Small Molecule Inhibitors in Rheumatoid arthritis
Venkatesh.S, MD, DM fellow Dept of Clinical Immunology SGPGIMS Lucknow India email@example.com
• Rheumatoid arthritis – autoimmune synovitis • 0.5-1.0% of the population • Adaptive + Innate immune responses synovial hyperplasia/ pannus formation cartilage and bone destruction • Search for newer treatment options – DMARDS, biologics, and now small molecule inhibitors • Signal transduction – kinases in the nexus of proinflammatory pathways
Kinase activity and inhibition
Kinases enzymatically transfer a phosphate group from ATP to the target molecule
Inhibition of kinase function by small molecules occurs by one of two basic mechanisms
Kinases and their inhibition
• Tyrosine kinases – Syk, JAK • MAP kinases – p38, JNK, ERK • NF-kB kinase 2
Tyrosine kinases: the front runners
Tyrosine kinases involved in RA pathogenesis
Activation of Tyrosine kinases
Receptor tyrosine kinases [RTKs]
Increase in stability of transmembrane RTK dimers
Autophosphorylation of intracellular domains. creating binding sites or activating substrate proteins. including a conformational change that allows ATP and substrate binding
Active kinase then catalyzes transfer of phosphate from ATP -OH ions of tyrosine residues on the receptor itself or on substrate proteins. respectively. to promote signal transduction
Activation of Tyrosine kinases
Non-Receptor tyrosine kinases [Non-RTKs] – Src-family kinase [Lck]
Lipid moiety attaches here Plasma membrane localisation Specific interaction with RTKs & NRTKs Interacts with target signaling molecules
Activation loop C-terminal tail domain
[unfolding – revealing the Ty 416 for autophosphorylation]
[Folded upon itself]
Expression of select tyrosine kinases in human RA
Small molecule inhibitors of select Tyks
had potent anti-inflammatory activity • A 12-week.189 patients with active RA despite MTX. ascending-dose. an oral prodrug R406. NCT00326339) . randomized. neutrophils. placebo-controlled trial (ClinicalTrials. R788 (fostamatinib disodium). a significant reduction in arthritis activity and in serum levels of IL-6 and MMP-3
Arthritis Rheum 2008. mast cells.The Spleen tyrosine kinase (Syk)
• An intracellular cytoplasmic tyrosine kinase[non-RTK] • Important mediator of immuno-receptor signaling in macrophages.gov number. and B cells • Present in the synovium of patients with RA • TNF-α induced activation of Syk in FLS Cytokine and MMP • In rodent models of collagen-induced arthritis.58:3309-18
double-blind.at weeks 1. Poland.# Multi-center. Mexico. placebo-controlled trial # at 64 sites in six countries (Bulgaria. and 8 and monthly and the principal investigators
. Romania. 4. randomized. Colombia. and the United States) # between May 2008 and June 2009
100mg bd 152 R788 304
150mg od 152
bd dose 77
od dose 76
# designed jointly by the sponsor (Rigel) Follow up . 2. 6.
# Cancer (except for basal-cell or squamouscell carcinoma of the skin) within the previous 5 years # Uncontrolled hypertension # ALT >1.mm # S.Inclusion criteria
Active rheumatoid arthritis for at least 6 months. NSAIDs. or oral corticosteroids (≤10 mg of prednisone per day or the equivalent) was permitted
Patients who completed the study or withdrew early were eligible to enter a long-term open-label study in which all patients received R788 according to the dosing regimen to which they had been assigned in the randomized study
.allowed if patient has had a washout period
# Active or untreated latent infection.000/ cu. including hepatitis B or C.Creat > ULN
Concurrent treatment with stable doses of sulfasalazine.2x ULN # Hb < 10g/dL # Platelet count < 125.5 and 25 mg per week) for a minimum of 3 months Active RA .TJC ≥6 + SJC ≥6 + at least ½[↑ESR or CRP] Previous Rx with biologics . on a stable dose of MTX (between 7. chloroquine/ HCQS.
Clinical responses over 6 months
67% 43% 32% 57% 19% 35%
one case of B-cell lymphoma. and one documented MI
Previous h/o non-responsiveness to biologics . cerebral hemorrhage on heparin therapy for pulmonary emboli. and one a sudden death of unknown cause with past h/o MI 27 serious adverse events: including the three deaths.3 deaths: septicemia (possibly pneumococcal).15% patients R788 100mg bd dose 43% achieved ACR 20 at 6 mon Placebo 14%
. one case of cervical ca.
