Drug interactions of cytokines and anti-cytokine therapeutic proteins

Greg Slatter

Early Development, Clinical Pharmacology

Amgen Inc., Seattle WA

PNWBIO 14 August 2013

The trilogy of commonly observed indirect TP-DDIs

Schmitt C, et al., Disease-drug-drug interaction involving tocilizumab and simvastatin in patients with rheumatoid arthritis. Clin Pharmacol Ther. 2011;89(5):735-40. Maini RN, et al. Therapeutic efficacy of multiple intravenous infusions of anti-tumor necrosis factor alpha monoclonal antibody combined with low-dose weekly methotrexate in rheumatoid arthritis. Arthritis Rheum. 1998; 41:1552-63. Abuqayyas L, Balthasar, JP. Pharmacokinetic mAb-mAb interaction: anti-VEGF mAb decreases the distribution of anti-CEA mAb into colorectal tumor xenografts. AAPS J 2012 ;14: 445-55. 2

Kenny JR, et al., 2013 Therapeutic Protein-Drug-Drug Interactions: navigating the knowledge gaps. Highlights from the 2012 AAPS NBC Roundtable and IQ Consortium/FDA Workshop. AAPS Journal. 2013. Jun 21. [Epub ahead of print]

Outline • P450 Suppression by Inflammation

• Tocilizumab: Simvastatin Interaction

• Nonclinical Studies in Human Hepatocytes

• Genomics Aspects & Biomarkers • C-reactive protein

• Clinical Experience

• Conclusion

3

P450 Suppression and Normalization

• Small molecule clearance can be modified by Inflammation

• Inflammation can be modified by anti-cytokine mAbs

• Thus anti cytokine mAb can modify small molecule clearance mechanisms

• Drug-Disease Interaction!

Slatter, NBC 2011 4

Acute Inflammation

Chronic Inflammation

Treatment with anti-cytokine mAB

[Cp]

Time Time

P450 Suppression by Cytokines

Same direction as P450

inhibition

Clinical Ex: Interferons, IL-2, IL-10

Risk: Supratherapeutic

Concentrations of Narrow Therapeutic Index Drugs

P450 Normalization (De-suppression) by Anti-

cytokine Treatment

Same direction as P450 induction

Clinical Ex: IL-6R mAb

Risk: Subtherapeutic

Concentrations of Narrow Therapeutic Index Drugs

Slide concept similar to: Morgan ET, Clin Pharmacol Therapeut 2009; 85(4):434-38

How Big is De-suppression? Tocilizumab (anti-IL6R) Effects on Simvastatin

Perpetrator Victim AUC before AUC after Ratio

(fold decrease) Reference

Tocilizumab (10 mg/kg)

Simvastatin 100% 43% 2.3* Schmitt et al., Clin Pharmacol Ther 2011; 89 735-40,

Rifampicin Simvastatin 17.3 2.4 7.2 Kyrklund et al., Clin Pharmacol Ther 2000; 68:592

Rifampicin Simvastatin 29 2.6 11.1 Chung E et al., Clin Pharmacol Ther 2006, 79(4):350-61

Modified from Slatter, NBC 2011 5

*DDI label language in Tocilizumab (ActemraTM) Label

P450 de-suppression is smaller in magnitude than induction by Rifampicin Effect should be no larger than the Cl difference between diseased and healthy subjects!

Other DDI Studies: Omeprazole/CYP2C19 (88% PM & IM, 72% EM), Dextromethorphan /CYP2D6 No significant change

Tocilizumab–Simvastatin DDI Triggered Significant Regulatory Interest in TP-SM DDI assessment

Huang SM, et al. Clin Pharmacol Therapeut 2010 87(4):497-503

2010 Draft FDA Flowchart for assessing TP-SM DDIs 2008: Tocilizumab Clinical DDI

“Plasma concentrations of simvastatin were higher in RA patients prior to RoActemra/Actemra administration than those reported for healthy volunteers.” (~50% reduction)

