JAK-INHIBITORER MODE OF ACTION - danbio-online.dk · JAK-INHIBITORER – MODE OF ACTION DANBIO KURSUS 19. ... •Lipid metabolism ... Mukhopadhyay AK: Int J Med Sci (2004)

JAK-INHIBITORER – MODE OF ACTION DANBIO KURSUS 19. JANUAR 2018

Uffe Møller Døhn

Center for Rheumatology and Spine Diseases & COPECARE

Rigshospitalet, Glostrup

Denmark

RA PATHOGENESIS

Figure adapted from http://www.medical-artist.com/scientific-illustrations.html.

B cell

Dendritic cell

Cytokines IL-1, IL-6

TNF

Co-stimulation

Rheumatoid factor and other antibodies

T cell

T cell T cell

T cell

Macrophage

Rheumatoid arthritis

Biologics target cytokines and

extracellular signalling

Small molecules target intracellular signalling

pathways

The inflammatory cascade continues downstream into the cell

TARGETED THERAPIES Intracellular pathways can be targeted by small molecules

Monoclonal Antibody Biological DMARDS

Targeted Synthetic DMARDs

Size: ~150.000 Da ~500 Da

Structure: Immunoglobulin Chemical entity

Production: Made from cell culture media;

very complex

Controlled chemical synthesis;

not complex

Target: Extracellular Intracellular or extracellular

Target specificity: High Low(er)

Metabolism: RES Hepatic/renal

Administration: Parenteral Oral

Antidrug antibodies Yes No

Dosing: ~Q2W-Q4W ~QD

Cross blood-brain

barrier: No Potentially

Price: High High

TARGETED SYNTHETIC VS. MONOCLONAL ANTIBODY BIOLOGICAL DMARDS

Smolen J et al.: Ann Rheum Dis 2016

JAK/STAT SYSTEM

The JAK/STAT system:

• Is a signaling pathway transmitting information from extracellular cytokines to the nucleus

• Signaling results in DNA transcription and expression of genes involved in immune system, proliferation, differentiation, apoptosis and oncogenesis.

• Consists of three main components:

1. Cell surface receptor

2. Janus kinase (JAK)

3. Signal Transducer and Activator of Transcription (STAT) proteins

• Disrupted or dysregulated JAK-STAT system can result in immune deficiency syndromes and cancers

CYTOKINE SIGNALLING PATHWAYS IN RA

1. Mavers M, et al. Curr Rheum Rep 2009;11:378–385. 2. Rommel C, et al. Nat Rev Immunol 2007;7:191–201. 3. Taskén K, et al. Physiol Rev2004; 84:137–167. 4. Baier G, et al. Curr Opin Cell Biol 2009;21:262–267. 5. O’Sullivan LA, et al. Molec Immunol 2007; 44:2497–2506.

BTK3 JAK

JAK

AC, adenylyl cyclase; BTK, Bruton tyrosine kinase; cAMP, cyclic adenosine monophosphate; ERK, extracellular-signal-regulated kinases; IKK, κB kinase; JAK,

Janus kinase; JNK, c-Jun NH2-terminal kinase; MAPK, mitogen-activated protein kinase; NF-κB, nuclear factor kappa-light-chain-enhancer of activated B cells; PDE4, phosphodiesterase 4; PIK3, phosphatidylinositol-4,5-bisphosphate 3-kinase; PKC, protein kinase C; STAT, signal transducer and activator of transcription; Syk, spleen tyrosine kinase.

Cytokines act via receptor binding

JANUS KINASES (JAKS)

• A subgroup of non-receptor protein tyrosine kinases1,2

– JAK1, JAK2, JAK3, and TYK2

• Characterised by two adjacent kinase domains (JH1 and JH2)3

• Implicated in cell growth, survival, development and cell differentiation1

• Essential for immune and hematopoietic cells1

1. Ghoreschi K, et al. Immunol Rev 2009;228:273–287. 2. Wilks AF. Proc Natl Acad Sci USA 1989;86:1603–1607. 3. Thomas SJ, et al. Br J Cancer 2015; 113:365–371.

