total PCSK9 levels are defined as all circulating, including PCSK9 that is free (unbound), as well as PCSK9 that is bound by anti-PCSK9 antibodies (and inactive). For patients with total PCSK9 levels below the median, the percentage change from baseline in calculated LDL-C was significantly greater in the alirocumab group (mean by MC vs. baseline -60.1%) compared with the placebo group (mean by MC vs. baseline level -2.8%) (mean difference by MC vs. placebo of -57.3%, p <0.0001). For patients with total PCSK9 levels at or above the median, the percentage change from baseline in calculated LDL-C was significantly greater in the alirocumab group (mean by MC vs. baseline -62.1% ) compared to the placebo group (mean by MC vs. baseline 4.1%) (mean difference by MC vs. placebo of -66.0%, p <0.0001). The percentage change in LDL-C from baseline to Week 24 showed a statistically greater reduction in subjects with total PCSK9 levels at or above the median compared to total PCSK9 levels below the median ( interaction p value 0.0003).

Similarly, for patients with free PCSK9 levels below the median, the percentage change from baseline in calculated LDL-C was significantly greater in the alirocumab group (mean by MC vs. baseline -59.4%). compared to placebo group (mean by MC vs. baseline -1.6%) (mean difference by MC vs. placebo of -58.0%, p <0.0001). For patients with free PCSK9 levels at or above the median, the percentage change from baseline in calculated LDL-C was significantly greater in the alirocumab group (mean by MC vs. baseline -62.7% ) compared to the placebo group (mean by MC vs. baseline 3.0%) (mean difference by MC vs. placebo of -66.0%, p <0.0001). The percentage change in LDL-C from baseline to week 24 showed a statistically greater reduction in subjects with free PCSK9 levels at or above the median compared to those with free PCSK9 levels below the median. (interaction p value 0.0015).

The decrease in percent change in LDL-C from baseline to Week 24 observed in this study was also statistically significant in the alirocumab groups compared to the placebo groups in both men and women. In men, the percentage change from baseline in calculated LDL-C was significantly greater in the alirocumab group (mean by MC vs. baseline -65.5%) compared to the placebo group (mean by MC vs. baseline -0.7%) (mean difference by MC vs. placebo of -64.7%, p <0.0001). In women, the percentage change from baseline in calculated LDL-C was significantly greater in the alirocumab group (mean by MC vs. baseline -53.4%) compared to the placebo group (mean by MC vs. baseline 3.2%) (mean difference by MC vs. placebo of -56.6%, p <0.0001). The percentage change in LDL-C from baseline to week 24 showed a statistically greater reduction in men than in women (interaction p value 0.0014).

The decrease in percent change in LDL-C from baseline to Week 24 seen in the ODDYSEY LONG TERM study was also statistically significant in the alirocumab groups compared to the placebo groups in different subgroups, including race. , age, BMI, moderate chronic kidney disease, diabetes status and baseline fasting TG levels (see Figure 13), different subgroups of statin and lipid-lowering therapy (LTT) (see Figure 14). All patients received a prior statin (at the maximum tolerated level). A subset of patients also received additional lipid-lowering therapy.

Two consecutive calculated LDL-C values <25 mg / dL (<0.65 mmol / L) were observed in 562 (37.4%) patients. An analysis of the frequency of TEAE (PT) was made against the global alirocumab group that evaluated clear imbalances.

TEAEs that were AESI that occurred in patients with two consecutive calculated LDL-C values <25 mg / dL (<0.65 mmol / L) for frequency were compared with the global alirocumab group. Finally, the theoretical AE were reviewed to ensure that there was no such reported term, and if it was present they were further investigated in the data at the patient level. No particular safety concern has been observed from such an assay in these patients.

Table 42 - Number (%) of patients with 2 LDL-C in a row <25 mg / dL (<0.65 mmol / L) during the treatment period - Safety population (at the time of the previously specified analysis)

Placebo Alirocumab 150 c / 2 weeks (N = 788) (N = 1550) Patients with 2 consecutive values of calculated LDL-C 0/767 562/1503 (37.4%) <25 mg / dL 1

Time to first calculated LDL-C value

<25 mg / dL (weeks) 2

Number 0 562

Mean (SD) 11.03 (11.51) Median 4.86

Min: Max 2.3: 65.1

Patients with 2 consecutive values of calculated LDL-C 0/767 223/1503 (14.8%) <15 mg / dL 1

Time to first calculated LDL-C value

<15 mg / dL (weeks) 2

Number 0 223

Mean (SD) 12.99 (12.43) Median 8.14

Min: Max 3.1: 64.6

The number (n) represents the subset of the total number of patients who met the criteria

The denominator (/ N) within a treatment group is the number of patients for the treatment group who had at least two calculated LDL-C values evaluated at least 21 days apart in the efficacy period.

