Clinical studies
14 CLINICAL STUDIES 14.1 Weight Reduction and Long-Term Maintenance Studies in Adults with Obesity or Overweight Weight Reduction in Adults with Obesity or Overweight, with or without Type 2 Diabetes Mellitus (Study 1 and Study 2) Overview of Study 1 and Study 2 The efficacy of ZEPBOUND for weight reduction in conjunction with a reduced-calorie diet and increased physical activity was studied in two randomized, double-blind, placebo-controlled fixed-dosage trials (Study 1 and Study 2) in adults aged 18 years and older. In Studies 1 and 2, all patients received a standard lifestyle intervention which included instruction on a reduced-calorie diet (approximately 500 kcal/day deficit) and increased physical activity counseling (recommended minimum of 150 min/week) that began with the first dose of study medication or placebo and continued throughout the trial. Patients also received counseling on behavior modification strategies to adhere to diet and exercise recommendations. In both trials, weight reduction was assessed after 72 weeks of treatment (at least 52 weeks at maintenance dose). Study 1 (NCT04184622) was a 72-week trial that enrolled 2,539 adult patients with obesity (BMI ≥30 kg/m 2 ), or with overweight (BMI 27 to <30 kg/m 2 ) and at least one weight-related comorbid condition, such as dyslipidemia, hypertension, obstructive sleep apnea, or CV disease; patients with type 2 diabetes mellitus were excluded. Patients were randomized in a 1:1:1:1 ratio to once weekly fixed dosage of ZEPBOUND 5 mg, ZEPBOUND 10 mg, ZEPBOUND 15 mg, or placebo, with an escalation period of up to 20 weeks followed by the maintenance period. At baseline, mean age was 45 years (range 18-84 years), 68% were female, 71% were White, 11% were Asian, 9% were American Indian/Alaska Native, and 8% were Black or African American. A total of 48% were Hispanic or Latino ethnicity. Mean baseline body weight was 104.8 kg and mean BMI was 38 kg/m 2 . Baseline characteristics included 32% with hypertension, 30% with dyslipidemia, 8% with obstructive sleep apnea, and 3% with CV disease. Study 2 (NCT04657003) was a 72-week trial that enrolled 938 adult patients with BMI ≥27 kg/m 2 and type 2 diabetes mellitus. Patients included in the trial had HbA1c 7-10% and were treated with either diet and exercise alone, or any oral anti-hyperglycemic agent except dipeptidyl peptidase-4 (DPP-4) inhibitors or GLP-1 receptor agonists. Patients who were taking insulin or injectable GLP-1 receptor agonists for type 2 diabetes mellitus were excluded. Patients were randomized in a 1:1:1 ratio to once weekly fixed dosage of ZEPBOUND 10 mg, ZEPBOUND 15 mg, or placebo with an escalation period of up to 20 weeks followed by the maintenance period. At baseline, mean age was 54 years (range 18-85 years), 51% were female, 76% were White, 13% were Asian, and 8% were Black or African American. A total of 60% were Hispanic or Latino ethnicity. Mean baseline body weight was 100.7 kg and mean BMI was 36.1 kg/m 2 . Baseline characteristics included 66% with hypertension, 61% with dyslipidemia, 8% with obstructive sleep apnea, and 10% with CV disease. Results for Study 1 and Study 2 The proportions of patients who discontinued study drug in Study 1 were 14.3%, 16.4%, and 15.1% for the 5 mg, 10 mg, and 15 mg ZEPBOUND-treated groups, respectively, and 26.4% for the placebo-treated group. The proportions of patients who discontinued study drug in Study 2 were 9.3% and 13.8% for the 10 mg and 15 mg ZEPBOUND-treated groups, respectively, and 14.9% for the placebo-treated group. For Studies 1 and 2, weight reduction was assessed after 72 weeks of treatment (at least 52 weeks at maintenance dose). In both studies, the primary efficacy parameters were mean percent change in body weight and the percentage of patients achieving ≥5% weight reduction from baseline to Week 72 (see Table 2 ). After 72 weeks of treatment, ZEPBOUND resulted in a statistically significant reduction in body weight compared with placebo, and greater proportions of patients treated with ZEPBOUND 5 mg, 10 mg, and 15 mg achieved at least 5% weight reduction compared to placebo. Among patients treated with ZEPBOUND 10 mg and 15 mg, greater proportions of patients achieved at least 10%, 15%, and 20% weight reduction compared to placebo (see Table 2 ). A reduction in body weight was observed with ZEPBOUND irrespective of age, sex, race, ethnicity, baseline BMI, and glycemic status. Table 2: Changes in Body Weight at Week 72 in Studies 1 and 2 in Patients with Obesity or Overweight Abbreviations: ANCOVA = analysis of covariance; CI = confidence interval; N = number of patients randomly assigned to study drug. a The intention-to-treat population includes all randomly assigned patients. For Study 1 at Week 72, body weight was missing for 21.6%, 10.2%, 10.5%, and 9.4% of patients randomly assigned to placebo, ZEPBOUND 5 mg, 10 mg, and 15 mg, respectively. For Study 2 at Week 72, body weight was missing for 11.1%, 4.8%, and 8.4% of patients randomly assigned to placebo, ZEPBOUND 10 mg, and 15 mg, respectively. The missing values were imputed by a hybrid approach using retrieved dropouts from the same treatment group (if missing not due to COVID-19) or using all non-missing data assuming missing at random (for missing solely due to COVID-19). b Least-squares mean from ANCOVA adjusted for baseline value and other stratification factors. c Analyzed using logistic regression adjusted for baseline value. d p-value<0.001 (unadjusted 2-sided) for superiority, controlled for type I error rate. e Not controlled for type I error rate. Study 1 Study 2 Intention-to-Treat (ITT) Population a Placebo N = 643 ZEPBOUND 5 mg N = 630 ZEPBOUND 10 mg N = 636 ZEPBOUND 15 mg N = 630 Placebo N = 315 ZEPBOUND 10 mg N = 312 ZEPBOUND 15 mg N = 311 Body Weight Baseline mean (kg) 104.8 102.9 105.8 105.6 101.7 100.9 99.6 % Change from baseline b -3.1 -15.0 -19.5 -20.9 -3.2 -12.8 -14.7 % Difference from placebo b (95% CI) -11.9 (-13.4, -10.4) d -16.4 (-17.9, -14.8) d -17.8 (-19.3, -16.3) d -9.6 (-11.1, -8.1) d -11.6 (-13.0, -10.1) d % of Patients losing ≥5% body weight 34.5 85.1 88.9 90.9 32.5 79.2 82.8 % Difference from placebo (95% CI) 50.3 (44.3, 56.2) c,d 54.6 (49.1, 60.0) c,d 56.4 (50.9, 62.0) c,d 46.8 (39.5, 54.1) c,d 50.4 (43.1, 57.8) c,d % of Patients losing ≥10% body weight 18.8 68.5 78.1 83.5 9.5 60.5 64.8 % Difference from placebo (95% CI) 49.3 (43.6, 54.9) c,e 59.5 (54.2, 64.9) c,d 64.8 (59.6, 70.1) c,d 51.0 (44.4, 57.7) c,d 55.3 (48.6, 62.0) c,d % of Patients losing ≥15% body weight 8.8 48.0 66.6 70.6 2.7 39.7 48.0 % Difference from placebo (95% CI) 38.7 (33.6, 43.7) c,e 58.1 (53.2, 63.0) c,d 62.0 (57.2, 66.8) c,d 37.0 (31.1, 42.9) c,d 45.4 (39.4, 51.4) c,d % of Patients losing ≥20% body weight 3.1 30.0 50.1 56.7 1.0 21.5 30.8 % Difference from placebo (95% CI) 26.6 (22.4, 30.7) c,e 47.3 (42.7, 51.9) c,d 53.8 (49.3, 58.3) c,d 20.5 (15.7, 25.4) c,d 29.7 (24.3, 35.0) c,d The cumulative frequency distributions of change in body weight are shown in Figure 1 for Study 1 and Figure 2 for Study 2. One way to interpret this figure is to select a change in body weight of interest on the horizontal axis and note the corresponding proportions of patients (vertical axis) in each treatment group who achieved at least that degree of weight reduction. For example, note that the vertical line arising from -10% in Figure 1 intersects the ZEPBOUND 15 mg and placebo curves at approximately 83.5%, and 18.8%, respectively, which correspond to the values shown in Table 2 . Figure 1: Changes in Body Weight (%) from Baseline to Week 72 in Study 1 in Patients with Obesity or Overweight (without Type 2 Diabetes) Note: Based on average percent weight change of each randomized patient within each specific treatment arm from 100 imputed datasets including observed data and imputed data using hybrid approach for missing values. Figure 2: Changes in Body Weight (%) from Baseline to Week 72 in Study 2 in Patients with Obesity or Overweight and Type 2 Diabetes Note: Based on average percent weight change of each randomized patient within each specific treatment arm from 100 imputed datasets including observed data and imputed data using hybrid approach for missing values. The time courses of weight reduction with ZEPBOUND and placebo from baseline through Week 72 are depicted in Figure 3 for Study 1 and Figure 4 for Study 2. Figure 3: Change from Baseline (%) in Body Weight in Study 1 in Patients with Obesity or Overweight (without Type 2 Diabetes) Note: Displayed results are from the Intent-to-Treat Population. (1) Observed mean value from Week 0 to Week 72, and (2) least-squares mean ± standard error at Week 72 hybrid imputation (HI). Figure 4: Change from Baseline (%) in Body Weight in Study 2 in Patients with Obesity or Overweight and Type 2 Diabetes Note: Displayed results are from the Intent-to-Treat Population. (1) Observed mean value from Week 0 to Week 72, and (2) least squares mean ± standard error at Week 72 hybrid imputation (HI). Changes in waist circumference and cardiometabolic parameters with ZEPBOUND are shown in Table 3 for Study 1 and Study 2. Table 3: Changes in Anthropometry and Cardiometabolic Parameters at