JAK, Janus family kinase; TYK2, tyrosine kinase 2.

BINDING OF CYTOKINE RECEPTORS ACTIVATES JAK SIGNALLING PATHWAYS

• Rapid membrane to nucleus signalling: – Cytokines bind trans-membrane

receptors that are associated with JAKs

JAK, Janus kinase; P, phosphate; STAT, signal transducer and activator of transcription. 1. Shuai K, et al. Nat Rev Immunol 2003;3:900–911.

Gene transcription

Binding activates JAKs

STATs bind to DNA and activate gene transcription to produce proteins mediating immune response/inflammation

JAKs phosphorylate receptors

STATs bind to receptors

JAKs phosphorylate STATs

STATs translocate to the nucleus

JAKs activate STATs, which then act as transcription factors

Frøling M et al: Ugeskr Læger 2017


Winthrop KL. Nat Rev Rheumatol. 2017 Mar 2. doi: 10.103.


CELLULAR DISTRIBUTION OF JAKS

• JAK1, JAK2, and TYK2 are expressed ubiquitously in mammals1

• JAK3 has restricted expression, predominately in cells of hematopoietic origin2,3

• At the cellular level, JAKs reside in the cytosol, endosome and plasma membrane, along with their associated receptors4

• JAK3 has been localised in cells with dendritic morphology in the RA synovium5

JAK, Janus family kinase; TYK2, tyrosine kinase 2.

1. Ghoreschi K, et al. Immunol Rev 2009;228:273–287. 2. O’Sullivan LA, et al. Molec Immunol 2007;44:2497–2506. 3. Kawamura M, et al. Proc Natl Acad Sci USA 1994;91:6374–6378. 4. Yamaoka A, et al. Genome Biol 2004;5:253. 5. Walker JG, et al. Ann Rheum Dis 2006:65:1558–1564.

Figure Reproduced from Annals of the Rheumatic Diseases, Walker JG, et al. 65, 1558-64, 2006 with permission from BMJ Publishing Group Ltd.

Synovial biopsy specimen stained for JAK35

Tao Wei TS&T June 2012 Data generated by Neurocrine Biosciences, Inc. and downloaded from GEO (GSE7307).

JAK1 and JAK2 are ubiquitous in tissue expression and JAK3 has limited distribution

CELLULAR DISTRIBUTION OF JAKS

IFNα and IFNβ

IL-6 IL-7

IL-10 IL-12 IL-15 IL-21 IL-23

GM-CSF

IL-1 IL-17 IL-18 TGF-β TNF

CYTOKINES REQUIRING JAKS FOR INTRACELLULAR SIGNALLING

1. O’Sullivan LA, et al. Mol Immunol 2007;44:2497–2506. 2. Riese RJ, et al. Best Pract Clin Res Rheumatol 2010;24:513–526.

GM-CSF, granulocyte-macrophage colony-stimulating factor, IFN, interferon; IL, interleukin; JAK, Janus kinase; TGF, transforming growth factor; TNF, tumour necrosis factor.

Key cytokines in the pathogenesis of RA

IFNα and IFNβ IL-6 IL-7

IL-10 IL-12 IL-15 IL-21 IL-23

GM-CSF

Key cytokines in RA that utilise JAK1,2

γ-chain cytokines2

Type1 interferons, IL-10, IL-22

IL-6

IL-11 IFN-γ

IL-12 IL-23

EPO, TPO GM-CSF, IL-3,

IL-5

Example of cytokines that signal through JAK combinations 1–4

JAK/STAT SIGNALLING PATHWAYS

1. O’Sullivan LA, et al. Mol Immunol 2007;44:2497–2506. 2. Ghoreschi K, et al. Immunol Rev 2009;228:273–287. 3. Sanjabi S, et al. Curr Opin Pharmacol 2009;9:447–453. 4. Chizzolini C, et al. Arthritis Res Ther 2009;11:246. 4. Gadina M et al, Arthritis Rheumatol. 2016 Jan; 68(1): 31–34.