12 values are considered in a row if they are separated by at least 21 days

2 First calculated LDL-C value <25 or <15 mg / dL among the first 2 values in a row of calculated LDL-C <25 or <15 mg / dL per patient

Table 43 - Percentage Change from Baseline in LDL-C Calculated at Week 24: By HeFH Status at Randomization - ITT Population

Subgroup factor

Percentage change from baseline on Placebo Alirocumab 150 LDL-C p-value calculated at week 24 (%) (N = 780) w / 2w (N = 1530) interaction HFhe 0.6038 Population of HFhe

Number 145 271

Means by CM (SE) 7.0 (2.4) -56.3 (1.9)

Mean difference by CM (SE) vs placebo -63.2 (2.9)

95% CI (-69.0 to -57.5)

HNFhe population

Number 635 1259

Means by MC (SE) -0.5 (1.1) -62.1 (0.8)

Mean difference by MC (SE) vs placebo -61.5 (1.4)

95% CI (-64.3 to -58.8)

Note: Least squares means (LC), standard errors (SE) and p-value taken from MMRM analysis (mixed effects model with repeated measures).

The model includes the fixed categorical effects of treatment group, randomization strata according to IVRS, subgroup factor, moment of time, and treatment interactions by moment of time, strata by moment of time, subgroup factor by moment of time, group treatment by subgroup factor, and treatment group by subgroup factor by moment of time, as well as the continuous fixed covariates of baseline LDL-C value and baseline LDL-C value interaction by moment of time interaction.

The number corresponds to the number of patients with a baseline value and a post-baseline value in at least one of the analysis windows used in the model.

The p-value is provided for descriptive purposes only

Summary of efficacy results:

At week 24, the percentage change from baseline in LDL-C calculated in the ITT population was significantly greater in the alirocumab group (mean by MC vs. baseline -61.0%) compared to the group placebo (mean by MC vs. baseline 0.8%) (mean difference by MC vs. placebo of -61.9%, p <0.0001) (see Table 35). The analysis during treatment of the change in the percentage of LDL-C from baseline to week 24 shows results consistent with the ITT analysis with a mean difference by MC vs placebo of -63.5% in the analysis during treatment (p <0.0001). In fact, at week 24, some patients (2.5% of overall patients) had LDL-C values collected after treatment (that is, more than 21 days after the last injection). At week 24, the effect of treatment on measured LDL-C (mean by MC vs. baseline -61.3%) is comparable to the effect on calculated LDL-C (ITT analysis).

In the alirocumab group, a consistent reduction in LDL-C was observed from baseline from week 4 to week 52.

The homogeneity of the treatment effect on baseline lipid levels was evaluated and showed a significant interaction of treatment by baseline LDL-C level (p <0.0001). This observation appears to be due to changes in the placebo group. In fact, the change in LDL-C from baseline to week 24 is consistent across the different LDL-C subcategories within the alirocumab group. The mean percent change by MM (SE) from baseline to week 24 for LDL-C in patients in the alirocumab group was statistically significant and consistent over a baseline LDL-C range (Table 37).

All key secondary endpoints were statistically significant according to the hierarchical testing procedure.

Two consecutive calculated LDL-C values <25 mg / dL (<0.65 mmol / L) were observed in 562 (37.4%) patients. No particular safety concern has been observed in these patients.

Summary of safety results:

For the purposes of this study, TEAE are adverse events that developed, worsened, or aggravated during the TEAE period (time from the first dose of double-blind treatment to seventy days after the last dose). At the time of the previously specified analysis, the percentages of patients experiencing TEAE, severe TEAE, and TEAE leading to treatment discontinuation were similar between treatment groups (see Table 44).

