Novel Tuberculosis Drugs of the 21st Century Tuberculosis (TB) - “An infectious disease of humans and animals caused by the tubercle bacillus and characterized by the formation of

Novel Tuberculosis Drugs of the 21st Century

N

NO2N O N O

Philip Bentley

October 7, 2009

N

O

OCF3

PA-824

Br NOH

TMC207

Introduction

Tuberculosis (TB)-

“An infectious disease of humans and animals caused by the

tubercle bacillus and characterized by the formation of tubercles on the lungs and other tissues of the body, often tubercles on the lungs and other tissues of the body, often developing long after the initial infection.”

Tubercle bacillus-“A rod- shaped aerobic bacterium (Mycobacterium

tuberculosis) that causes tuberculosis.”

2

Pickett, J.P., et al., Eds. The American Heritage College dictionary, 4th ed.; Houghton Mifflin Company: Boston, MA, 2002; p 1477.

Image taken from: Jabado, N.; Gros, P. Nature 2005, 434, (7034), 709-711.

An Ancient Disease

“Consumption” and “white plague”

“Hippocrates, the ancient Greek physician, noted that ‘phthisis’ (consumption) was the most widespread ‘phthisis’ (consumption) was the most widespread and fatal disease of his time.” (>2,000 yrs ago)

Found in skulls and spines of Egyptian mummies (4,000 yrs old)

3Nobel Prize Website: http://nobelprize.org/educational_games/medicine/tuberculosis/readmore.html (accessed September 15, 2009).

Today

As of March 24, 2009 (World TB Day)

9.27 million NEW cases in 2007

4Donald, P. R.; van Helden, P. D. N. Engl. J. Med. 2009, 360, (23), 2393-2395.

22 Asian and African countries account for 80% of global TB

Cost to diagnose and treat 1.4 million cases

in high burden regions

$16.9 billion

Pathogenesis of TB

Mode of Infection

Ingestion (intestines)Consumption of contaminated milk

Inhalation (lungs)

5

Reddy, C.A. Veterinary Pathogenic Bacteriology, Department of Microbiology & Molecular Genetics: Michigan State University, 2008, pp194.Jabado, N.; Gros, P. Nature 2005, 434, (7034), 709-711.

Inhalation (lungs)Intake of airborne pathogens

Deposited in Lymph nodes

(~2 weeks)

Pathogenesis of TB

Regional Lymph nodes

Bloodstream

A few Days

1-2 weeks

6

Reddy, C.A. Veterinary Pathogenic Bacteriology, Department of Microbiology & Molecular Genetics: Michigan State University, 2008, pp194.Jabado, N.; Gros, P. Nature 2005, 434, (7034), 709-711.

Also, latent forms

(1/3 population)

Throughout Body

Cell-mediated immuneResponse

infection progressesto Tuberculosis

Organism uptakenby activatedmacrophage

Main Challenge

7Image from: http://www3.niaid.nih.gov/topics/tuberculosis/Research/basicResearch/biology_cell.htm

Normal bacteria cell wall TB cell wall

Vs.

Main Challenge

O

(CH2)23CH3

(CH2)17

OH

(CH2)10CH3(CH2)17

Trehalose =

8

Tonge, P. J. Nat. Struct. Mol. Biol. 2000, 7, 94-96.Yuan, Y.; Barry, C. E., III Proc. Natl. Acad. Sci. U. S. A. 1996, 93, 12828-12833.Image from: http://www3.niaid.nih.gov/topics/tuberculosis/Research/basicResearch/biology_cell.htm

TB cell wall

R =

O

(CH2)23CH3

(CH2)17

OH

(CH2)10CH3(CH2)17

O

(CH2)23CH3

(CH2)17

OH

(CH2)10CH3(CH2)17

H3C OCH3

O

(CH2)23CH3

(CH2)17

OH

(CH2)10CH3(CH2)17

H3C O

O

(CH2)23CH3

(CH2)17

OH

(CH2)10CH3(CH2)17

H3C OH

Mycolyl Transfer Mechanism

9Ronning, D. R.; Klabunde, T.; Besra, G. S.; Vissa, V. D.; Belisle, J. T.; Sacchettini, J. C. Nat. Struct.

Biol. 2000, 7, 141-146.

ag85C protein

Strides Towards a Cure

Nobel Prizes Awarded inPhysiology and Medicine

Robert Koch- 1905Discovery of Mycobacterium

Nobel Prize Website: http://nobelprize.org/educational_games/medicine/tuberculosis/readmore.html (accessed September 15, 2009).

