Introduction:Systemic inflammation and mitochondrial bioenergetic failure are central drivers of multi-organ dysfunction in advanced liver disease, sepsis, and acute kidney injury (AKI). Currently available therapies remain largely supportive and fail to directly address intracellular NAD+ depletion and immune-metabolic dysregulation. We investigated MP-04, a novel intravenous formulation of dihydronicotinamide riboside (NRH), for its ability to restore NAD+ homeostasis, modulate immune metabolism, and confer organ protection in relevant preclinical models. Methods:The NAD+-enhancement activity of nicotinamide riboside (NR) and MP-04 was evaluated in human hepatoma (HepG2), T-cell (Jurkat), kidney (HEK293) cell lines, and peripheral blood mononuclear cells (PBMCs). Cellular bioenergetics were assessed using Seahorse extracellular flux analysis. Immunomodulatory effects were examined in polyclonally activated human PBMCs and in a murine endotoxin-induced systemic inflammation model. Pharmacokinetics and pharmacodynamics were assessed following intravenous (IV) dosing in rats, and organ protection was evaluated in a cisplatin-induced AKI mouse model. Safety of MP-04 was evaluated in rat and dog Good Laboratory Practice (GLP) toxicology studies. Results:MP-04 produced rapid, distinct, and dose-dependent increases in intracellular NAD+ across all tested human cell types and was markedly more potent than NR. IV administration in rats resulted in sustained elevations of NAD+ and NADH in blood, liver, and kidney that persisted beyond the systemic clearance of MP-04, with strong correlations between blood and tissue NAD+ levels. In activated immune cells, MP-04 reduced reliance on aerobic glycolysis, and significantly attenuated pro-inflammatory cytokine production without affecting resting cells. In vivo, MP-04 reduced systemic inflammatory cytokines following endotoxin challenge and conferred significant biochemical and histological protection against cisplatin-induced AKI. MP-04 was safe and well tolerated in rat and dog following once daily IV administration for 7 days. Conclusion:MP-04 is a safe and highly potent intravenous NAD+ precursor that modulates cellular metabolism, reduces maladaptive immune activation, and protects against inflammation-associated organ injury in preclinical models. These findings support MP-04 as a promising metabolic-immunomodulatory therapeutic strategy for conditions characterized by systemic inflammation and organ failure, including hepatorenal syndrome-associated AKI, beyond the limits of current supportive care.

Introduction and Objective: Obesity results from an imbalance between energy intake and expenditure, yet incretins primarily reduce appetite. TLC-6740 is a liver-targeted mitochondrial protonophore designed to increase energy expenditure. We evaluated TLC-6740 combined with tirzepatide (TZP) in a Phase 2a proof-of-concept study in obesity. Methods: In this double-blind trial (NCT05822544), 55 adults with obesity (BMI ≥30 kg/m2) without diabetes were randomized 3:2 to once-weekly TZP (5 mg SC) plus either daily oral TLC-6740 180 mg (n=33) or placebo (n=22) for 24 weeks (W24). The primary endpoint was safety and key efficacy endpoint was percent change in weight from baseline (BL) to W24. Exploratory assessments included glycemic parameters and liver fat and body composition by MRI. Results: At BL, mean body weight was 109.2 kg; 60% were female. At W24, mean weight change was -8.8% with TZP plus placebo and -13.3% with TZP plus TLC-6740, an additional 4.5% weight loss with the combination (p=0.018, ITT), which also produced greater improvements in insulin, HOMA-IR, liver tests, adiponectin, and hsCRP. In an MRI substudy, TZP plus TLC-6740 (n=25) vs TZP plus placebo (n=12) produced greater reductions in visceral adipose tissue (-24.8% vs -15.9%; p=0.052) and total adipose tissue without affecting lean mass. Among participants with BL liver fat ≥5% (MASLD), MRI-PDFF decreased -60.6% with TLC-6740 (n=13) vs -44.0% with placebo (n=7; p=0.12). TLC-6740 plus TZP was well tolerated. AEs led to discontinuation in 3 participants (14%) on placebo and none on TLC-6740; Grade ≥2 AEs (59% vs 49%) and GI AEs (55% vs 48%) were similar. Conclusion: The liver-targeted mitochondrial protonophore TLC-6740 combined with TZP was well tolerated