1 from the bench ………. to the bedsideBiP/Rasolvir: from the bench ………. to the bedside Val Corrigall and Gabriel Panayi Academic Department of Rheumatology King’s College London

2 Acknowledgements ALL the PATIENTS PRE-CLINICAL In Vitro KCL Chris HallHannah Cornell Mark Bodman-Smith Thierry LeQuerre Olivier Vittecoq Adrian Shields Vikesh Devlia Jill Pleasance Agi Grigoriadis Brian Henderson UCL Protein production design Paul Brown, Renee Tata and Mitla Garcia CBC GMP facility Paul Lloyd-Evans Denise Phillips In Vivo (mouse) Linda Myers Tennessee USA Paul Wooley Witchita USA Georg Schett, Jean-Pierre David Mario Zaiss University of Erlangen Kaoru Yoshida, Akira Ochiai, Hiroaki Matsuno Toin University Japan Steve Thompson KCL Becky Brownlie Helen Collins CLINICAL Clinical Trial/BRC/Quintiles Bruce Kirkham Khal Chaabo Gerry Tillana Tim Mant, Liz Allen Jackie Pullen, Salma Kibaida, Data Monitoring and Safety Committee David Scott ALL the PATIENTS 2 2

3 From the bench ………………

4 BiP/RasolvirTM Human stress proteinProduced in high yield and purity by recombinant technology Approved for human use Successful conclusion Phase I/IIA Clinical Trial in patients with RA who had failed DMARDs and even biologics New biologic treatment for rheumatoid arthritis 4 4

5 Unified Mode of Action BiP/Rasolvir works by modifying development from pre-cursor mononuclear cells of: Antigen presenting cells to tolerising APC; Osteoclasts: inhibiting development & activity; Macrophage development deviated to anti- inflammatory function.

6 Pre-clinical studies 6 6

7 Collagen-Induced Arthritis (CIA) modelProtection BiP i.v Therapy BiP i.v or s.c bCII/CFA bCII/IFA day arthritis d0 d21 Prof Linda Myers Dr Steve Thompson

8 A single low dose of Rasolvir™ “cured” arthritis in the CIA model.1μg Rasolvir™ was injected at onset of paw swelling Vehicle Control  Rasolvir™ 1μg IV Days after immunization A single low dose of Rasolvir™ “cured” arthritis in the CIA model. 8 8

9 BiP/Rasolvir™ single IV injectionSaline control BiP/Rasolvir™ single IV injection 9 9

10 Adoptive transfer therapy CIA modelPBS or BiP (200μg sc) Spleen+LN cells from +/- BiP-treated mice d12 bCII + IFA bCII + CFA d0 d21 d24/25 arthritis 10 10

11 BiP-treated (■) 0r PBS-treated (●)Therapy CIA by adoptive transfer of lymphoid cells from BiP-treated mice Regulatory cells induced in the spleen/lymph node cell population (60% T cells) of the BiP-treated mouse suppress CIA. Immune cell development has been altered in the BiP treated mice to give long-term therapy in the absence of additional BiP Mean disease severity score BiP-treated (■) 0r PBS-treated (●) lymphoid cells Time (days) Brownlie,R.J.; Arthritis Rheum 54: 11 11

12 Conclusion from CIA model:Rasolvir™/BiP does not block a ligand/receptor interaction Rasolvir™/BiP does not have to be present after the initial treatment for a therapeutic effect to be seen Rasolvir™/BiP is an immunomodulator Rasolvir™/BiP alters immune cell development 12 12

13 In vivo pre-clinical studies13 13

14 Collaborative project hTNFα transgenic mouseDepartment of Internal Medicine and Institute for Clinical Immunology at the University of Erlangen-Nuremberg, Germany M Zaiss, J-P David and G Schett M Zaiss 14 14

15 Experimental protocolArthritis BiP birth w11 w5 ip 10μg Weekly monitoring Arthritis

16 Clinical parameters (n=4 mice/group)Body weight 6 7 8 9 10 11 12 14 16 18 20 Time [week] Weight [g] Grip strength -3 -2 -1 Arthritis Score Paw swelling 1 2 3 4 TNFtg control TNFtg + Bip Paw Swelling * * * Single dose ip PBS or BiP (10μg/mouse) Wk 5

17 Histology of the paw (n=4 mice/group)

18 ip 250μg weekly anti-TNF Weekly monitoring Arthritis ArthritisAnti -TNF blocks a ligand-receptor interaction Multiple doses of anti-TNF required for the same effect as single dose BiP Hence superiority of immunoregulation

19 Conclusion from TNFtg mouse model:BiP inhibits inflammation BiP inhibits osteoclastogenesis BiP inhibits pre-osteoclast and mature osteoclast function Rasolvir™ could protect patients from inflammation and bone loss 19 19

20 In vivo pre-clinical studies20 20

22 Xenogeneic SCID model Rheumatoid arthritis synovial membrane (RASM) transplanted into SCID mice Transplantation of RASM iv mouse BiP or HSA Mice killed SM transplants removed vascular anastomosis Wk0 Wk 4 Wk6 Histology ELISA Kaoru Yoshida,et al. Arthritis Research and Therapy 13:R 22 22

23

24 Reduced Cellular infiltration of RASM transplantsControl (HSA) BiP 24 24 24

25 Immunohistological examination of transplantsA single intravenous administration of BiP (10μg) into the SCID mouse suppresses inflammation in the human RASM explant Control (HSA) CD86 HLA-DR TNFα IL-6 BiP 25 25

27 Rasolvir™ resolves rheumatoid synovitis To the bedside

28 The RAGULA Trial Clinical team GSTT GSTT BRC Gerry Trillana QuintilesProf Gabriel Panayi Dr Bruce Kirkham Dr Khal Chaabo BRC Gerry Trillana Quintiles Prof Tim Mant Dr Liz Allen Marco Da Sa 28 28

29 First in Human, Randomised, Placebo Controlled, Double Blind, Single Escalating Dose, Phase I/IIa Study of BiP/Rasolvir in RA Infusion months 29 29

30 Primary Endpoint: SafetyNo serious adverse (SAE) or adverse events (AE) from treatment with BiP 30 30

31 Tertiary endpoint – serum biomarkersSecondary endpoint – Efficacy Disease Activity Score 28 (DAS28) > 5.1 active disease; <3.2 low disease activity; <2.6 remission Tertiary endpoint – serum biomarkers C-reactive protein (CRP) Vascular Endothelial Growth Factor (VEGF) Interleukin-8 (IL-8) 31 31

32 “Remission is an ambitious primary end point for RA clinical trials.”Mack EE, Hsia E, Aletaha D (2016) Arth. Rheum, doc: /art.3945

33 DAS28 response : 12 weeks post infusionRemission Good Moderate None 15mg group 2/6 patients (33%) 2/6 (30%) 5mg group 1/6 patient (16%) 1/6 3/6 (50%) 1mg group No 1/6 (15%) 2/6 (30%) 3/6 (50%) Placebo 4/6 (60%) 33 33

34 Remission with anti-TNF biologicsData from clinical trials; at 6 months. RA-ATTRACT: infliximab placebo <1% Infliximab 4-6% GO-FORWARD: golilumab placebo <3% golilumab 13%

35 Serum Biomarker: VEGF 35 35

36

37 Future Plans To develop BiP/Rasolvir as a new biologic for the treatment of: RA Other inflammatory joint diseases: JIA, ank spondylitis Other inflammatory/autoimmune diseases: Crohn’s disease, Type I diabetes mellitus (prevention) Prevention allograft rejection Bone loss: systemic/localised