Discovery of Mycobacterium

tuberculosis in 1882

Selman Waksman- 1952 Isolated active antibiotic from

Streptomyces griseus in 1943

10

History of Drug Therapy

Alkaline mineral water, mercury, antimony, cod-liver oil, copper salts

Roman physicians recommended Bathing in human urine, eating wolf liver, and drinking elephant blood

Streptomycin (1943)

OH

OHO

HO NO

H3C

HO

NH2

NH2

OHC

11Borchardt, J.K. Drug News Perspect. 2002, 15, (8), 535-542.

Streptomycin (1943)Intravenous administration

First reported TB resistance (1947)

Para-aminosalicylic acid (1949)Prevented TB resistance

Need for long term use

Streptomycin

OHO

N

HO

O

NH2

NH2O

HO

HO

HONH

CH3


Isoniazid (1952)Prodrug: Inhibits mycolic acid synthesis

Prevents latent to active TB N

HNO

NH2

Isoniazid

12

Rouche Phamaceuticals in the U.S.: About US. http://www.rocheusa.com/about/history.html (accessed Oct 4, 2009).Timmins, G. S.; Deretic, V. Mol. Microbiol. 2006, 62, 1220-1227.Borchardt, J.K. Drug News Perspect. 2002, 15, (8), 535-542.

Pyrazinamide (1954)Mechanism of action uncertain

Disrupts plasma membrane?

Disrupts energy metabolism?


Ethambutol (1962)inhibits the synthesis of arabinogalactan

13

Rifampin (rifampicin) (1965)Inhibits RNA synthesis

Can eliminate dormant bacteria

O

OH

OH

NH

N

OH

O

O

N

O

OH

HO

O

N

O

O

Rifampin

Belanger, A. E.; Besra, G. S.; Ford, M. E.; Mikusova, K.; Belisle, J. T.; Brennan, P. J.; Inamine, J. M. Proc. Natl. Acad. Sci. U. S. A. 1996, 93, 11919-11924.Tonge, P. J. Nat. Struct. Mol. Biol. 2000, 7, 94-96.Borchardt, J.K. Drug News Perspect. 2002, 15, (8), 535-542.

Combination Drug Therapy

Isoniazid and rifampingreatly decrease TB chance of survival

Isoniazid, rifampin, and pyrazinamide (Aventis: Rifater)shortened drug therapy


Isoniazid, rifampin, pyrazinamide, and ethambutolif resistant to isoniazid

Isoniazid, rifampin, pyrazinamide, ethambutol, and streptomycin

if resistant to both isoniazid and rifampin

Summary of the Drug Regime

O

OH

NH

N

OH

O

N

OH

HO

O

O

O


N

N

O

NH2

Pyrazinamide

OHOO

N

Rifampin

TB in the United States

22000

24000

26000

28000

30000# o

f P

ers

on

s I

nfe

cte

dTB Case Notifications (USA)

16

Global tuberculosis control: epidemiology, strategy, financing: WHO report 2009 (Publication no. WHO/HTM/TB/2009.411.). Geneva: World Health Organization, 2009.Weis, S. E.; Slocum, P. C.; Blais, F. X.; King, B. ; Nunn, M.; Matney, G. B.; Gomez, E.; Foresman, B. H. N. Engl. J. Med. 1994, 330, 17), 1179-1184.

10000

12000

14000

16000

18000

20000

1975 1980 1985 1990 1995 2000 2005 2010

# o

f P

ers

on

s I

nfe

cte

d

Year

Multi Drug Resistance (MDR)

17

Global tuberculosis control: epidemiology, strategy, financing: WHO report 2009 (Publication no. WHO/HTM/TB/2009.411.). Geneva: World Health Organization, 2009.Donald, P. R.; van Helden, P. D. N. Engl. J. Med. 2009, 360, (23), 2393-2395.

Need for 21st Century Drugs

Development of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB strains

(Not a single new compound since 1965)

Help reduce cost of MDR treatment

($15,000 for a 2 year treatment course)

Minimize fatalities

(30 million claimed btw 2000 and 2020)


Drugs with Promising Results

N

NO2N O

O

OCF3

19

PA-824

N

Br NOH

O

TMC207

Clinical Trial Phases

Phase of Clinical Trial

Number ofPatients

What they test

Preclinical N.A.In-vivo (Animal)

and in-vitro

Metabolic and pharmacologic

20

Phase I 20-30Metabolic and pharmacologic

properties

Phase II >100Test drug effectiveness &

Side effects and risks

Phase III 100s-1000sEfficacy, safety, benefit to risk

Gain FDA approval

Phase IV --- Long term effects

National Marrow Donor Program: What is a Clinical Trial? http://www.marrow.org/PATIENT/Undrstnd_Disease_Treat/Undrstnd_Treat_Opt/Lrn_Clinical_Trials/What_is_a_Clinical_Trial/index.html (accessed Oct 1, 2009).