Week 72 in Studies 1 and 2 in Patients with Obesity or Overweight Abbreviations: ANCOVA = analysis of covariance; CI = confidence interval; N = number of patients randomly assigned to study drug. a The intention-to-treat population includes all randomly assigned patients. The missing values were imputed by a hybrid approach using retrieved dropouts from the same treatment group (if missing not due to COVID-19) or using all non-missing data assuming missing at random (for missing solely due to COVID-19). b Least-squares mean from ANCOVA adjusted for baseline value and other stratification factors. c Analyzed using log-transformed data. d p-value<0.001 (unadjusted 2-sided) for superiority, controlled for type I error rate. e Not controlled for type I error rate. f Least-squares mean from mixed model for repeated measures adjusted for baseline value and other stratification factors. g Baseline value is the geometric mean. Study 1 Study 2 Intention-to-Treat (ITT) Population a Placebo N = 643 ZEPBOUND 5 mg N = 630 ZEPBOUND 10 mg N = 636 ZEPBOUND 15 mg N = 630 Placebo N = 315 ZEPBOUND 10 mg N = 312 ZEPBOUND 15 mg N = 311 Waist Circumference (cm) Baseline mean 114.0 113.2 114.8 114.4 116.0 114.2 114.6 Change from baseline b -4.0 -14.0 -17.7 -18.5 -3.3 -10.8 -13.1 Difference from placebo b (95% CI) -10.1 (-11.6, -8.6) e -13.8 (-15.2, -12.3) d -14.5 (-15.9, -13.0) d -7.4 (-9.0, -5.9) d -9.8 (-11.2, -8.3) d Systolic Blood Pressure (mmHg) Baseline mean 122.9 123.6 123.8 123.0 131.0 130.6 130.0 Change from baseline b -1.0 -6.6 -7.7 -7.4 -1.2 -5.6 -7.1 Difference from placebo b (95% CI) -5.6 (-7.2, -3.9) e -6.7 (-8.4, -5.0) e -6.4 (-8.0, -4.8) e -4.4 (-6.7, -2.1) e -5.9 (-8.3, -3.6) e Diastolic Blood Pressure (mmHg) Baseline mean 79.6 79.3 79.9 79.3 79.4 80.2 79.7 Change from baseline b -0.8 -4.9 -5.0 -4.5 -0.3 -2.1 -2.9 Difference from placebo b (95% CI) -4.1 (-5.2, -3.0) e -4.2 (-5.3, -3.0) e -3.7 (-4.8, -2.7) e -1.8 (-3.3, -0.4) e -2.7 (-4.2, -1.2) e Pulse Rate (beats per minute) Baseline mean 72.9 72.4 71.8 72.4 74.8 75.9 75.6 Change from baseline f 0.1 0.6 2.3 2.6 -0.5 0.6 1.0 Difference from placebo f (95% CI) 0.5 (-0.5, 1.5) e 2.2 (1.2, 3.2) e 2.5 (1.5, 3.4) e 1.2 (-0.1, 2.5) e 1.5 (0.2, 2.8) e Total Cholesterol (mg/dL) Baseline mean g 187.5 187.1 190.6 187.5 174.9 173.9 167.0 % change from baseline b -1.8 -3.8 -4.4 -6.3 2.8 -2.8 -1.0 Relative difference from placebo b (95% CI) -2.1 (-4.5, 0.4) c,e -2.7 (-5.1, -0.2) c,e -4.6 (-6.8, -2.2) c,e -5.5 (-8.7, -2.2) c,e -3.8 (-7.1, -0.3) c,e LDL Cholesterol (mg/dL) Baseline mean g 109.4 108.7 112.3 109.3 92.4 90.5 85.7 % change from baseline b -1.7 -4.6 -5.6 -7.1 7.4 1.8 4.1 Relative difference from placebo b (95% CI) -2.9 (-6.6, 0.9) c,e -4.0 (-7.5, -0.5) c,e -5.5 (-8.9, -2.0) c,e -5.2 (-10.1, 0.1) c,e -3.0 (-8.4, 2.6) c,e HDL Cholesterol (mg/dL) Baseline mean g 46.6 47.6 47.6 47.6 42.7 43.8 42.2 % change from baseline b -0.7 6.9 9.2 8.0 0.2 8.2 9.7 Relative difference from placebo b (95% CI) 7.7 (4.6, 10.8) c,e 9.9 (6.7, 13.2) c,e 8.7 (5.7, 11.8) c,e 8.0 (4.2, 11.8) c,e 9.5 (5.6, 13.5) c,e Non-HDL Cholesterol (mg/dL) Baseline mean g 138.3 137.0 140.4 137.5 129.6 127.2 121.9 % change from baseline b -2.3 -8.0 -9.4 -11.7 3.7 -6.6 -5.2 Relative difference from placebo b (95% CI) -5.8 (-8.9, -2.6) c,e -7.2 (-10.3, -4.1) c,e -9.6 (-12.4, -6.6) c,e -9.9 (-14.1, -5.6) c,e -8.5 (-12.9, -4.0) c,e Triglycerides (mg/dL) Baseline mean g 130.8 128.7 125.7 128.1 165.0 158.8 158.5 % change from baseline b -5.6 -21.2 -23.8 -29.1 -3.3 -27.1 -27.3 Relative difference from placebo b (95% CI) -16.5 (-21.2, -11.4) c,e -19.3 (-23.9, -14.4) c,e -24.9 (-29.1, -20.4) c,e -24.6 (-30.0, -18.7) c,e -24.8 (-30.3, -18.9) c,e HbA1c (%) Baseline mean 5.6 5.6 5.5 5.6 8.0 8.0 8.1 Change from baseline b -0.1 -0.4 -0.4 -0.4 -0.5 -2.1 -2.1 Difference from placebo b (95% CI) -0.3 (-0.3, -0.2) e -0.4 (-0.4, -0.3) e -0.4 (-0.4, -0.3) e -1.6 (-1.7, -1.4) d -1.6 (-1.8, -1.4) d Figure 1 Figure 2 Figure 3 Figure 4 Weight Reduction Following Intensive Lifestyle Intervention in Adults with Obesity or Overweight (Study 3) Overview of Study 3 Study 3 (NCT04657016) was an 84-week trial with a 12-week intensive lifestyle intervention lead-in period (Week -12 to Week 0), followed by a 72-week randomized treatment period of ZEPBOUND versus placebo (Week 0 to Week 72) with a standard lifestyle intervention. Only patients who lost ≥5% body weight during the 12-week intensive lifestyle lead-in period entered the 72-week randomized treatment period. The trial initially enrolled 806 adult patients (aged 18 years and older) with obesity (BMI ≥30 kg/m 2 ), or with