and produced greater weight loss and metabolic benefits than TZP alone. These findings support combining incretins with therapies that increase energy expenditure to improve weight loss and metabolic outcomes in obesity. Disclosure R. Huss: Employee; Current; OrsoBio, Inc. E. Gane: None. A. Letica: None. J. Kerr: None. S. Smith: None. S. Zenhari: Employee; Current; OrsoBio, Inc. J. Sur: Employee; Current; OrsoBio, Inc. S. Weng: Employee; Current; OrsoBio, Inc. Stock/Shareholder; Current; OrsoBio, Inc. E. Murakami: Employee; Current; OrsoBio, Inc. Stock/Shareholder; Current; OrsoBio, Inc. B.J. Kirby: Employee; Current; OrsoBio. Consultant; Current; Actio BioSciences, SiteOne Therapeutics, Lilac Therapeutics. Consultant; Ended; Terns Pharmaceuticals. Consultant; Current; Recludix Pharma, Eurofarma. Employee; Ended; Gossamer Bio. S. Chahal: None. M. Schneider: Employee; Current; Antaros Medical. A. Vijayakumar: Employee; Current; OrsoBio, Inc. G. Shulman: Consultant; Current; Novo Nordisk A/S. Research Support; Current; Novo Nordisk A/S. Other - collaboration; Current; Ionis Pharmaceuticals. Advisory Panel; Current; ESPERION Therapeutics, Inc. Research Support; Current; Novo Nordisk Foundation. Advisory Panel; Current; Orsobio. Research Support; Current; Orsobio. Advisory Panel; Current; Village S.S.D. G. Subramanian: Employee; Current; OrsoBio. R.P. Myers: Employee; Current; OrsoBio, Inc.

Despite advances in lipid-lowering treatment, atherosclerotic cardiovascular disease remains the leading cause of mortality, underscoring the need to address residual risk. Targeting both the synthesis and clearance of triglyceride (TG)-rich lipoproteins is a promising approach. Liver X receptor (LXR) repression can reduce plasma TG and cholesterol and improve insulin sensitivity by suppressing de novo lipogenesis and intestinal lipid absorption and enhancing clearance of TG-rich lipoproteins, but its clinical utility remains unexplored. Here we demonstrate the role of LXR inverse agonists in lipid metabolism and metabolic diseases in preclinical models and humans. Given concerns that systemic LXR repression may impair reverse cholesterol transport, we developed TLC-2716, an orally administered, gut- and liver-restricted LXR inverse agonist. In human liver organoids modeling steatohepatitis, TLC-2716 reduced lipid accumulation and suppressed inflammation and fibrotic gene expression. In a randomized, placebo-controlled phase 1 clinical trial, 14-day treatment with TLC-2716 was well tolerated (primary endpoints) and resulted in placebo-adjusted reductions up to 38.5% in plasma TG and 61% in postprandial remnant cholesterol (secondary endpoints). In conclusion, these results highlight the tolerability and therapeutic potential of TLC-2716 as a treatment for managing dyslipidemia and reducing residual atherosclerotic cardiovascular disease risk in humans. ClinicalTrials.gov identifier: NCT05483998.

Impaired myocardial energetics, including fatty acid oxidation (FAO), is a hallmark feature in the pathophysiology of various disorders. Deficiency of adipose triglyceride lipase (ATGL) results in impaired FAO which leads to severe heart failure due to massive triglyceride accumulation in cardiac muscle and coronary vasculature. Acetyl-CoA carboxylase 2 (ACC2) is a mitochondrial enzyme that regulates FAO; ACC2 inhibition increases transport of fatty acids into mitochondria for oxidation. In this study, the murine ATGL knockout (KO) model of severe heart failure was used to evaluate the effects ACC2 inhibition induced by whole body genetic KO (Atgl/Acc2 double KO mice) and pharmacological inhibition with TLC-3595, an oral, selective small molecule inhibitor of ACC2. Both genetic deletion of Acc2 and treatment with TLC-3595 in Atgl KO mice promoted mitochondrial FAO, reduced cardiac lipid accumulation and remodeling, and led to significant improvements in cardiac function, locomotor activity, and survival. Metabolite profiling of cardiac tissue of Atgl/Acc2 double KO mice and Atgl KO mice treated with TLC-3595 revealed ACC2-specific changes, including reduced malonyl-CoA and increased short-, medium-, and long-chain acylcarnitines, consistent with improved FAO. These findings support the therapeutic targeting of ACC2 for the treatment of heart failure associated with impaired FAO.