PA- 824

Phase II

No cross-resistance

Potentially inhibits drug-sensitive and drug-resistant strains

N

NO2N O

O

OCF3

resistant strains

In vitro activity against non-replicating TB

Unique mechanism of action

Inhibits TB cell wall mycolic acid synthesis

Pro-drug metabolized by TB

21

Stover, C. K.; Warrener, P.; VanDevanter, D. R.; Sherman, D. R.; Arain, T. M.; Langhorne, M. H.; Anderson, S. W.; Towell, J. A.; Yuan, Y.; McMurray, D. N.; Krelswirth, B. N.; Barry, C. E.; Baker, W. R. Nature 2000, 405, (6789), 962-966.

Synthesis of PA- 824

22Baker, W. R.; Cai, S.; Keeler, E. L. 96-US10904, 9701562, 19960625, 1997.

TBAF = N

F

Synthesis of PA- 824

23Baker, W. R.; Cai, S.; Keeler, E. L. 96-US10904, 9701562, 19960625, 1997.

PA- 824: Activity Against MDR TB

Drug Resistance MIC90 (µµµµg/ ml)

[PA-824]

MIC90 (µµµµg/ ml)

[isoniazid]

Drug susceptible strains 0.015 to 0.25 0.03 to 0.06

R 0.03 0.03

I, R 0.03

24


I, R, E 0.03

I, S, E 0.25

I, R, S, E 0.03

I, R, E, P 0.06

I, S, E, P 0.25

I= isoniazid; R= rifampin; E= ethambutol; S= streptomycin; P= pyrazinamide

Activity Against Non- Replicating TB

4.5

5

5.5

6

Activity on Non-Replicating TBControl PA-824 Isoniazid

Drug anaerobic No drug, aerobic

25


1

1.5

2

2.5

3

3.5

4

-7 -5 -3 -1 1 3 5 7

Lo

g10

CF

U

Time (days)

0-7 1 2 4 7

PA- 824: Mechanisms of Action

Two suggested mechanisms

Disruption of the mycolic acids of the TB cell envelope

Yuan, Y.; Zhu, Y.; Crane, D. D.; Barry, C. E., III, Mol. Microbiol. 1998, 29, (6), 1449-1458.Singh, R.; Manjunatha, U.; Boshoff, H. I. M.; Ha, Y. H.; Niyomrattanakit, P.; Ledwidge, R.; Dowd, C. S.; Lee, I. Y.; Kim, P.; Zhang, L.; Kang, S.; Keller, T. H.; Jiricek, J.; Barry, C. E., III Science 2008, 322, (5906), 1392-1395.

26

Intracellular NO release

via a deazaflavin-dependent nitroreductase (Ddn) and the reduced form of cofactor F420


2

3

�

�

27

Yuan, Y.; Zhu, Y.; Crane, D. D.; Barry, C. E., III, Mol. Microbiol. 1998, 29, (6), 1449-1458.Stover, C. K.; Warrener, P.; VanDevanter, D. R.; Sherman, D. R.; Arain, T. M.; Langhorne, M. H.; Anderson, S. W.; Towell, J. A.; Yuan, Y.; McMurray, D. N.; Krelswirth, B. N.; Barry, C. E.; Baker, W. R. Nature 2000, 405, (6789), 962-966.

2

3


Activity as a Prodrug

Little mycolic acid repair

28

Singh, R.; Manjunatha, U.; Boshoff, H. I. M.; Ha, Y. H.; Niyomrattanakit, P.; Ledwidge, R.; Dowd, C. S.; Lee, I. Y.; Kim, P.; Zhang, L.; Kang, S.; Keller, T. H.; Jiricek, J.; Barry, C. E., III Science 2008, 322, (5906), 1392-1395.