overweight (BMI 27 to <30 kg/m 2 ) and at least one weight-related comorbid condition, such as dyslipidemia, hypertension, obstructive sleep apnea, or CV disease; patients with type 2 diabetes mellitus were excluded. During the intensive lifestyle intervention lead-in period, lifestyle instruction was delivered 8 times over 12 weeks by a dietician or dietician-equivalent, with all patients receiving instruction to exercise for at least 150 minutes per week and to reduce their caloric intake to approximately 1,200 kcal/day (females) or 1,500 kcal/day (males). Patients also received counseling on behavior modification strategies to adhere to diet and exercise recommendations. At the end of the 12-week intensive lifestyle intervention lead-in period, 579 patients who achieved ≥5% weight reduction were randomized in a 1:1 ratio to ZEPBOUND or placebo for 72 weeks. ZEPBOUND dosages were escalated over a period of up to 20 weeks to a maximum tolerated dosage (MTD) of 10 mg or 15 mg subcutaneous once weekly. During the randomized treatment period, patients received a standard lifestyle instruction every 12 weeks on reduced-calorie diet (approximately 500 kcal/day deficit) and increased physical activity (recommended minimum of 150 min/week) that began with the first dose of ZEPBOUND or placebo and continued throughout the 72-week treatment period; behavior modification strategies were recommended as needed. Weight reduction was assessed after 72 weeks of treatment (at least 52 weeks at maintenance dose). For the 579 patients who were randomized, mean body weight at enrollment prior to entering the 12-week lifestyle lead-in period (Week -12) was 109.5 kg and mean BMI was 38.6 kg/m 2 . At randomization (Week 0), after the 12-week intensive lifestyle lead-in period, mean body weight was 101.9 kg and mean BMI was 35.9 kg/m 2 . The mean age of patients randomized to treatment was 46 years (range 18-77 years), 63% were female, 86% were White, 11% were Black or African American, and 1% were Asian. A total of 54% were Hispanic or Latino ethnicity. Baseline characteristics for the 579 randomized patients included 34% with hypertension, 26% with dyslipidemia, 10% with obstructive sleep apnea, and 2% with CV disease. Results for Study 3 At the end of the 12-week intensive lifestyle intervention lead-in, for patients who subsequently entered the randomized treatment period (n=579), the average body weight loss due to lifestyle was 6.9% (Week -12 to Week 0). Eighty-six percent (86%) of ZEPBOUND-treated patients had a maximum tolerated dosage of 15 mg weekly based on their final dose during the double-blind treatment period. The time course of weight reduction during the lead-in and from Week 0 to Week 72 with ZEPBOUND and placebo are depicted in Figure 5 . Figure 5: Change in Body Weight (%) After 12-Week Intensive Lifestyle Intervention Lead-In Followed by Randomized Treatment and a Standard Lifestyle Intervention (Study 3) in Patients with Obesity or Overweight Note: Displayed results are from the randomized Population. (1) Observed mean value from Week -12 to Week 72, and (2) least squares mean ± standard error at Week 72 hybrid imputation (HI). Change from Week -12 is not a primary endpoint in Study 3. The proportions of patients who discontinued study drug after randomization were 21.3% for the ZEPBOUND-treated group and 30.5% for the placebo-treated group. For Study 3, the primary efficacy parameters were mean percent change in body weight from randomization (Week 0) to Week 72 and the percentage of patients achieving ≥5% weight reduction from randomization (Week 0) to Week 72. Amongst randomized patients who already lost ≥5% body weight during the 12-week intensive lifestyle lead-in period, subsequent treatment with ZEPBOUND resulted in a statistically significant reduction in body weight compared to placebo from randomization (Week 0) to Week 72. A greater proportion of patients treated with ZEPBOUND achieved at least 5%, 10%, 15%, and 20% weight reduction from Week 0 to Week 72 compared to placebo (see Table 4 ). Table 4: Changes in Body Weight After 12-Week Intensive Lifestyle Intervention Lead-In Followed by Randomized Treatment and a Standard Lifestyle Intervention (Study 3) in Patients with Obesity or Overweight Abbreviations: ANCOVA = analysis of covariance; CI = confidence interval; MTD = maximum tolerated dose; N = number of patients randomly assigned to study drug. a The intent-to-treat population included only randomized patients with ≥5% weight loss at Week 0 after 12 weeks of intensive lifestyle intervention. During the 12-week lead-in period, 