Introduction and Objective: TLC-1180 is a novel, potent mitochondrial protonophore with extended pharmacology. Here, we evaluated ‘1180 as monotherapy (mono), in combination (combo) with semaglutide (SEMA), and for maintenance post SEMA discontinuation (D/C) in diet-induced obese (DIO) mice. Methods: Male DIO mice were treated with ‘1180 in 2 studies: de novo combo of ‘1180 + high-dose SEMA (SEMAhigh) followed by continued ‘1180 mono post D/C of SEMAhigh (4 + 2 wk maintenance), and ‘1180 mono (3 wk) followed by combo with SEMAlow (3 wk; sequencing). Body weight (BW) and fat (FM) and lean mass (LM) were quantified. Results: ‘1180 mono significantly reduced BW (-11-20%) and FM (-22-41%) without LM loss, while SEMAhigh mono reduced BW (-20%), FM (-36%), and LM (-8%). ‘1180 + SEMAhighde novo combo further lowered BW (-26%) and FM (-48%) vs SEMAhigh over 4 wks (Fig A). Post SEMAhigh D/C, ‘1180 maintenance blunted regain of BW and FM (+18%, +5%) vs vehicle (+46%, +27%) (Fig A). ’1180 + SEMAlow sequencing combo lowered BW and FM (–30%, -59%) vs SEMAhigh mono (-25%, -47%) (Fig B). In both studies, LM loss was similar between combo and SEMAhigh. Conclusion: In DIO mice, ‘1180 caused BW and FM loss while preserving LM. These benefits were amplified in combo with SEMA and maintained post SEMA D/C. These data highlight the potential of ‘1180 as mono and in combo with incretins in obesity and associated metabolic disorders. M. Sharma: None. N. Sroda: Employee; OrsoBio, Inc. E. Murakami: Employee; OrsoBio, Inc. C. Logan: None. S. Weng: Employee; OrsoBio, Inc. B.J. Kirby: Employee; OrsoBio, Inc, Gossamer Bio, Inc. Consultant; Lilac Therapetutics, TERNS Pharmaceuticals, Actio Biosciences, SiteOne Therapeutics, IconOVir Bio, Recludix Pharma. R.P. Myers: Employee; OrsoBio, Inc. Stock/Shareholder; OrsoBio, Inc. M. Subramanian: Employee; OrsoBio, Inc. G.I. Shulman: Advisory Panel; Novo Nordisk. Consultant; Ionis Pharmaceuticals. Research Support; AstraZeneca, Merck & Co., Inc, ESPERION Therapeutics, Inc., Novo Nordisk. Advisory Panel; OrsoBio, Inc. A. Vijayakumar: Employee; OrsoBio, Inc.