N

NN

O

R

O

Oreduction

H

N

NN

O

R

O

HO

N

NN

O

R

O

HO

N

NN

O

O

O

protonation

4

5

N

NO

NOH

O

hydrolysis

N

NN

OHO

reduction

N

R

N

NO

R

N

O

HO

5a

6a

29


N

R

N

NO

R

O

N

O

H

5b

6b

N

R

N

H2NO

R

reduction

5c

6c


Deazaflavin- dependent nitroreductase (Ddn)

AND


30

OPC- 67683

Completed Phase II

No cross-resistance

Inhibits drug-sensitive and drug-resistant strains

Similar mechanism of action to PA- 824

O

OCF3

N

O

O

N

NNO2

31Matsumoto, M.; Hashizume, H.; Tomishige, T.; Kawasaki, M.; Tsubouchi, H.; Sasaki, H.; Shimokawa, Y.; Komatsu, M. PLoS Med. 2006, 3, (11), 2131-2144.

Similar mechanism of action to PA- 824

Inhibits TB cell wall mycolic acid synthesis

Pro-drug metabolized by TB

Decreased time on drug regime

High efficacy in immunocompromised micesuggesting treatment for TB/HIV patients

Synthesis of OPC- 67683

NHN

O2N

Cl

+Et3N, AcOEt,

60-65 oC, 6 h

87%

OO

O

K2CO3, MeOH,r.t., 2 h97%

7 8

NN

O2N

Cl

OOH

O

NO2

NN

O2N

Cl

OHOH

32Sasaki, H.; Haraguchi, Y.; Itotani, M.; Kuroda, H.; Hashizume, H.; Tomishige, T.; Kawasaki, M.; Matsumoto, M.; Komatsu, M.; Tsubouchi, H. J. Med. Chem. 2006, 49, (26), 7854-7860.

O

NO2

1.) MsCl, py., <15 oC, 2 h

2.) DBU, AcOEt, r.t., 2 h

(75% for 2 steps)8

9

NN

O2N

Cl

O





TB Strain (MIC90) MIC90 (µµµµg/ml)

rifampin- susceptible (0.288: 24x) 0.01248

isoniazid- susceptible (0.099: 8x) 0.01194

OPC- 67683: Pharmacokinetics

isoniazid- susceptible (0.099: 8x) 0.01194

ethambutol- susceptible (3.636: 303x) 0.01213

streptomycin- susceptible (2.938: 244x) 0.01203

Average (0.012)



TB Strain (MIC90) MIC90 (µµµµg/ml)

rifampin- susceptible 0.01248

rifampin- resistant 0.01221

isoniazid- susceptible 0.01194isoniazid- susceptible 0.01194

isoniazid- resistant 0.01279

ethambutol- susceptible 0.01213

ethambutol- resistant 0.01341

streptomycin- susceptible 0.01203

streptomycin- resistant 0.0134


4

5

6

7

CF

U

ORP RIEP


6/6

0

1

2

3

4

0 1 2 3 4 5 6

Lo

g10

CF

U

Time (month)


6/6

6/6

6/6

6/66/6

6/6

1/6 0/6

1/6 4/5

0/60/6

O= OPC- 67683; R= rifampin; P= pyrazinamide; I= isoniazid; E= ethambutol

# of mice with CFU / total # mice

OPC- 67683: Mechanism of Action

Same Mechanism of action as PA- 824

38

Yuan, Y.; Zhu, Y.; Crane, D. D.; Barry, C. E., III, Mol. Microbiol. 1998, 29, (6), 1449-1458. Stover, C. K.; Warrener, P.; VanDevanter, D. R.; Sherman, D. R.; Arain, T. M.; Langhorne, M. H.; Anderson, S. W.; Towell, J. A.; Yuan, Y.; McMurray, D. N.; Krelswirth, B. N.; Barry, C. E.; Baker, W. R. Nature 2000, 405, (6789), 962-966.

TMC207 (R207910)

Phase II

Unique mechanism of action

Inhibits membrane-bound ATP synthase

Potentially inhibits drug-sensitive and drug-resistant strains

Reduced time to negative sputum culture

39

Diacon, A. H.; Pym, A.; Grobusch, M.; Patientia, R.; Rustomjee, R.; Page-Shipp, L.; Pistorius, C.; Krause, R.; Bogoshi, M.; Churchyard, G.; Venter, A.; Allen, J.; Palomino, J. C.; De Marez, T.; van Heeswijk, R. P. G.; Lounis, N.; Meyvisch, P.; Verbeeck, J.; Parys, W.; de Beule, K.; Andries, K.; McNeeley, D. F. N. Engl. J. Med. 2009, 360, (23), 2397-2405.

Synthesis of TMC207

40Van Gestel, J. F. E.; Guillemont, J. E. G.; Venet, M. G.; Poignet, H. J. J.; Decrane, L. F. B.; Vernier, D. F. J.; Odds, F. C. 2004-7026, 2005148581, 20041208, 2005.