227 of 806 patients (28.2%) discontinued from the study. Of these 141 (17.5%) discontinued due to not achieving the randomization criteria of ≥5% weight reduction. b The intent-to-treat population includes all randomly assigned patients. For Study 3 at Week 72, body weight was missing for 23.6% and 8.7% of patients randomly assigned to placebo and ZEPBOUND MTD (10 or 15 mg). The missing values were imputed by a hybrid approach using retrieved dropouts from the same treatment group (if missing not due to COVID-19) or using all non-missing data assuming missing at random (for missing solely due to COVID-19). c Least-squares mean from ANCOVA adjusted for baseline value and other stratification factors. d Analyzed using logistic regression adjusted for baseline value. e p-value<0.001 (unadjusted 2-sided) for superiority, controlled for type I error rate. Study 3 N = 579 a Body Weight Mean (kg) at Week -12 109.5 Intention-to-Treat (ITT) Population a,b Placebo N = 292 ZEPBOUND MTD (10 mg or 15 mg) N = 287 Body Weight Mean (kg) at Week 0 101.3 102.5 % Change from randomization at Week 72 c 2.5 -18.4 % Difference from placebo, at Week 72 c (95% CI) -20.8 (-23.2, -18.5) e % of Patients losing ≥5% body weight 16.5 87.5 % Difference from placebo (95% CI) 71.1 (63.6, 78.5) d,e % of Patients losing ≥10% body weight 8.9 76.7 % Difference from placebo (95% CI) 67.9 (60.7, 75.1) d,e % of Patients losing ≥15% body weight 4.2 65.4 % Difference from placebo (95% CI) 61.3 (54.5, 68.1) d,e % of Patients losing ≥20% body weight 2.2 44.7 % Difference from placebo (95% CI) 42.6 (36.0, 49.1) d,e Changes in waist circumference and cardiometabolic parameters are shown in Table 5 . Table 5: Changes in Anthropometry and Cardiometabolic Parameters After 12-Week Intensive Lifestyle Intervention Lead-In Followed by Randomized Treatment and a Standard Lifestyle Intervention (Study 3) in Patients with Obesity or Overweight Abbreviations: ANCOVA = analysis of covariance; CI = confidence interval; N = number of patients randomly assigned to study drug. a The intent-to-treat population included all randomly assigned patients. The missing values were imputed by a hybrid approach using retrieved dropouts from the same treatment group (if missing not due to COVID-19) or using all non-missing data assuming missing at random (for missing solely due to COVID-19). b Least-squares mean from ANCOVA adjusted for baseline value and other stratification factors. c Analyzed using log-transformed data. d p-value<0.001 (unadjusted 2-sided) for superiority, controlled for type I error rate. e Not controlled for type I error rate. f Least-squares mean from mixed model for repeated measures adjusted for baseline value and other stratification factors. g Baseline and randomization values are the geometric mean. h Observed means are shown for change from Week -12 to Week 0. Least-square means are shown for change from Week 0 to Week 72. Intention-to-Treat (ITT) Population a All Randomized Patients N=579 Placebo N=292 ZEPBOUND MTD (10 mg or 15 mg) N=287 Baseline (Week - 12) Change from Week - 12 to Week 0 Randomization (Week 0) Change from Week 0 to Week 72 Randomization (Week 0) Change from Week 0 to Week 72 Difference from placebo, Week 0 to Week 72 (95% CI) Waist circumference (cm) h 116.1 -6.7 109.6 0.2 b 109.3 -14.6 b -14.8 b (-17.2, -12.5) d Systolic Blood Pressure (mmHg) h 126.2 -5.0 120.8 3.5 b 121.7 -5.1 b -8.6 b (-11.3, -6.0) e Diastolic Blood Pressure (mmHg) h 81.7 -2.9 78.3 2.1 b 79.3 -3.2 b -5.3 b (-6.9, -3.7) e Pulse Rate (beats per minute) h 73.0 -1.6 70.7 0.9 f 72.2 2.7 f 1.8 f (0.3, 3.4) e HbA1c (%) h 5.5 -0.1 5.4 0.0 b 5.3 -0.4 b -0.4 b (-0.5, -0.3) e Total Cholesterol (mg/dL) g,h 190.2 -8.6 181.6 4.3 181.7 -2.4 -6.4 b (-9.0, -3.6) c,e LDL Cholesterol (mg/dL) g,h 111.6 -3.5 107.5 4.4 108.0 -5.6 -9.6 b (-13.7, -5.4) c,e HDL Cholesterol (mg/dL) g,h 48.4 -1.2 47.8 5.4 46.9 15.2 9.3 b (4.5, 14.2) c,e Non-HDL Cholesterol (mg/dL) g,h 139.2 -7.4 131.5 4.4 132.4 -8.8 -12.6 b (-15.9, -9.3) c,e Triglycerides (mg/dL) g,h 123.1 -19.8 108.8 2.1 111.7 -23.5 -25.1 b (-30.9, -18.9) c,e Figure 5 Weight Reduction Following Randomized Withdrawal in Adults with Obesity or Overweight (Study 4) Overview of Study 4 Study 4 (NCT04660643) was an 88-week randomized withdrawal trial in which all patients received open-label ZEPBOUND during a 36-week lead-in period, followed by randomization to either continue ZEPBOUND or switch to placebo for 52 weeks. The trial enrolled 783 adult patients (aged 18 years and older) with obesity (BMI ≥30 kg/m 2 ), or with overweight (BMI 27 to <30 kg/m 2 ) and at least one