Drug development case studies: TNF

resistance
CD28
The good, the bad and the ugly…..
(and maybe some more good !)

Associate Professor Kellie Charles

FMH, Pharmacology (SoMS)
TNF
CTLA4
PDL1

The University of Sydney Page 1

Lecture 1 – Overview of drug development and regulation
Lecture 2 - Pre-clinical pharmacology
Lecture 3 – Toxicology
Lecture 4 – Clinical trials
Lecture 5 – Research seminar – The good, the bad and the ugly
(of drug development)

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 Learning outcomes
– Describe and give examples of drug targets in the immune
system and explain the relevance to clinical diseases.

– Appreciate the different approaches to drug development for

immune diseases.

– Explain potential problems in experimental design at various

stages of the drug development pathway and understand
strategies employed to overcome the challenges.

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 Immune system
Innate immune cells
– First defenders + responders
– Myeloid cells
– Granulocytes
– NK cells
– Platelets

Adaptive immune cells

– On-call warriors
– Lymphocytes – T & B cells

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 Immune response – acute injury

What
happens
next ?

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 Auto-immunity
– Video from pfizer

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 Acute immune response
Steps
1. Primary response
Platelets
Macrophages
Neutrophils

Fibroblasts 2. Resolution
Capillaries,
epithelium

Lymphocytes
3. Secondary response

Immediate Secondary Adaptive Resolution of acute 4. Resolution

Myeloid cell Lymphocyte response inflammation phase
& clotting Tissue restoration phase
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Sydney Page 7
The University of Sydney Page 8
Rheumatoid arthritis
Incidence: Australians (2.5%), more common in women
Associated with significant disability and economic loss (disease burden)

Clinical presentation: Signs and symptoms:

Persistent joint pain and swelling (3 areas), Morning stiffness >30min
Symmetrical involvement in hand and feet joints
Systemic flu-like symptoms (inflammation)
Raised CRP, ESR, RhF, anti-CCF, ANA- antibodies

Excessive, chronic
inflammation of
multiple joints

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 Auto-immunity
– Video from pfizer

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 RA drug targets
Main drug targets in RA
1.

2.

3.

4.

The University of Sydney van Vollenhoven, R. F. (2009) Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2009.182 Page 11
 The good: TNFa inhibitors

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 Clinical trials - Efficacy & toxicity
Efficacy
Rapid reduction in
inflammation
Rapid reduction in CRP
Rapid reduction joint swelling
& pain
Improved QOL & ADL

Toxicity
Immunosuppression
Reactivation of latent
Infections – TB, HVC/B
Increased infection risk
Death from sepsis

? Increased risk of cancer

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 The bad: drug resistance

Initial response rates positive

Declining response over time = “resistance”

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 Cause of drug resistance – auto-antibodies

Imai and Takaoka Nature Reviews Cancer 6, 714–727 (September 2006) | doi:10.1038/nrc1913
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 The good (again): alternative cytokine antagonists

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Woodrick, R. S. & Ruderman, E. M. (2011)Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2011.145
 The bad and ugly: TGN412
– Drug discovery dogma – “always aim for the rate limiting step”

What alternatives should we

consider ?

cytokines

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 6 healthy men did consented to the study
Within 16h all 6 men were in ICU

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 Clinical trial - TGN412 efficacy and toxicity

• On March 13, 2006 6 men

received TGN412 iv. Bolus

• 2 additional men had the

placebo

• All 6 men administered

TGN412 went into multi-
organ failure

• Due to rapid and unexpected

cytokine storm

Suntharalingam G et al. N Engl J Med 2006;355:1018-1028.

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 TGN412 initiates a “cytokine storm”

Suntharalingam G et al. N Engl J Med 2006;355:1018-1028.

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 Leading to activation and
proliferation of immune cells

And development of auto-

immune response =
Pain, fever, N&V, then kidney
and liver damage

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Suntharalingam G et al. N Engl J Med 2006;355:1018-1028.
 Why did this drug go so badly wrong ?
• Failed to identify risk based on the intended target and mechanism of action
CD28 is required for activating strong T cell responses in vivo in animals

• Failed to explain discordant preclinical data

Antibodies tested in animal models

• Concentrations tested resulted in complete receptor occupancy
• Inconsistency in T cell proliferation and cytokine release assay – sometime in mice, human
cells, but not monkeys
• No relationship between binding and efficacy in monkey in vivo data and no toxicity
observed = NOAEL would be difficult to calculate
• Questionable extrapolation of results to humans – HIGH SAFETY RISK

• Follow-up studies by independent groups showed dose given in trial also resulted in full
receptor occupancy in human PBMCs and errors in preclinical methodology

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 What happened next?
UK Health Minister convened special task force to review findings/practices
Medicines and Healthcare Regulatory Agency made 22 recommendations

Mainly about conduct of trials – less participants treated

Also trial reporting needs to be transparent, even if not published

2015 – MHRA reported 95,000 UK people take part in clinical trials,

~8% or 7000 patients have a serious/unexpectant toxicity
<0.5% or 450 patients will experience in fatal drug-related toxicity

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 Can’t end on a bad note…..the final good news story
– My mum’s philosophy…”if you fail to succeed… try, try again”

Initiation phase Resolution phase

Prevents over-activity
Immune RA Auto-immune disease
response
Acute Healthy
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Time (days)
 The good (again): Immune Checkpoints
CTLA4 – cytotoxic lymphocyte-associated antigen 4
CTLA4 –
expressed on T cells and binds to CD80 and CD86
Functions – counter balances CD28 co-stimulation during early phases of T cell activation

Main inhibitors – ipilimumab and tremelimumab

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 CTLA4 agonistic antibodies

Drew M. Pardoll Nature Reviews Cancer 12, 252-264 (April

2012) The blockade of immune checkpoints in cancer
The University of Sydney
immunotherapy Page 26
 What lessons can
be learnt ?

How do make sure

the public gets safe
and effective drugs

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 Drug development challenges
– Complementary medicines – gingko & memory

– Medicinal cannabis & pain

– Fecal transplants – Clostridium difficle infections

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 Key points
– Understand your drug targets very well
– Find the ”driver” or rate-limiting event – lead drug identification

– Drug resistance is common

– Attack drug discovery problems from different angles
– Multiple ways/drug targets that can inhibit clinical symptoms
– If you fail…. Don’t give up, keep trying !!!

– We don’t always get drug regulation right, but it is independent and

transparent in Australia

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