70 and remission rates [DAS28<2. will slow or prevent the development of erosions will be of great interest
• Whether R788. infections.Conclusions of this R788 phase II study…
• R788 at dose of 100mg bd/ 150mg od superior to placebo • Significant difference in rates of ACR 20. 50.6] • Earliest response at 1 week of initiation of Rx • Patients with previous non-responsiveness to biologics also significantly benefited from R788 compared to placebo • Adverse events – diarrhea[MC]. elevated ALT. reversible neutropenia. alone or in combination with methotrexate.
The Janus kinase (Jaks)
• Intracellular/ Cytoplasmic Tyks Cytokine receptors • Cytokine receptors with common γ-chain subunit Jak 1/ Jak 3 • Cytokine receptors for hematopoietic growth factors Jak 2
Jak 1 Site of expression Critical function Kinase Inhibitors Adverse effects of inhibition expected Lymphopoeisis Jak 2 Hematopoesis Jak 3 Immune cells Lymphocyte activation/ proliferation/ functioning Ubiquitously expressed
INCB18424/ INCB28050 CP690.550/ Tasocitinib More serious side effects since ubiquitously expressed Likely to have lesser side effects Jak mutations – severe immunodeficiency
• • • • •
Study 28050-201. 7 or 10 mg QD) of INCB28050 or placebo Primary Outcome Measures: Safety and tolerability. dose-ranging trial 125 patients with active RA with an inadequate response to any disease modifying anti-rheumatic drug (DMARD) therapy including biologics duration of the study was six months with the primary endpoint assessed at three months patients were randomly assigned to one of three doses (4. Efficacy as determined by percent of patients achieving ACR20 improvement at three months
. a randomized. placebo-controlled. double-blind.
safety. in patients with active rheumatoid arthritis (RA) in whom methotrexate. orally active JAK inhibitor. a potent.550 twice daily for 6 weeks.550. 15 mg of CP-690.Objective: To determine the efficacy.550. etanercept. 5 mg of CP-690. and were followed up for an additional 6 weeks after treatment The primary efficacy end point was the American College of Rheumatology 20% improvement criteria (ACR20) response rate at 6 weeks
.550. or 30 mg of CP-690. infliximab. or adalimumab caused an inadequate or toxic response Methods: n = 264 were randomized equally to receive placebo. and tolerability of 3 different dosages of CP690.
respectively.5%.04– 0.Results: By week 6.8% in the 5 mg.2% in the placebo group).550 treatment arms
. and 30mg twice daily groups. the ACR20 response rates were 70.2%. 81.06 mg/dl) were seen in all CP-690. and 76.4% (versus 26. No opportunistic infections or deaths occurred Increases in mean LDL-C.2% in the placebo group (P < 0.001) Adverse effects . 15 mg. and HDL-C and mean serum creatinine level (0. compared with 29.headache and nausea The infection rate in both the 15mg twice daily group and the 30 mg twice daily group was 30.
Disease Activity Score using the erythrocyte sedimentation rate (DAS28-4 [ESR]). John Bradley.550) is an oral. Richard Riese.550). open label study of 1070 patients Either 5 or 10 mg tasocitinib twice daily Primary endpoints were laboratory safety and adverse event (AE) reports Secondary endpoints included ACR20. small molecule Janus kinase inhibitor Phase 2/3. ACR50 and ACR70 response rates. Susan Wood. Exhibits Sustained Safety and Efficacy in the Treatment of Rheumatoid Arthritis over 24 Months. and the Health Assessment Questionnaire-Disability Index (HAQ-DI)
.Tasocitinib (CP-690. 1Pfizer Inc
• • • • • Tasocitinib (CP-690. Samuel H Zwillich. an Orally Available Selective Janus Kinase Inhibitor.
Carol A Connell.
. and 796. of which 48 (25. the most frequently reported classes of events were infections and infestations (197.• 1070 patients • Total duration .4%). • 188 serious AEs (SAEs) were reported.1%.5 (ALL. gastrointestinal disorders (109. 655. 3. 18.41 (ALL). 2.1295.70 (ALL) and at month 24. the most frequent SAE was infection (34. 18. at month 12.7 patient-years • Median days of treatment 518. n=207) • Adverse effect related discontinuance . 3. n=648). 10.5%) were considered possibly related to treatment.70 patients • Total of 929 treatment-related AEs (TRAEs) were reported.2%).0 (M24. n=1070).0 (M12.62/100 patient-years of tasocitinib treatment)
• Mean DAS28-4(ESR) at baseline was 6.
and HAQ-DI over a 24-month period.