weight-related comorbid condition, such as dyslipidemia, hypertension, obstructive sleep apnea, or CV disease; patients with type 2 diabetes mellitus were excluded. All patients received a standard lifestyle intervention which included instruction on a reduced-calorie diet (approximately 500 kcal/day deficit) and increased physical activity counseling (recommended minimum of 150 min/week) that began with the first dose of ZEPBOUND, during the lead-in period, and continued throughout the trial. During the 36-week open-label ZEPBOUND lead-in period, ZEPBOUND dosages were escalated over a period of up to 20 weeks to an MTD of 10 mg or 15 mg subcutaneous once weekly. After the lead-in period, patients were randomized at Week 36 to continue ZEPBOUND or switch to placebo for 52 weeks. Of the 783 patients who started ZEPBOUND at Week 0, 14.4% discontinued treatment before randomization at Week 36, and adverse events were the most common reason for discontinuation (6.8%). At Week 36, a total of 670 patients were randomized in a 1:1 ratio to ZEPBOUND MTD or placebo for 52 weeks. For the 670 randomized patients, at study entry (Week 0) mean body weight was 107.3 kg and mean BMI was 38.4 kg/m 2 , and at randomization (Week 36, after the open-label ZEPBOUND lead-in period) mean body weight was 85.2 kg and mean BMI was 30.5 kg/m 2 . Among the randomized patients, the mean age was 49 years (range 19-81 years), 71% were female, 80% were White, 11% were Black or African American, and 7% were Asian. A total of 44% were Hispanic or Latino ethnicity. Baseline characteristics for the 670 randomized patients included 35% with hypertension, 32% with dyslipidemia, 12% with obstructive sleep apnea, and 6% with CV disease. Results for Study 4 At the end of the 36-week open-label ZEPBOUND lead-in period, of the 670 randomized patients, 93% were on ZEPBOUND MTD of 15 mg weekly and 7% were on MTD of 10 mg weekly. After open-label ZEPBOUND treatment, randomized patients (n=670) had an average body weight loss of 20.9% (Week 0 to Week 36). The time course of weight reduction from Week 0 through Week 88 is depicted in Figure 6 . Figure 6: Change in Body Weight (%) After 36-Week Open-Label Treatment Followed by Randomized Withdrawal (Study 4) in Patients with Obesity or Overweight Note: Displayed results are from the randomized population. (1) Displayed results are observed mean value from Week 0 to Week 88 and (2) least squares mean ± standard error at Week 88 hybrid imputation (HI). Change from Week 0 was not a primary endpoint in Study 4. The proportions of patients who discontinued study drug after randomization at Week 36 were 10.4% for the ZEPBOUND-treated group and 17.9% for the placebo-treated group. For Study 4, the primary efficacy parameter was mean percent change in body weight from randomization (Week 36) to Week 88. After weight loss with ZEPBOUND treatment during the open-label lead-in period (Week 0 to Week 36), continued treatment with ZEPBOUND from randomization (Week 36) to Week 88 resulted in a statistically significant reduction in body weight compared with placebo (see Table 6 ). Table 6: Changes in Body Weight After 36-Week Open-Label Treatment Followed by Randomized Withdrawal (Study 4) in Patients with Obesity or Overweight Abbreviations: ANCOVA = analysis of covariance; CI = confidence interval; MTD = maximum tolerated dose; N = number of patients randomly assigned to study drug. a The intent-to-treat population included all randomly assigned patients and did not include 113 patients who were enrolled but not randomized. At Week 88, body weight was missing for 13.7% and 7.5% of patients randomly assigned to placebo and ZEPBOUND MTD (10 or 15 mg), respectively. The missing values were imputed by a hybrid approach using retrieved dropouts from the same treatment group (if missing not due to COVID-19) or using all non-missing data assuming missing at random (for missing solely due to COVID-19). b Least-squares mean from ANCOVA adjusted for baseline value and other stratification factors. c p-value<0.001 (unadjusted 2-sided) for superiority, controlled for type I error rate. Study 4 N=670 a Body Weight Mean at Week 0 (kg) 107.3 Intention-to-Treat (ITT) Population a Placebo N=335 ZEPBOUND (MTD 10 mg or 15 mg) N=335 Body Weight Mean at Week 36 (kg) 85.8 84.6 % change from Week 36 at Week 88 b 14.0 -5.5 % difference from placebo at Week 88 (95% CI) b -19.4 (-21.2, -17.7) c Changes in waist circumference and cardiometabolic parameters in Study 4 are shown in Table 7 . Table 7: Mean Changes in Anthropometry and Cardiometabolic Parameters After 36-Week Open-Label