Synthesis of TMC207

41Van Gestel, J. F. E.; Guillemont, J. E. G.; Venet, M. G.; Poignet, H. J. J.; Decrane, L. F. B.; Vernier, D. F. J.; Odds, F. C. 2004-7026, 2005148581, 20041208, 2005.

4

5

6

7

8

10

CF

U

Untreated (Day 0) 1 month 2 month

TMC207: Pharmacokinetic Studies

T = TMC207

20% 0% 0% 0%0%% of mice culture (-)

after 2 month

0

1

2

3

4

Untreated T R I P

log

10

Monotherapy

42

Ibrahim, M.; Andries, K.; Lounis, N.; Chauffour, A.; Truffot-Pernot, C.; Jarlier, V.; Veziris, N. Antimicrob. Agents Chemother. 2007, 51, 1011-1015.Andries, K.; Verhasselt, P.; Guillemont, J.; Goehlmann, H. W. H.; Neefs, J.-M.; Winkler, H.; Van Gestel, J.; Timmerman, P.; Zhu, M.; Lee, E.; Williams, P.; de Chaffoy, D.; Huitric, E.; Hoffner, S.; Cambau, E.; Truffot-Pernot, C.; Lounis, N.; Jarlier, V. Science 2005, 307, (5707), 223-227.

T = TMC207R = rifampinI = isoniazidP = pyrazinamide


T = TMC2073

4

5

6

7

8

log

10

CF

U


20% 100% 30% 20%0% 20% 0% 0%% of mice culture (-)

after 2 month

43

T = TMC207P = pyrazinamideR = rifampinI = isoniazid0

1

2

3log

Two- drug therapy



T = TMC2073

4

5

6

7

8

log

10

CF

U


20% 100% 70% 78%0% 20% 0%% of mice culture (-)

after 2 month

44

T = TMC207P = pyrazinamideR = rifampinI = isoniazid0

1

2

3log

Three- drug therapy


Phase II Key Findings

TMC207 (N) Placebo (N)

Median Log10 CFU Count(Week 1)

4.7 (8) 5.2 (13)

(Week 2) 1.8 (9) 3.5 (11)

(Week 4) ~0 (6) 2.6 (12)

(Week 6) ~0 (5) 2.2 (11)

45

Diacon, A. H.; Pym, A.; Grobusch, M.; Patientia, R.; Rustomjee, R.; Page-Shipp, L.; Pistorius, C.; Krause, R.; Bogoshi, M.; Churchyard, G.; Venter, A.; Allen, J.; Palomino, J. C.; De Marez, T.; van Heeswijk, R. P. G.; Lounis, N.; Meyvisch, P.; Verbeeck, J.; Parys, W.; de Beule, K.; Andries, K.; McNeeley, D. F. N. Engl. J. Med. 2009, 360, (23), 2397-2405.

(Week 6) ~0 (5) 2.2 (11)

(Week 8) ~0 (7) ~0 (7)

Side Effects

(Nausea)26% (23) 4% (24)

(+) to (-) culture in 8 weeks

48% (23)[10:21]

9% (24)[2:23]

TMC207: Mechanism of Action

H2N

H

Arg-186

a-subunit

46Image taken from: http://www.biologie.uni-hamburg.de/b-online/e19/19d.htm.

O

O

H

Glu-61

c-subunit

Inhibition of c-subunit of ATP synthase

TMC207: Mechanism of Action

47de Jonge, M. R.; Koymans, L. H. M.; Guillemont, J. E. G.; Koul, A.; Andries, K. Proteins: Struct.

Funct. Bioinf. 2007, 67, (4), 971-980.

PA- 824 Activity against non-replicating

OPC-67683High efficacy in immunocompromised

In Summary

High efficacy in immunocompromised

TMC207Increased potency against multidrug resistant strains

All of the AboveActivity against drug-susceptible and resistant stains

48

Although excellent promise,

If used incorrectly, resistance will develop

Understanding disease evolution

The Take Home Message

Better approach to treating a target disease

49

Acknowledgements

Prof. Xuefei Huang

Prof. Babak Borhan

Group Members

Bo, Gopi, Mohammad, Dino, Gilbert, Hovig, Vivian

Medha, Ashley, Dennis, Steve

50

Go State!

51

26 - 20Image from: http://scores.espn.go.com/ncf/photos?photoId=2347018&gameId=29276012713

Documents

Novel Tuberculosis Drugs of the 21st Century Tuberculosis (TB) - “An infectious disease of humans and animals caused by the tubercle bacillus and characterized by the formation of