• Efficacy is demonstrated by sustained improvement in ACR response rates. DAS284(ESR).• Tasocitinib is effective in the long-term treatment of RA with a manageable safety profile.
and c-Kit activation in mast cells
• C-Fms and its ligand M-CSF – integral to MQ and osteoclast formation • PDGFR – fibroblast proliferation FLS pannus formation • C-Kit – mast cell activation [Masitinib – C-kit inhibitor] • BTK transduces BCR signaling in B cells. TLR signaling in monocytes • VEGFR inhibitors – cardiotoxicity and hypertension
. FceR1 signaling in mast cells.Other Tyk inhibitors studied in preclinical/animal models
• Imatinib – attenuation of CIA due to suppression of c-Fms activation in synovial macropahges. of PDGFR activation on FLS.
JNKs • All three are activated in the RA synovium and proposed as therapeutic targets in Rx of RA
.γ and δ) – Extracellular signal regulated kinase(ERK1 and ERK2)) – c-Jun-N-terminal kinase(JNK1. with the terminal kinases being p38.β. JNK2 and JNK3)
• MAPK pathways – sequential activation of multiple kinases.Mitogen-Activated Protein kinases(MAPK)
• 3 interrelated parallel interactive signaling pathways – each mediated by a distinct terminal MAPK family
– p38 MAPK(α. ERKs.
The MAPK signaling cascade
. IL-1.p38 (MAPK)
• Inflammation and cytokine production – TNFα.
Functions of p38MAPK activation in RA
(A) Endothelial cell function / Angiogenesis
(B) Synovial inflammation
(C) Bone and Cartilage Degeneration
brain & skin toxicity • Identification of p38α as the important isoform in RA – selective p38 inhibitors [SCIO-323 – skin toxicity and AMG-548 – liver toxicity.Enthusiasm for p38 Inhibitors .subsided!!
• Many tested in preclinical studies – did not extend to the Rx of RA • First generation molecules – pan-p38 inhibitors Clinical trials – failed due to liver. some which entered the phase II trials proved ineffective]
• Recently – p38α has some anti-inflammatory role also • Components downstream of p38α may yet constitute viable therapeutic targets MK2[post-transcriptionally promotes expression of proinflammatory genes] MK2 deficient mice – protected against CIA
and inflammation • 3 isoforms – JNK1. heart.SP600125 and AS601245 Long tem suppression of JNK Tumorogenicity JNK1 def mice – intestinal tumors
Not thought to be involved in RA
Poor specificity for JNK – unfavorable pharmacokinetic profile
• Matrix regulation. JNK2 and JNK3
JNK1 Site of expression JNK2 JNK3 Brain. testes Ubiquitously expressed
Role in RA Inhibitors
Phospho-JNK1/JNK2 detected in RA synovium but not in OA
Expression of MMP-3 and IL-6 JNK1 regulates diffn of T cells Th1 Pan-JNK inhibitors . apoptosis.
p50/p105 and p52/p100.The Master Regulator The NF-ĸB pathway
• NF-κB regulates transcription of many genes that encode cytokines. normally bind to inhibitor of NF-κB (IκB). c-Rel. RelB. including RelA (p65). which retains NF-κB in the cytoplasm
. chemokines and cell adhesion molecules • The NF-κB family of proteins.
Role of NF-ĸB in pathogenesis of RA IKK inhibition should work wonders!
A regulatory comp: [NEMO] / NEMO / Dominant / Dominant
P100/ NF-ĸB2 IKKα def-MQs (+) thru TLRs prolonged expression of pro-inflam: cytokines by NFĸB pathway
.NF-ĸB is regulated by IKK complex
Selective inhibition of IKKβ – potential target in RA
The IKK Complex .2 catalytic components .
IKK inhibitors tested in preclinical models
Safety concerns of NF-ĸB inhibition
Possible mechanism based adverse effects: Embryonic development • IKKβ-def mice & mice deﬁcient in other components of the NF-kB pathway. in fact.skin and limb abnormalities .massive epidermal hyperproliferation defect in keratinocyte differentiation
Hepatotoxicity .would not lead to mechanism-based hepatoxicity in a developed organ and. including p65-/.mice extensive liver apoptosis • Heterozygotes – develop normally [though NF-kB activation is inhibited by 70–80% in these animals] • IKKα knockouts are also embryonic lethal . could be hepatoprotective
Summary of clinical trials
• Success of small molecule kinase inhibitors in cancer Rx identification of kinase targets in RA • Many kinases – convincingly implicated and their inhibitors proved efficacious in preclinical models • Few have made it into clinical development – narrow therapeutic index • All clinical trials – pharma sponsored
• Promising molecules – Syk inhibitors. JAK inhibitors