Treatment Followed by Randomized Withdrawal (Study 4) in Patients with Obesity or Overweight Abbreviations: ANCOVA = analysis of covariance; CI = confidence interval; N = number of patients randomly assigned to study drug. a The intent-to-treat population included all randomly assigned patients. The missing values were imputed by a hybrid approach using retrieved dropouts from the same treatment group (if missing not due to COVID-19) or using all non-missing data assuming missing at random (for missing solely due to COVID-19). b Least-squares mean from ANCOVA adjusted for baseline value and other stratification factors. c Analyzed using log-transformed data. d p-value<0.001 (unadjusted 2-sided) for superiority, controlled for type I error rate. e Not controlled for type I error rate. f Least-squares mean from mixed model for repeated measures adjusted for baseline value and other stratification factors. g Baseline and randomization values are the geometric mean. h Observed means are shown for change from Week 0 to Week 36. Least-square means are shown for change from Week 36 to Week 88. Intention-to-Treat (ITT) Population a All Randomized Patients N=670 Placebo N=335 ZEPBOUND MTD (10 mg or 15 mg) N=335 Baseline (Week 0) Change from Week 0 to Week 36 Randomization (Week 36) Change from Week 36 to Week 88 Randomization (Week 36) Change from Week 36 to Week 88 Difference from placebo, Week 36 to Week 88 (95% CI) Waist circumference (cm) h 115.2 -17.8 98.2 7.8 b 96.8 -4.3 b -12.1 b (-13.5, -10.6) d Systolic Blood Pressure (mmHg) h 126.1 -11.2 114.8 8.2 b 115.0 2.0 b -6.2 b (-8.2, -4.3) e Diastolic Blood Pressure (mmHg) h 80.9 -5.1 76.2 3.2 b 75.4 -0.7 b -3.8 b (-5.2, -2.4) e Pulse Rate (beats per minute) h 72.5 5.0 77.8 -5.2 f 77.1 -2.1 f 3.1 f (1.9, 4.3) e HbA1c (%) h 5.5 -0.5 5.0 0.3 b 5.1 -0.0 b -0.3 b (-0.3, -0.2) e Total Cholesterol (mg/dL) g,h 188.3 -12.4 176.1 8.0 175.9 2.7 -4.9 b (-7.4, -2.4) c,e LDL Cholesterol (mg/dL) g,h 108.6 -1.9 107.6 3.2 105.9 -3.5 -6.5 b (-10.0, -2.9) c,e HDL Cholesterol (mg/dL) g,h 49.9 -2.7 47.3 14.8 47.7 18.7 3.4 b (0.2, 6.6) c,e Non-HDL Cholesterol (mg/dL) g,h 135.8 -9.8 126.3 5.1 126.0 -3.4 -8.1 b (-11.3, -4.8) c,e Triglycerides (mg/dL) g,h 121.4 -40.4 85.5 13.5 90.9 -4.8 -16.1 b (-21.7, -10.0) c,e Figure 6 14.2 Obstructive Sleep Apnea Studies in Adults with Obesity Overview of Study 5 and Study 6 The efficacy of ZEPBOUND for moderate to severe obstructive sleep apnea (OSA) (apnea-hypopnea index [AHI] ≥15) in patients with obesity (BMI ≥30 kg/m 2 ) was evaluated in a master protocol clinical trial (NCT05412004) that included two randomized, double-blind, placebo-controlled trials (Study 5 and Study 6) of 52 weeks duration. The two trials enrolled a total of 469 adult patients. In Studies 5 and 6, patients were randomized in a 1:1 ratio to receive ZEPBOUND or placebo for 52 weeks. ZEPBOUND dosages were escalated over a period of up to 20 weeks to maximum tolerated dosage (MTD) of 10 mg or 15 mg subcutaneous once weekly [see Dosage and Administration ( 2.1 , 2.2 )] . Patients with type 2 diabetes mellitus were excluded and all patients received instruction on a reduced-calorie diet and increased physical activity counseling throughout the study. Study 5 enrolled 234 adult patients with moderate to severe OSA and obesity who were unable or unwilling to use Positive Airway Pressure (PAP) therapy. Patients had a mean age of 48 years (range: 20 to 76 years), 67% were male, 66% were White, 20% were Asian, 8% were American Indian/Alaska Native, and 6% were Black or African American. A total of 42% were Hispanic or Latino ethnicity. Study 6 enrolled 235 adult patients with moderate to severe OSA and obesity who were on PAP therapy. Patients had a mean age of 52 years (range: 26 to 79 years), 72% were male, 73% were White, 14% were Asian, 8% were American Indian/Alaska Native, and 5% were Black or African American. A total of 32% were Hispanic or Latino ethnicity. Table 8 describes the baseline disease characteristics of patients in Studies 5 and 6. Table 8: Baseline Disease Characteristics of Patients with OSA and Obesity in Study 5 and Study 6 Abbreviations: AHI = Apnea-Hypopnea Index; BMI = body-mass index; ESS = Epworth Sleepiness Score; OSA = obstructive sleep apnea; SD = standard deviation. a Moderate OSA was defined as an AHI ≥15 – 30 events/hour on polysomnogram at baseline. b Severe OSA was defined as an AHI ≥30 events/hour on polysomnogram at baseline. Study 5 (N=234) Study 6 (N=235) Baseline AHI (events/hour), mean (SD) 51.5 (31) 49.5 (26.7) Moderate OSA, % a 35.2 30.9 Severe OSA, % b 63.1 68.2 ESS Total, mean (SD) 