Dominick J. Angiolillo, MD, PhD Director of Cardiovascular Research Assistant Professor of Medicine University of Florida College of Medicine – Jacksonville, Fl A Randomized Study Assessing the Impact of Cilostazol on Platelet Function Profiles in Patients with Diabetes Mellitus and Coronary Artery Disease on Dual Antiplatelet Therapy: Results of the OPTIMUS-2 (Optimizing anti-Platelet Therapy In diabetes MellitUS) Study CRT 2008 Wednesday February 13 th, 2008

Presenter Disclosure Information Name: Dominick J Angiolillo Within the past 12 months, the presenter or their spouse/partner have had a financial interest/arrangement or affiliation with the organization listed below. Company Name:Relationship: Bristol Myers SquibbConsultant/Speaker bureau Sanofi-AventisConsultant/Speaker bureau Eli LillyConsultant/Speaker bureau Daiichi SankyoConsultant/Speaker bureau PortolaConsultant GSKEducational Grant OPTIMUS 2 was an investigator-initiated study. Dr Angiolillo was recipient of the 2006 GSK International Competitive Educational Grant to perform the study. Otsuka pharmaceuticals provided study medication.

% Platelet aggregation (LTA-ADP 20  M) Number of patients Angiolillo DJ et al. Am J Cardiol 2006; 97: Individual response variability to dual antiplatelet therapy OPTIMUS-2 Ischemic Risk (including stent thrombosis)

78% 14% 8% p=0.04 Influence of Diabetes Mellitus on Clopidogrel-induced Antiplatelet Effects Angiolillo DJ et al. Diabetes 2005; 54: Non responders (Platelet inhibition  10%) Low responders (Platelet inhibition 10-29%) Responders (Platelet inhibition >30%) 56% 6% 38% DM No-DM Acute phase of treatment Long-term phase of treatment 24 hrs post 300 mg LD Angiolillo DJ et al. J Am Coll Cardiol 2006; 48: OPTIMUS Platelet aggregation (%) p=0.002 p< ADP 20  MADP 6  M DM No-DM DM No-DM

P2X 1 P2Y 12 ATP Shape change adapted from Angiolillo DJ et al JACC 2007 P2Y 1 GqGq Initiation of Platelet Aggregation IP3 PKC GP IIb/IIIa receptor activation G 12 DAG + Shape change Granule secretion Stabilization of Platelet Aggregation βγβγ GP IIb/IIIa receptor activation Rap1b PKB/Akt αiαi AC VASP cAMP VASP-P cAMP GiGi PI3K Clopidogrel 15% active metabolite HOOC * HS N O Cl OCH 3 N S O Cl O CH 3 C 85% inactive metabolites (Esterases in blood) Gastro-intestinal absorption ADP Ca 2+ flux Ca 2+ mobilization PLCβ MLCK-P “Rho” Hepatic CYP Biotransformation AC GsGs GP IIb/IIIa receptor activation PGE 1 PIP2 Upregulation of P2Y 12 receptor signaling in type 2 diabetes mellitus Cilostazol PDE-III

Objectives To evaluate platelet function profiles obtained with the adjunct of cilostazol in patients with type 2 diabetes mellitus and coronary artery disease while on standard dual (aspirin and clopidogrel) antiplatelet therapy. OPTIMUS-2

Study Design Type 2 Diabetes Mellitus patients with coronary artery disease on aspirin (81 mg) + clopidogrel (75 mg) therapy for ≥ one month OPTIMUS-2 Inclusion Criteria Prospective, randomized, double-blind, placebo controlled, cross-over design Randomization Cilostazol 100 mg b.i.d. for 2 weeks Placebo b.i.d. for 2 weeks Cilostazol 100 mg b.i.d. for 2 weeks Baseline Visit 1 2 weeks Visit 2 4 weeks Visit 3

Endpoints Primary: P2Y 12 reactivity index (PRI) OPTIMUS-2 Power Calculation: Cilostazol will lead to a 15 ± 16% decrease in PRI; a minimum of 17 patients required to achieve a power of 95% (  two-sided = 0.05) Secondary: - VASP-P - VerifyNow P2Y 12 (%inhibition and PRU) - Light Transmittance Aggregometry (LTA) Agg max and Agg late following 5 and 20  mol/L ADP stimuli w/wo 5nM PGE 1 (post treatment platelet reactivity, IPA, platelet disaggregation) VASPVASP-P PGE1 ADP Activated or resting platelets Inhibited platelets