EPO, erythropoietin; GM-CSF, granulocyte-macrophage colony-stimulating factor; IFN, interferon; IL, interleukin; JAK, Janus kinase; STAT, signal transducer and activator of transcription; TPO, thrombopoietin; TYK, tyrosine kinase.

Four JAK family members: JAK1, JAK2, JAK3, and TYK2

• T-cell growth and differentiation

• B-cell function • NK growth and

cytolytic activity

• TH1 differentiation • Macrophage

activity • NK, CD8 cytolytic

activity

• TH1 and TH17 differentiation

• Hematopoisis • Thrombopoiesis • Myelopoiesis • Growth • Anabolic

metabolism

• Acute phase response • Lymphocyte groth and

differentiation • Catabolic metabolism • Lipid metabolism • Bone resoprtion

• Antiviral response

• NK cytolytic activity

STAT 1, 3, 5, 6

STAT 1, 3, 5

STAT 1, 3, 5

STAT 1, 3, 5

STAT 3, 4

STAT 5

JAK/STAT INHIBITORS 1. Ruxolitinib

– JAK1/JAK2 inhibitor

– FDA approval 2011 & 2014 for myelofibrosis and PCV

– Being investigated for plaque psoriasis, alopecia areata, relapsed diffuse large B-cell lymphoma, and peripheral T-cell lymphoma

2. Tofacitinib – JAK1/JAK3 inhibitor

– FDA & EMA approval (2012 & 2017) for rheumatoid arthritis. FDA approval december 2017 for psoriatic arthritis

– Being investigated for ankylosing spondylitis, ulcerative colitis, psoriasis, atopic dermatitis, alopecia areata, vitiligo, JIA, SLE

3. Baricitinib – JAK1/JAK2 inhibitor

– EMA approval 2017 for rheumatoid arthritis

– Being investigated for psoriatic arthritis, GCA, SLE, atopic dermatitis

THE JAK/STAT SIGNALLING PATHWAYS

Furumoto et al. BioDrugs . 2013; 27: 431–438.

ATP-binding site of protein kinases

Paul MK, Mukhopadhyay AK: Int J Med Sci (2004)

Adenosin-tri-phosphat (ATP)

Sulfasalazin

Methotrexate

Adenosin-tri-phosphat (ATP)

• Methotrexate were independently identified as strong inhibitors of the Drosophila JAK/STAT pathway, an effect conserved to human cells.

• Methotrexate did not affect protein phosphorylation in other intracellular signalling pathways.

• Methotrexate caused significant suppression of JAK/STAT activation at a concentration equivalent to that seen in patients taking low-dose oral methotrexate (p≤0.001).

JAK/STAT INHIBITORS

Thomas S.: The Lancet, Volume 385, Supp. 1, 2015, Page S98

PHARMAKOKINETICS

TOFACITINIB BARICITINIB

Bioavailability: ~75% ~80%

Peak plasma concentration: 30-60 min 30-180 min

Plasma half-life: ~3 hours ~12 hours

Steady state: ~24-48 hours ~72 hours

Plasma protein bound: ~40% ~50%

Elimination: Liver: 70% Renal: 30%

Faeces: 20% Renal: 75%

TOFACITINIB BARICITINIB

Mode of action: JAK1, JAK3, (JAK2) JAK1, JAK2

Indication: Mono therapy or in combination with MTX or other csDMARDs

Mono therapy or in combination with MTX

Dosing 5 mg BID 4 mg QD

Elimination: Hepatic Renal

Reduced dose: Moderate liver impairment Moderate kidney impairment Age >75 yrs

Drug interactions: CYP3A4, CYP2C (Clarithromycin, Ketoconazole …)

OAT3 (Probenecid)

Recommended lab tests:

Neutrophiles, leukocytes, Hgb, transaminases, lipids

Neutrophiles, leukocytes, Hgb, transaminases, lipids, creatinine

PHARMAKOKINETICS

Hodge et al.: Clin Exp Rheumatol 2016; 34: 318-328

MODE-OF-ACTION

JAK inhibitors has high in-vitro passive permeability properties

and entries intracellularly by transcellular diffusion

Hodge et al.: Clin Exp Rheumatol 2016; 34: 318-328

Inhibitory effect (10 mg): ~89-95% Inhibitory effect (5 mg): ~80-90%

Inhibitory effect (10 mg): ~42-60% Inhibitory effect (5 mg): ~26-43%

MODE-OF-ACTION

TOFACITINIB & BARICITINIB: IN VITRO COMPARISON (IL-6)

• IL-6: signals via JAK1/JAK2, TYK2 a

McInnes I et al.: EULAR 2016, Poster number THU0182

• IL-15: signals via JAK1/JAK3

26



• IL-21: signals via JAK1/JAK3



TOFACITINIB1 BARICITINIB2

Safety population: 19.406 patient years

(5 mg & 10 mg) 6.637 patient years

(2 mg & 4 mg)

Follow-up period: 8.5 years 5.5 years

1) Cohen et al. Ann Rheum Dis. 2017 2) Genovese et al. ACR 2017; poster 511

SAFETY

INFECTIONS IR (100 pt. years) TOFACITINIB1 BARICITINIB2

Serious infections 2.7 3.2

Herpes zoster 3.9 3.4

Herpes zoster serious 0.3 0.53

1) Cohen et al. Ann Rheum Dis. 2017 2) Genovese et al. ACR 2017; poster 511 3) Eli Lilly data on file

MALIGNANCIES IR (100 pt. years) TOFACITINIB1 BARICITINIB2

Malignancies (excl. NMSC) 0.9 0.8

1) Cohen et al. Ann Rheum Dis. 2017 2) Genovese et al. ACR 2017; poster 511

SAFETY

TOFACITINIB & BARICITINIB: HAEMOGLOBIN

Hemoglobin

Schulze-Koops H et al.: Rheumatology; 2017, 56:46-57

Taylor P et al.: NEJM; 2017, 376:652-62 (suppl.)

Neutrophiles

Lymphocytes


TOFACITINIB & BARICITINIB: WHITE BLOOD CELLS


MEAN CHANGES TOFACITINIB BARICITINIB

Hemoglobin ↑ ↓ then →

Neutrophils ↓ ↓

Lymphocyte count ↑ then → ↑ then →

NK cells ↓ ↑ then →

Thrombocytes ↓ ↑

References:

Yamanaka et al. Arthritis Res Ther. 2016; 18: 34.

Tanaka.THU.0209 EULAR 2016 Poster.

TOFACITINIB & BARICITINIB: HEMATOLOGICAL EFFECTS

LDL

HDL


TOFACITINIB & BARICITINIB: LIPIDS


JAK INHIBITORS ON THE WAY Name: JAK inhibition: Disorders under investigation:

Filgotinib JAK1 RA, AS, PsA, Sjogren, CD, UC, uveitis

Upadacitinib JAK1 RA, AS, PsA, UC, CD

Peficitinib JAK3 RA

PF-04965842 JAK1 Atopic dermatitis, Psoriasis

Gandotinib JAK2 Myeloproliferative neoplasms

Lestaurtinib JAK2 AML

Momelotinib JAK1/JAK2 Myeloproliferative disorders, metastatic pancreatic cancer

Pacricitinib JAK2 Relapsed lymphoma, advanced myeloid malignancies,

myelofibrosis, myeloproliferative neoplasms, MDS

Fedratinib JAK2 Primary myelofibrosis, PCV, essential thrombocythemia

Coffeecitinib Chococitinib

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JAK-INHIBITORER MODE OF ACTION - danbio-online.dk · JAK-INHIBITORER – MODE OF ACTION DANBIO KURSUS 19. ... •Lipid metabolism ... Mukhopadhyay AK: Int J Med Sci (2004)