10.5 (5.2) 10 (4.6) Total Hypoxic Burden (% min/hour), mean (SD) 208.4 (189.1) 193 (174.6) BMI (kg/m 2 ), mean (SD) 39.1 (7) 38.7 (6) Pre-diabetes, % 65 56.6 Hypertension, % 75.6 77.4 Cardiac disorders, % 10.3 11.1 Dyslipidemia, % 80.8 83.8 Results for Study 5 and Study 6 The primary endpoint for Studies 5 and 6 was the change from baseline in the apnea-hypopnea index (AHI) at Week 52. Patients in Study 5 were unable or unwilling to use PAP therapy, and patients in Study 6 were on PAP therapy and instructed to suspend PAP for 7 days prior to assessment of the primary endpoint. The clinical studies for OSA did not evaluate the timing or appropriateness of PAP discontinuation in patients who were previously compliant with PAP therapy. In Studies 5 and 6, treatment with ZEPBOUND for 52 weeks resulted in a statistically significant reduction in AHI compared with placebo, and greater proportions of patients treated with ZEPBOUND achieved remission or mild non-symptomatic OSA compared to placebo. Table 9 provides the efficacy results for Studies 5 and 6. A reduction in AHI was observed with ZEPBOUND irrespective of age, sex, ethnicity, baseline BMI, or baseline OSA severity. In both Studies 5 and 6, patients treated with ZEPBOUND achieved a greater reduction in systolic blood pressure and high-sensitivity C-reactive protein levels compared to placebo. Table 9: Changes in Apnea-Hypopnea Index (AHI), Hypoxic Burden, and Body Weight at Week 52 in Study 5 and Study 6 Abbreviations: AHI = Apnea-Hypopnea Index; ANCOVA = analysis of covariance; CI = confidence interval; ESS = Epworth Sleepiness Scale; h = hour; MTD = maximum tolerated dose; N = number of participants randomly assigned and received at least 1 dose of study drug. a Analyses were based on the modified intent-to-treat population which was defined as randomly assigned participants who were exposed to at least 1 dose of study intervention; two participants in Study 6 were randomized but did not receive study drug. b Least-squares mean from ANCOVA adjusted for baseline values and stratification factors, with multiple imputation for missing data at Week 52. c Analyzed using log transformed data. d Calculated by combining proportion of participants achieving target in imputed datasets. e p-value <0.001 (unadjusted 2-sided) for superiority, controlled for multiplicity. f Baseline value is the geometric mean. Modified Intent-to-Treat (mITT) Population a Study 5 Study 6 Placebo N = 120 ZEPBOUND MTD (10 mg or 15 mg) N = 114 Placebo N = 114 ZEPBOUND MTD (10 mg or 15 mg) N = 119 AHI (events/hr) Baseline mean 50.1 52.9 53.1 46.1 Change from baseline b -5.3 -25.3 -5.5 -29.3 Difference from placebo b (95% CI) -20 (-25.8, -14.2) e -23.8 (-29.6, -17.9) e % change in AHI % change from baseline b -3 -50.7 -2.5 -58.7 % difference from placebo b (95% CI) -47.7 (-65.8, -29.6) e -56.2 (-73.7, -38.7) e % of patients with ≥50% reduction in AHI d 19 61.2 23.3 72.4 % difference from placebo (95% CI) 42.8 (30.8, 54.8) e 48.6 (36.6, 60.7) e Remission or mild non-symptomatic OSA % of Patients with AHI <5 or AHI 5-14 and ESS≤10 d 15.9 42.2 14.3 50.2 % difference from placebo (95% CI) 28.7 (18.3, 39.2) e 33.2 (22.1, 44.3) e Sleep apnea-specific hypoxic burden (% min/h) Baseline mean f 137.8 153.6 142.1 132.2 Change from baseline b -25.1 -95.2 -41.7 -103 Difference from placebo b (95% CI) -70.1 (-90.9, -49.3) c,e -61.3 (-84.7, -37.9) c,e Body weight (kg) Baseline mean 112.8 116.7 115.1 115.8 % change from baseline b -1.6 -17.7 -2.3 -19.6 % difference from placebo b (95% CI) -16.1 (-18, -14.2) e -17.3 (-19.3, -15.3) e The time course of change in AHI with ZEPBOUND and placebo from baseline through Week 52 are shown in Figure 7 for Study 5. Similar results were demonstrated for Study 6. Figure 7: Change from Baseline in Apnea-Hypopnea Index (AHI) Through Week 52 (Study 5) Abbreviations: AHI = Apnea-Hypopnea Index; ANCOVA = analysis of covariance; MI = multiple imputation; MTD = maximum tolerated dose. Note: Displayed results are from modified Intent-to-Treat Population. (1) Observed mean value from Week 0 through Week 52, and (2) least squares mean ± standard error at Week 52 from ANCOVA adjusted for baseline values and stratification factors, with multiple imputation of missing data. Figure 7 Sleep-Related Impairment In OSA clinical studies (Study 5 and Study 6), ZEPBOUND-treated patients showed improvement in sleep-related impairment compared to those who received placebo. Sleep-related impairment was assessed using the Patient-Reported Outcomes Measurement Information System ® (PROMIS) Short Form Sleep-Related Impairment 8a.