The most frequently reported SOCs in both treatment groups (> 10%) were "infections and infestations" (45.5% in the alirocumab group vs 46.1% in the placebo group), "musculoskeletal and tissue disorders conjunctiva "(27.2% in the alirocumab group vs. 28.6% in the placebo group)," gastrointestinal disorders "(18.6% in the alirocumab group vs. 18.8% in the placebo group ), "nervous system disorders" (17.0% in the alirocumab group vs. 17.8% in the placebo group) "general disorders and administration site conditions" (15.4% in the alirocumab vs. 17% in the placebo group), "injury, poisoning, and procedural complications" (13.4% in the alirocumab group vs. 14.2% in the placebo group), and "respiratory, thoracic, and mediastinal "(11.0% versus 10.9%). Table 45 lists the TEAE number for the selected organ and system classes. Table 46 lists the percentage of different TEAEs in the alirocumab and placebo groups, as well as specifically lists the TEAEs observed in the alirocumab-treated patients (by percentage of patients) with two measurements in a row of LDL-C of less than 25 mg. / dL. All patients received a prior statin (at the maximum tolerated level). A subset of patients also received additional lipid-lowering therapy. Patients who have reached LDL-C levels below 25 mg / dL in two or more consecutive periods constitute 36.3% of the population of patients treated with alirocumab (562 patients out of 1550). Certain laboratory values of interest (alanine aminotransferase> 3 x ULN, aspartate aminotransferase> 3 x ULN, and creatine kinase> 3 x ULN) are shown in Table 47. Some patients with alirocumab (31 of the 1461.2.1%) had plasma vitamin E levels reduced below the outer limit of normal during the TEAE period (compared to 1 patient out of 738 in the placebo group, 0.1%).

There was no marked imbalance in the frequency of TEAE (preferred term). The following TEAEs were the most frequently reported in both treatment groups (> 5% in either group): nasopharyngitis (12.6% in alirocumab vs 12.7% in the placebo group), upper respiratory infection ( 7.0% vs. 8.0%), injection site reaction (5.7% vs. 4.3%), flu (5.4% vs. 5.5%), diarrhea (5.3% vs. 5.1%), urinary tract infection (5.2% vs 6.2%), bronchitis (5.2% vs 4.7%) and headache (4.8% vs 5.6%). Most injection site reactions (local injection site treatment emergent reactions) were mild or moderate in intensity, with the first reaction occurring in the first three months of therapy (57 days of alirocumab vs 100 days of placebo). for most patients.

TEAEs of special interest included: local reactions emerging from injection site treatment; general reaction allergic events; neurological events; neurocognitive disorders; adjudicated cardiovascular events; neurocognitive disorders; and hemolytic anemia. The prevalence of these events in the alirocumab and placebo groups is shown in Table 48. The prevalence of specific neurocognitive adverse events in the alirocumab and placebo groups is shown in Table 49.

Nineteen (19) deaths were reported during the study (11 (0.7%) in the alirocumab group vs 8 (1.0%) in the placebo group). Focusing on TEAEs leading to death, 7 (0.5%) deaths were reported in the alirocumab group versus 8 (1.0%) in the placebo group. By adjudication, the leading cause of death was cardiovascular in both treatment groups (during the TEAE period, 5 (0.3%) cardiovascular deaths in the alirocumab group versus 5 (0.6%) in the alirocumab group). placebo).

SAE was reported for 394 patients (255 (16.5%) patients in the alirocumab group and 139 (17.6%) patients in the placebo group) during the TEAE period. There is no imbalance between groups.

No specific pattern was reported among TEAEs leading to permanent treatment discontinuation.

Among the events of interest, no particular signal was detected for TEAE related to neurological events and ophthalmological events (including in the ophthalmological substudy). For neurocognitive disorders, 18 (1.2%) were observed in the alirocumab group compared to 4 (0.5%) in the placebo group which mainly includes amnesia, memory impairment and confusional state. No cases of hemolytic anemia were reported.

With regard to general allergic reaction, similar proportions of patients reported at least such an event in the alirocumab groups (140 [9.0%]) versus placebo (71 [9.0%]).

124 (5.3%) patients (90 (5.8%) of patients in the alirocumab group and 34 (4.3%) patients in the placebo group) had a local treatment-emergent reaction of the injection site. Most of these events were of mild or moderate intensity.

According to the exploratory analysis of "diabetes and impaired glucose control", a total of 36 (6.3%) patients in the alirocumab group and 10 (3.6%) patients in the placebo group classified as having "control altered glucose "at baseline were defined as diabetics in the period of TEAE. Two patients classified as normal at baseline became diabetic (one in each treatment group).

There was no imbalance for PCSA of laboratory parameters, ECG and vital signs.

Table 44 - Treatment-emergent adverse events (at previously specified time of analysis)

Table 45 - TEAE by class of systems and organs (> 2%) in any group (at the time of the previously specified analysis)

Table 46 - TEAE listed by patient subgroup (at the time of the previously specified analysis)

Table 47 - Laboratory values of interest (at the time of the previously specified analysis)

Table 48 - Adverse events of special interest (at the time of the previously specified analysis)

Table 49 - Neurocognitive Adverse Events (at the time of the previously specified analysis)

RESULTS II - FINAL ANALYSIS

Although all primary and secondary efficacy endpoints were completed at the time of the pre-specified interim analysis, the study continued to completion, allowing analysis of the entire safety population.