Introduction and Objective: TLC-6740, a liver-targeted MP, regulates body weight via increased energy expenditure and is complementary to incretins that reduce food intake. We evaluated weight loss with a sequential combination of ‘6740 and semaglutide (SEMA), and ‘6740 maintenance therapy post SEMA discontinuation (D/C) in diet-induced obese (DIO) mice. Methods: Male DIO mice were treated with ‘6740 (6 wk), ‘6740 (3 wk) followed by combo with SEMAlow (3 wk), or ‘6740 post D/C of SEMAhigh (3 + 3 wk). Body weight (BW), fat (FM) and lean mass (LM), and oral glucose tolerance (oGTT) were assessed. Results: ‘6740 caused significant BW (-18%, 6 wk) and FM loss (-52%) without altering LM vs vehicle, while SEMAhigh reduced BW (-24%), FM (-67%), and LM (-16%). ‘6740+SEMAlow combo was well tolerated and further lowered BW, FM, and oGTT AUC (-33%, -77%, and -28%), but did not affect LM (Fig A). Post SEMAhigh D/C, ‘6740 maintained BW and FM loss similarly to mice continuing on SEMAhigh, unlike mice switched to vehicle (Fig B). ‘6740 maintenance also blunted the worsening of glucose tolerance post SEMAhigh D/C vs vehicle. Conclusion: In DIO mice, ‘6740 combo with SEMAlow was more efficacious than SEMAhigh, maintained weight loss post SEMA D/C, and was LM neutral. These data support evaluation of ‘6740 in combo with incretins in obesity and associated metabolic disorders. N. Sroda: Employee; OrsoBio, Inc. M. Sharma: None. E. Murakami: Employee; OrsoBio, Inc. C. Logan: None. S. Weng: Employee; OrsoBio, Inc. B.J. Kirby: Employee; OrsoBio, Inc, Gossamer Bio, Inc. Consultant; Lilac Therapetutics, TERNS Pharmaceuticals, Actio Biosciences, SiteOne Therapeutics, IconOVir Bio, Recludix Pharma. R.P. Myers: Employee; OrsoBio, Inc. Stock/Shareholder; OrsoBio, Inc. M. Subramanian: Employee; OrsoBio, Inc. G.I. Shulman: Advisory Panel; Novo Nordisk. Consultant; Ionis Pharmaceuticals. Research Support; AstraZeneca, Merck & Co., Inc, ESPERION Therapeutics, Inc., Novo Nordisk. Advisory Panel; OrsoBio, Inc. A. Vijayakumar: Employee; OrsoBio, Inc.

Introduction and Objective: TLC-1180, a novel MP, and TLC-3595, an ACC2-selective inhibitor, enhance fatty acid oxidation via complementary mechanisms and are in development for obesity-associated disorders. Here, we compared the efficacy of a novel combination (combo) of ‘1180 and ‘3595 to semaglutide (SEMA) in diet-induced obese (DIO) mice. Methods: Male DIO mice housed at thermoneutrality were treated with ‘1180 or ‘3595 monotherapy (mono), a combo, or SEMA mono for 6 weeks. Body weight (BW) and fat and lean mass were quantified. Results: ‘3595 and ‘1180 mono lowered BW (-5% and -13%, respectively), primarily driven by fat mass loss (-12% and -27%, respectively) vs vehicle. ‘1180+’3595 combo further reduced BW by -16%, similar to SEMA (-17%, Fig A). Reductions in fat mass were similar with ‘1180+’3595 combo (-36%) and SEMA (-33%) (Fig B). While SEMA reduced food intake, no changes in food intake were seen with ‘1180+’3595 combo. Importantly, unlike SEMA which reduced lean mass, no decrease in lean mass was observed with ‘1180+’3595 combo (p<0.05 vs SEMA). Conclusion: In DIO mice, a novel combo of a MP and an ACC2 inhibitor caused comparable weight loss to an incretin but preserved lean mass. In sum, these data support the evaluation of combinations of these agents in people living with obesity and associated metabolic disorders. N. Sroda: Employee; OrsoBio, Inc. M. Sharma: None. E. Murakami: Employee; OrsoBio, Inc. C. Logan: None. S. Weng: Employee; OrsoBio, Inc. B.J. Kirby: Employee; OrsoBio, Inc, Gossamer Bio, Inc. Consultant; Lilac Therapetutics, TERNS Pharmaceuticals, Actio Biosciences, SiteOne Therapeutics, IconOVir Bio, Recludix Pharma. R.P. Myers: Employee; OrsoBio, Inc. Stock/Shareholder; OrsoBio, Inc. M. Subramanian: Employee; OrsoBio, Inc. G.I. Shulman: Advisory Panel; Novo Nordisk. Consultant; Ionis Pharmaceuticals. Research Support; AstraZeneca, Merck & Co., Inc, ESPERION Therapeutics, Inc., Novo Nordisk. Advisory Panel; OrsoBio, Inc. A. Vijayakumar: Employee; OrsoBio, Inc.