2009: Ustekinumab Approval Letter

“Conduct an in vitro study to assess whether IL-12 and/or IL-23 modulate expression of major CYP enzymes…”

2009-12: Numerous similar requests all across the industry

7

Primary Hepatocyte Models for Investigating Drug Interactions with

Cytokine Modulating Biologics

(Leslie Dickmann and Sonal Patel, PKDM)

General Experiment Design for P450 Suppression by Cytokines in Primary Hepatocytes

Slatter, NBC 2011 8

Plate Hepatocytes Overlay with Matrigel

Change Media and Replenish cytokine daily

Day 1

Days 2&3

Days 4-6

P450 Activity Assessment • Phenacetin /Testosterone probe substrates for CYP1A2 and CYP3A4 activity

mRNA Assessment • P450, UGT, and drug transporter RNA expression using real-time PCR

Viability Assessment • ATP levels (CellTiter-Glo) • Trypan Blue exclusion vs untreated cells

Cytokine Assessment APR Markers (CRP, SAA mRNA), select cytokine, cytokine receptor measurements

9

Cytochrome P450 mRNA was Globally Suppressed by IL-6

0 1 2 3 4 5

0

25

50

75

100CYP1A1CYP1A2CYP2B6CYP2C8CYP2C9CYP2C19

CYP3A4CYP3A5

CYP2D6

CYP4A11

Log[IL-6] (pg/mL)

mRN

A ex

pres

sion

(% o

f unt

reat

ed c

ells

)Physiological serum [IL-6]*

*IL-6 serum data from 7 published clinical studies

! EC50 values allows rank ordering of isoform sensitivity – CYP3A4 ≥ CYP2B6 > CYP3A5 = CYP2C19 > CYP2C9 >>CYP1A1

From data in Dickmann et al., DMD 2010 39 1415-22

An Anti-IL6 Monoclonal Antibody is Able to Partially Block CYP3A4 Suppression by IL-6

Dickmann et al., DMD 2010 39 1415-22 10

-1 0 1 2 3 4 50

50

100- mAb

Log [IL-6] (pg/mL)

6β-H

ydro

xyte

stos

tero

ne fo

rmat

ion

(% o

f unt

reat

ed c

ells

) + mAb

Donor 1 CYP3A4

-1 0 1 2 3 4 50

25

50

75

100- mAb+ mAb

Log[IL-6] (pg/mL)

6β-h

ydro

xyte

stos

tero

ne fo

rmat

ion

(% o

f unt

reat

ed c

ells

)

Donor 2 CYP3A4

19-fold shift in EC50 13-fold shift in EC50

Dashed red lines = normal range of serum IL-6 (ca. 0.5-100 pg/mL)

All previous literature studies were done at supra-physiological IL-6 concentrations

In Vitro Hepatocyte Studies on IL-6: A mechanistic understanding of the biology

Log[IL-6] (pg/mL)

CR

P m

RN

A(%

unt

reat

ed)

CY

P3A

4/IL6R m

RN

A(%

untreated)

0 1 2 3 4 50

2.0×104

4.0×104

6.0×104

8.0×104

1.0×105

1.2×105

0

25

50

75

100

125

CYP3A4IL6RCRP

IL6Ra

Gp130TNFR

TGFBR1IL4R

IL1R1

IL17Ra

IL17Rc

IL1RAP

IL10Rb

IL1R2

IL22Ra1

IL10RaIL2R

gIL7R

IL21RIL23

RIL2R

aIL3R

aIL5R

aIL9R

a05

1015202550

100150200250300350400

Rel

ativ

e m

RNA

leve

ls(%

of I

L6R

a)

Hepatocytes are OK for measuring direct effects of a single or subset of cytokines, but

oversimplify in vivo inflammation

Draft DDI Guidance (2012): “In vitro or animal studies have limited value in the qualitative and quantitative projection of clinical interactions”