Summary of the characteristics of the safety population:

The mean study drug exposure was 70 weeks in the 2,338 patients included in the safety analysis (1,550 in the alirocumab groups and 788 in the placebo groups), providing 2,061 patient-years of exposure to alirocumab 150 mg every two weeks. The overall mean compliance to study treatment (ie, the percentage of days a patient received their injections according to the planned administration schedule) was 98.0% and 97.6% in the alirocumab and placebo groups, respectively. The mean duration of follow-up (regardless of adherence to treatment) in the safety population was 80.9 weeks for alirocumab and 80.1 weeks for placebo. The study treatment discontinuation rates were 28% for alirocumab and 25% for placebo.

Effectiveness

Consistent LDL cholesterol reduction from baseline was observed from week 4 to 78 in the alirocumab group (Figure 15). The results for measured LDL were in agreement with those for calculated LDL cholesterol. The percentage decrease in LDL cholesterol was slightly lower at week 78 (52%) versus week 24 (61%) in the intention-to-treat analysis; this observation was influenced by the values collected after premature treatment interruption.

Safety

Similar percentages of patients experienced treatment-emergent adverse events in both treatment groups (81% with alirocumab vs 83% with placebo) (Table 50). Treatment-emergent adverse events leading to study drug discontinuation occurred in 7.2% of alirocumab patients and 5.8% of placebo patients. Regarding specific adverse events, there were differences between the alirocumab and placebo groups in the rates of injection site reactions (5.9% vs. 4.2%, respectively), myalgia (5.4% vs. 2.9%, respectively), neurocognitive events (1.2% versus 0.5%, respectively), and ophthalmologic events (2.9% versus 1.9%, respectively; Table 50).

Among the alirocumab patients, 575 (38% of the total) had two consecutive levels of calculated LDL cholesterol less than 25 mg / dL. The treatment-emergent adverse event rates among these patients were comparable to those among the global alirocumab group.

Table 50. AE of interest and laboratory values to assess safety (safety analysis) N ° of patients Alirocumab Placebo p-value Patients with maximum tolerated statin ± other THL (N = 1550) (N = 788) Summary of TEAE *

TEAE 1,255 (81.0) 650 (82.5) 0.3983 Treatment-emergent SAE 290 (18.7) 154 (19.5) 0.6555 TEAE leading to death 8 (0.5) 10 (1, 3) 0.0760 TEAE leading to discontinuation 111 (7.2) 46 (5.8) 0.2559 cardiovascular AE of interest

Death from CHD including unknown cause 4 (0.3) 7 (0.9) 0.2559 Non-fatal MI 14 (0.9) 18 (2.3) 0.0129 Fatal and non-fatal ischemic stroke 9 (0 .6) 2 (0.3) 0.3528 Unstable angina requiring hospitalization 0 1 (0.1) 0.337 Congestive heart failure requiring hospitalization 9 (0.6) 3 (0.4) 0.761 Coronary revascularization procedure guided by 48 (3.1) 24 (3.0) 1 ischemia

Positively adjudicated cardiovascular events 72 (4.6) 40 (5.1) 0.682 (including all listed cardiovascular AE

previously)

A posteriori analysis of a subgroup of awarded MACE1 '27 (1.7) 26 (3.3) 0.0116 Other AE of interest

General allergic reaction events 156 (10.1) 75 (9.5) 0.7142 Local injection site reaction 91 (5.9) 33 (4.2) 0.0968 Myalgia 84 (5.4) 23 (2.9) 0.0063 Neurological events * 65 (4.2) 35 (4.4) 0.8289 Neurocognitive disorders§ 18 (1.2) 4 (0.5) 0.1727 Amnesia 5 (0.3 ) 0 0.1747 Memory impairment 4 (0.3) 1 (0.1) 0.6686 Confusional state 4 (0.3) 1 (0.1) 0.6686 Ophthalmological events 35 (2.9) 15 (1.9) 0.6516 Hemolytic anemia 0 0 NC Diabetes in patients without a history of diabetes, n / N (%) »18/994 (1.8) 10/509 (2.0) 0.8419 Worsening of diabetes in patients with a history of 72/556 (12.9) 38/279 (13.6) 0.8284 of diabetes, n / N (%) "

Laboratory values of interest

Alanine aminotransferase> 3 times ULN, n / N (%) 28/1533 (1.8) 16/779 (2.1) 0.748 Aspartate aminotransferase> 3 times ULN, n / N (%) 22/1533 (1.4 ) 18/779 (2.3) 0.1316 Creatine kinase> 3 times ULN, n / N (%) 56/1507 (3.7) 38/771 (4.9) 0.1819 p-values calculated using Fisher's exact test and unadjusted for multiplicity. : Provided for descriptive purposes only.