Background: TLC-6740, a liver-targeted mitochondrial uncoupler, and TLC-3595, a selective ACC2 inhibitor, are in development for obesity and diabetes. By enhancing substrate oxidation, 6740 and 3595 have complementary mechanisms to GLP-1R agonists. Here, we assessed effects of 6740, 3595, and SEMA monotherapy (mono) and combinations (combos) in db/db mice. Methods: Male db/db mice (fasting glucose, FG>180mg/dL) were treated for 4 wk with vehicle (Veh), 6740, 3595, or SEMA mono or dual/triple combos. At 3 wk, an oral glucose tolerance test (oGTT) was performed and incremental AUC (iAUC) of glucose was calculated normalizing for glycemia before glucose bolus. Results: FG was lower in all groups vs Veh with the greatest reductions in 6740+3595, 6740+SEMA, and 6740+3595+SEMA combos (-42 to -56%) (Fig). While HbA1c was lower with all monos vs Veh (-0.6 to -1.0%), combos had the greatest effect (-1.4 to -1.7%). Food intake was lower in all SEMA groups, but only SEMA+3595 caused weight loss (-11%). oGTT iAUC was reduced vs Veh with only ‘6740 mono (-26%) and SEMA combos with 6740 (-40%), 3595 (-31%), and 6740+3595 (-41%). Conclusions: In db/db mice, 6740 improved glucose tolerance, FG, and HbA1c similarly to SEMA. Addition of 6740 and/or 3595 to SEMA improved glycemic parameters, supporting evaluation of combinations with GLP-1R agonists for diabetes. Disclosure A. Vijayakumar: Employee; OrsoBio, Inc. N. Sroda: Employee; OrsoBio, Inc. E. Murakami: Employee; OrsoBio, Inc. S. Weng: Employee; OrsoBio, Inc. R.P. Myers: Employee; OrsoBio, Inc. M. Subramanian: Board Member; OrsoBio, Inc. G.I. Shulman: None.

Heart failure (HF) is characterized by disordered energy metabolism including impaired mitochondrial oxidation and altered energy substrate preference. In triglyceride (TG) deposit cardiomyovasculopathy (TGCV; ORPHA code 565612), a rare form of HF characterized by impaired fatty acid oxidation (FAO), massive TG accumulation occurs in cardiac muscle and vasculature due to deficiency of adipose triglyceride lipase (ATGL). Since acetyl-CoA carboxylase 2 (ACC2) regulates fatty acid transport into mitochondria for oxidation, we hypothesized that genetic deletion or pharmacologic inhibition of ACC2 may improve cardiac function in the Atgl knockout (KO) mouse model of TGCV. Relative to Atgl KO mice, Atgl/Acc2 double KO mice had reduced cardiac TG accumulation and fibrosis, and significant improvements in cardiac function by echocardiography, locomotor activity, and survival (log-rank p <0.0001). These findings were recapitulated by treatment of Atgl KO mice with TLC-3595, a highly selective, systemic, small molecule ACC2 inhibitor in development for type 2 diabetes ( Figure ). After a single dose of TLC-3595 to Atgl KO mice, dose-dependent reductions in cardiac malonyl-CoA levels and TG content were observed. Further, in a detailed time-course echocardiographic analysis, Atgl KO mice had reduced left ventricular ejection fraction and evidence of cardiac remodeling which was ameliorated by TLC-3595 treatment. Metabolomic profiling of cardiac tissue revealed ACC2-specific changes, including reduced malonyl-CoA and increased acylcarnitines, consistent with increased FAO with TLC-3595 treatment. Moreover, levels of TCA cycle metabolites and acetylcarnitine were reduced in Atgl KO mice but increased with ACC2 deletion or TLC-3595. In summary, ACC2 deletion or pharmacologic inhibition restored cardiac energy metabolism towards increased FAO in Atgl KO mice, resulting in improved cardiac function and survival. These findings support the therapeutic targeting of ACC2, including with the selective small molecule ACC2 inhibitor TLC-3595, for the treatment of patients with HF associated with FAO deficiency.