Exclusion criteria: allergies to aspirin, clopidogrel or cilostazol impaired glucose tolerance or T2DM without pharmacologic treatment, gestational diabetes or transient hyperglycaemia blood dyscrasia serum creatinine level >2 mg/dL active bleeding or bleeding diathesis gastrointestinal bleed within last 6 months hemodynamic instability cerebrovascular accident within 3 months any malignancy concomitant use of other antithrombotic drugs (oral anticoagulants, dypiridamole, ticlopidine) or NSAIDs recent treatment (<30 days) with a GP IIb/IIIa antagonist platelet count <100x10 6 /µL hematocrit <25% liver disease (bilirubin level >2 mg/dL). OPTIMUS-2

Withdrawal due to side effects N=4 (migraine, GI symptoms, tachycardia) Withdrawal due to side effects N=1 (GI symptoms) Flow diagram OPTIMUS-2 Cilostazol N=13 Placebo N=12 20 patients Randomized N=25 Crossover Placebo N=9 Cilostazol N=11 Side effects not leading to withdrawal of study medication: cilostazol (N=3) and placebo (N=1)

Demographics Age (yrs) 64  10 Gender (male), n (%)15 (60) Race, n (% Caucasian19 (76) African-American5 (20) Hispanic1 (4) Risk factors/past medical history, n (%) Insulin-dependent diabetes9 (36) Non-insulin-dependent diabetes16 (64) HbA1C 7.7  1.8 Smoking6 (24) Hyperlipidemia23 (92) Hypertension24 (96) Body mass index 31.  5 Prior myocardial infarction16 (64) Prior CABG7 (28) Multivessel CAD19 (76) Treatment, n (%) Beta-blockers19 (76) Nitrates5 (20) ACE-Inhibitors/ARB21 (84) CYP3A4 metabolizing statin17 (68) Non-CYP3A4 metabolizing statin5 (20) OPTIMUS-2

Absolute Change in PRI from Baseline CILOSTAZOLPLACEBO p= OPTIMUS-2 (%)

CILOSTAZOLPLACEBO p= OPTIMUS-2 P2Y 12 reactivity index (PRI) Primary Endpoint (%)

Absolute Change CILOSTAZOLPLACEBO p= Content CILOSTAZOLPLACEBO p= OPTIMUS VASP-P (MFI ADP + PGE 1 )

OPTIMUS-2 P2Y 12 inhibtion CILOSTAZOLPLACEBO p= CILOSTAZOLPLACEBO p=0.002 PRU VerifyNow P2Y 12 Assay

LTA VARIABLE Post-treatment platelet reactivity CILOSTAZOL (n=20) PLACEBO (n=20) p value ADP + PGE 1 (%) Max ADP 20 µmol/L + PGE 1 23 ± 1140 ± Late ADP 20 µmol/L + PGE 1 10 ± 1029 ± Max ADP 5 µmol/L + PGE 1 10 ± 625 ± Late ADP 5 µmol/L + PGE 1 3 ± 213 ± ADP (%) Max ADP 20 µmol/L49 ± 1848 ± Late ADP 20 µmol/L39 ± 2142 ± Max ADP 5 µmol/L33 ± 1434 ± Late ADP 5 µmol/L21 ± 1520 ± OPTIMUS-2 Light Transmittance Aggregometry No changes in Placebo vs Baseline LTA parameters (p=ns for all assessments); Cilostazol vs Baseline: (p<0.001 for all ADP + PGE1; p=ns for ADP)

OPTIMUS-2 IPA Max ADP 20  mol/L + PGE 1 CILOSTAZOLPLACEBO p< CILOSTAZOLPLACEBO Inhibition of Platelet Aggregation p< IPA Late ADP 20  mol/L + PGE 1 (%) IPA (%) = (intensity of aggregation at baseline) – (intensity of aggregation post cilostazol/placebo)/ (intensity of aggregation at baseline)

OPTIMUS-2 Disaggregation CILOSTAZOLPLACEBO p< (%) ADP 20  mol/L + PGE 1 Platelet disaggregation (%) = 100 x (1- Agg max / Agg late )

Conclusions In patients with T2DM on chronic standard dual antiplatelet therapy, treatment with cilostazol is associated with enhanced suppression of P2Y 12 receptor signaling. Enhanced P2Y 12 inhibition achieved with cilostazol in adjunct to standard antiplatelet treatment regimens may explain why lower ischemic event rates, including stent thombosis, are achieved with triple oral antiplatelet therapy compared to dual therapy. However, side effects are common with cilostazol therapy which frequently lead to drug withdrawal. Need for further improvement in antiplatelet strategies …..awaiting more outcome data with novel and potent drugs currently under advanced clinical investigation. OPTIMUS-2