Claims (12)

1. An inhibitor of proprotein convertase subtilisin / human kexin type 9 (PCSK9), wherein said PCSK9 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to PCSK9 and comprises the amino acid sequence of the heavy chain variable region (HCVR) set forth in SEQ ID NO: 1. and the amino acid sequence of the light chain variable region (LCVR) set forth in SEQ ID NO: 6, for use in the treatment of hypercholesterolemia in a high cardiovascular risk patient who has: (a) a serum low-density lipoprotein cholesterol (LDL-C) level greater than 70 mg / dL despite taking a stable maximum daily tolerated dose of statin therapy for at least 4 weeks; Y (b) established coronary heart disease (CHD) or CHD risk equivalents, the equivalents being defined as including one or more of the following four criteria: 1) peripheral arterial disease (PAD); 2) ischemic stroke; 3) chronic kidney disease; and / or 4) history of diabetes mellitus and 2 or more additional risk factors selected from the group consisting of: a) history of hypertension, b) history of ankle-brachial index <0.90, c) history of microalbuminuria or macroalbuminuria or dipstick urinalysis at screening visit with> 2+ protein, d) history of preproliferative or proliferative retinopathy or laser treatment for retinopathy, and e) known family history of premature CHD. 2. The PCSK9 inhibitor for use according to claim 1, wherein the patient has received at least one other lipid-lowering therapy. 3. The PCSK9 inhibitor for use according to claim 1, wherein the patient has pre-existing arterial hypertension. 4. The PCSK9 inhibitor for use according to claim 1, wherein the patient has pre-existing type 2 diabetes mellitus. 5. The PCSK9 inhibitor for use according to any one of claims 1-4, wherein the antibody or antigen-binding fragment thereof is administered in a dose of about 75 mg, about 150 mg, or about 300 mg. 6. The PCSK9 inhibitor for use according to any one of claims 1-5, wherein the antibody or antigen-binding fragment thereof is administered in a dose of about 75 mg or about 150 mg every two weeks. The PCSK9 inhibitor for use according to claim 6, wherein (a) the dose of about 75 mg is maintained if the patient's LDL-C measured after five or more doses is <70 mg / dL, and / or (b) the approximately 75 mg dose is discontinued if the patient's LDL-C measured after five or more doses remains> 70 mg / dL, and the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is subsequently administered to the patient in a dose of approximately 150 mg at a frequency of once every two weeks. 8. The PCSK9 inhibitor for use according to any one of claims 1-7, wherein the antibody or antigen-binding fragment thereof is administered subcutaneously. The PCSK9 inhibitor for use according to any one of claims 1-8, wherein the antibody or antigen-binding fragment thereof is administered subcutaneously with a pen delivery device, preferably a pen delivery device. pre-filled pen from a reusable pen delivery device using a replaceable cartridge containing the antibody or antigen-binding fragment thereof, or with an auto-injector delivery device. The PCSK9 inhibitor for use according to any one of claims 1-9, wherein the PCSK9 inhibitor is administered to the patient in combination with maximum tolerated dose statin therapy. The PCSK9 inhibitor for use according to any one of claims 1-10, wherein the antibody or antigen-binding fragment thereof accomplishes one or more of the following when administered to the subject: (i) reduction of the patient's LDL-C by at least 40%; (ii) reduction of the patient's apolipoprotein B100 (ApoB) by at least 35%; (iii) reduction of the patient's non-high-density lipoprotein (non-HDL-C) cholesterol by at least 35%; (iv) reduction of the patient's total cholesterol by at least 20%; (v) increase in the patient's high-density lipoprotein cholesterol (HDL-C) by at least 1%; (vi) reduction of triglycerides of the patient by at least 1%; (vii) reduction of the patient's lipoprotein a (Lp (a)) by at least 10%; Y (viii) increase in the patient's apolipoprotein A1 by at least 1%. 12. A pharmaceutical composition comprising the PCSK9 inhibitor according to claim 1 for use according to claim 1, wherein the pharmaceutical composition is administered by bolus injection.