Cytokine receptors on hepatocytes

Slatter et al., Drug Interactions of cytokines and anticytokine therapeutic proteins. in Zhou and Meibohm, 2013, Drug Interactions of Therapeutic Proteins (Wiley)

Clinical Literature: IL-6 and C-reactive Protein Inversely Correlate with CYP3A Activity after Surgery and in Cancer Patients

12

Metabolism of erythromycin inversely correlated with plasma IL-6

Metabolism of erythromycin inversely correlated with CRP in cancer patients

Rivory, L.P., et al., Hepatic cytochrome P450 3A drug metabolism is reduced in cancer

patients who have an acute-phase response. British Journal of Cancer. 87(3):277-80, 2002 .

Haas, C.E., et al., Cytochrome P450 3A4 activity after surgical stress.

Critical Care Medicine, 2003. 31(5): p. 1338-46.

N= 19 points P= 0.03

Slatter NBC 2012

Genomic Clues to Mechanism and Predictive Biomarkers?

Dickmann, TP-DDI Workshop, 05Jun12 13

• GWAS Study by Rosetta Inpharmatics (Merck) • 466 human liver samples from multiple centers • Gene expression analysis for > 30,000 genes • P450 marker activity for 389 livers • Genotyping using Affymetrix 500K SNP array

Yang X et al., Genome Research 2010 Aug;20(8):1020-36

Genomic Correlation Between P450s and Acute-Phase Response in 487 Human Liver Donors

Dickmann, TP-DDI Workshop, 05Jun12 14

Turquoise module is significantly positively correlated with mRNA expression and activity of most P450 genes and contains the majority of P450 genes and P450 regulators.

Pink and brown modules were negatively correlated with most P450s. The pink module was highly enriched for acute phase inflammatory genes.

Modified After: Figure 3 in Yang X et al., Genome Research 2010 Aug;20(8):1020-36

CYP3A4 mRNA Expression Correlates with PXR and CRP mRNA in 487 Human Liver Donors*

Thanks to Dr. Yudong He (CBSS) Plots from GWAS data at sagebase.org from: Yang X et al., Genome Research 2010, 20, 1020-36

Inflammation in the liver subtly disregulates elements of steroid and lipid homeostasis 14 Slatter NBC 2012

Plasma C-reactive Protein as a Population Biomarker for P450 Effects in Inflammation DDI?

• IL-6 in human liver • Multiple functions

• Apoptosis, APR, regeneration

• Drives CRP secretion into plasma (IL-1β too)

• Drives CYP3A effects relative to IL-1 β

• C-reactive protein • Non specific indicator of

inflammation • Wide dynamic range • Made primarily in liver • Half life 5-7 h • Pentraxin APR protein that

opsonizes bacteria and apoptotic cells for clearance via complement and FcγR-mediated cytosis

• Inexpensive • Normal Ranges (mg/L)*

• Median 0.8 • 90th percentile <3 • 99th percentile <12 • *Genetic variants known that can alter CRP

response and baseline

Dickmann LJ et al., Current Drug Metabolism. 2012, 13, 930-7 13

Human Hepatocyte Data

Slatter NBC 2012

CRP Values in Inflammatory Disease Differ by Disease State and Drug Treatment!

17

ULN = 3 (90th %)

** **

Modified after Slatter NBC 2012

Note that C-reactive protein secretion is a direct hepatic response to IL-6 in the liver and data are inherently variable within patient groups (not shown)

**CRP data for influenza and cytokine storm were not DDI studies

Clinical Experience:

Therapeutic Protein DDI Study: Tocilizumab: Simvastatin DDI in 12 RA patients

1. PK of simvastatin & β-OH-simvastatin over 24 h 2. PK & PD (IL-6, sIL-6R, CRP) of TCZ over 2 months

Study design highlights all the key elements that differ from SM DDI studies:

Schmitt C, et al., Disease–Drug–Drug Interaction Involving Tocilizumab and Simvastatin in Patients With Rheumatoid Arthritis. Clin Pharmacol Ther; 2011. 89:735-40. Modeling Approach to these data: Machavaram KK, Almond LM, Rostami-Hodjegan A, Gardner I, Jamei M, Tay S, Wong S, Joshi A, Kenny JR. A Physiologically Based Pharmacokinetic Modeling Approach to Predict Disease-Drug Interactions: Suppression of CYP3A by IL-6. Clin Pharmacol Ther. 2013 Aug;94(2):260-8

Conclusions

Tools Conclusion Human Hepatocytes in vitro

• In vitro studies are interesting, but not “actionable” for label making or go/no go clinical study decisions

Potential Human Biomarker

• Human genomic and related data suggests a relationship between CRP and CYP3A suppression

Disease Effect Magnitude • How big is the difference in CYP3A status in a disease population relative to a matched healthy population (for RA, psoriasis, UC, Crohn’s etc)?

Clinical Studies • Clinical Study may be needed until more “no effect” studies on diverse targets and in diverse indications are published

20

Acknowledgements • PKDM, AWA

• Leslie Dickmann • Larry Wienkers • Sonal Patel • Dan Rock • Josh Pearson

• Inflammation, ATO • Helen McBride • Kent Miner

• Inflammation, AWA • Marc Gavin • Dina Alcorn

• CBSS, AWA • Yudong He • Chris DiPalma

• PKDM, ATO • Andrew Chow

• In Vitro TP Working Group of The IQ Consortium

Early & Clinical Development • Desmond Padhi • Allegra Kaufman • Rachel Wagman • Graham Jang

15

References: Slatter JG, Wienkers LC, Dickmann LJ. “Drug interactions of cytokines and anti-cytokine therapeutic proteins”. In: Drug Interactions of Therapeutic Proteins. H Zhou and B Meibohm, Editors. Wiley. Chapter 13, 215-37. Dickmann LD, Patel SK, Rock DA, Wienkers LC, Slatter JG. “Effects of Interleukin-6 (IL-6) and an anti-IL-6 Monoclonal Antibody on Drug Metabolizing Enzymes in Human Hepatocyte Culture” Drug Metabolism and Disposition. 39: 1415-22. 2011. Kenny JR, Liu MM, Chow AT, Earp JC, Evers R, Slatter JG, Wang DD, Zhang L, Zhou, H. 2013 Therapeutic Protein-Drug-Drug Interactions: navigating the knowledge gaps. Highlights from the 2012 AAPS NBC Roundtable and IQ Consortium/FDA Workshop. The AAPS Journal. 2013. Jun 21. [Epub ahead of print]. Evers R, Dallas S, Dickmann LJ, Fahmi, Kenny JR, Kraynov E, Nguyen T, Patel A, Slatter JG, Zhang L. 2013. Critical Review of Preclinical Approaches to Investigate Cytochrome P450-mediated Therapeutic Protein Drug-Drug Interactions and Recommendations for Best Practices: A White Paper. Drug Metabolism and Disposition. 2013. Jun 21. [Epub ahead of print]. Dickmann LJ, McBride HJ, Patel SK, Miner K, Wienkers LC, Slatter JG. 2012. Murine collagen antibody induced arthritis (CAIA) and primary mouse hepatocyte culture as models to study cytochrome P450 suppression. Biochemical Pharmacology. 83 1682-89. Dickmann LJ, Patel SK, Wienkers LC, Slatter JG. 2012. Effects of Interleukin 1β (IL-1β) and IL-1β /Interleukin 6 (IL-6) Combinations on Drug Metabolizing Enzymes in Human Hepatocyte Culture. Curr Drug Metab. 13:930-7. Yang X, Zhang B, Molony C, Chudin E, Hao K, Zhu J, Suver C, Zhong H, Guengerich F, Strom SC, Schuetz E, Rushmore T,Ulrich RG, Slatter JG, Schadt EE, Kasarskis A, and Lum P. Genetic and Genomic Analysis of Cytochrome P450 Enzyme Activities in Human Liver. Genome Research.. 20(8):1020-36. 2010.