TB Host-Directed Therapy (HDT) Candidate Agents December 2015 – Tuberculosis Clinical Research Branch, DAIDS, NIAID TB HDT Rationale TB drug resistance continues to develop and HDT will be effective despite resistance and may help to prevent increases Few new anti-TB drugs are in or entering clinical evaluation and some have issues with safety and significant PKIs interactions MANY candidate HDT drugs await clinical evaluation for rapid adaptation for TB – re-purposing avoids agent development costs • If only a small % of potential new classes of HDT drugs are useful, the number of available TB agents will be greatly expanded HDT agents for TB may also have therapeutic benefit for other infections and also may serve as vaccine “potentiators” 2 Rationale for Specific, Small Molecule Adjunctive Immunomodulators in TB Rx 1. Improving TB-induced immune defects – Particularly macrophages/other innate cells/autophagy 2. *Decreasing inflammatory tissue pathology/damage* AND protected Mtb sanctuaries – Less inflammation, necrosis, caseation, granulomas, lessened inhibitory molecules • Improved immune cell access/function • Improved anti-TB drug delivery to bacilli • “NRP” TB may reactivate to be killed more quickly by TB drugs 3. Overall Effect Improved TB clearance occurs in models NIAID RFA - HDT for TB: New approaches Objective: Identify and characterize adjunctive host-directed therapy agents to improve treatment outcomes • Agents with evidence of therapeutic benefit in animal models and have FDA approval or be in Phase II or III trials Mechanism: Phased UH2 / UH3 (5 yrs) • UH2 – Pre-clinically identify/optimize specific agent and dosing regimen to advance to POC clinical trial and trial preparation • UH3 - Phase II POC Trial performance 4 Four NIAID UH2/UH3 TB HDT Awards • Autophagy Inducers (Deretic) • Statins and other lipid-metabolism modulators (Karakousis) • Imatinib (Kalman) • Anakinra (Flynn) interleukin-1 receptor antagonist (IL-1Ra) [Metformin grant application under review] 5 Simvastatin increases the in vivo activity of the first-line tuberculosis regimen J Antimicrob Chemother 2014; 69: 2453–2457 Relative to the standard oral regimen of R/H/Z, addition of 25 mg/kg simvastatin in a BALB/c mouse model reduced lung cfu by an additional 1 log10 at Day 28 (P=0.01) and by a further 1.25 log10 at Day 56 (P=0.01) 6 • In Mtb-infected mice, adjunctive metformin (MET) reduces the intracellular growth of DS a DR Mtb in an AMPK–dependent manner • MET increased production of mitochondrial reactive oxygen species and facilitates phagosome-lysosome fusion • MET reduced inflammation and lung pathology, and enhanced specific immune responses and efficacy of conventional TB drugs Collectively, these data indicate that MET is a promising candidate host-adjunctive therapy for improving TB treatment 7 Tyrosine Kinase Inhibition Imatinib – abl and c-kit targets • Myelomonocytic targets – – Improved autophagy and phagosomal acidification – Mobilization of myeloid progenitor cells – Decreases the number and function of immune suppressor cells in some malignancies • Studies in NHP (Rhesus macaques) TB and TB-SIV models with MDR Rx combinations are ongoing and appear promising Planned BMGF Sponsored 5-arm Phase II Trial • PDE-4 inhibitor - CC-11050 • Auranofin (complexed gold) • Everolimus (mTOR inhibitor) • Vitamin D • Standard DS TB regimen 9 Next Generation HDT? First-generation HDT candidates were chosen as “antiinflammatory agents”, or empirically, e.g., steroids, anti-TNF, statins, imatinib, metformin Next generation HDT agents will be TARGETED agents chosen to reverse specific abnormalities caused by Mtb in • Cell regulatory pathways of infected/immune reactive cells - “Precision Medicine” • Immune effector functions of immune reactive cells - “Immuno-oncology” For BOTH innate and adaptive TREATMENT AND VACCINE Responses Cell regulatory pathways - Precision Medicine Advances for TB “Precision Medicine” Therapeutics • Targeted HDTs have revolutionized cancer treatment by reversing effects of “molecular drivers” subverting core cell regulatory pathways • Some of the same cell pathways exploited by cancers are also disrupted by Mtb to enhance survival/proliferation, e.g., altered cholesterol metabolism AND to impair reactive immune cell function by disruption of cell metabolism Many precision medicine agents now approved or in clinical trials can be re-purposed for TB and other infections 11 Precision Medicine and TB - Approaches What research is needed? • Identification of therapeutic targets - Precise determination of the immune cell regulatory pathways disrupted by Mtb to cause immunopathogenesis • Screening - A wide variety of clinically available precision medicine agents for effect on TB infection in improved in vitro “granuloma model” systems Animal models (as appropriate) POC clinical Trials Molecular Targets of Precision Medicine Agents of Relevance for TB HDT Evidence for PG role or benefit NOT YET EXPLORED for PG or benefit • • • • • • • • • • • • • • • • • • • • • • • • AMPK P13K-AKT-mTOR MAPKs – JNK, ERK Protein kinases: abl, c-kit, VEGF, EGFR, JAK/STAT Mevalonate pathway Autophagy inducers Rho/ROCK Ras Cathelicidin/AMPs – HDACs as inducers Wnt/beta-catenin MMPs PARPS Sirtuins – STACs/inhibitors Hedgehog Notch HIF-1α Other kinases – SIK, FAK-Src, S6… Inflammasomes DPP-4 ERS/UPR reduction Angiotensin II receptors Bcl-2 GSK-3 Many more 13 Reversing TB immunosuppressive Mechanisms 1) Immune checkpoint modifications (Directly on Mtb-reactive cells) Immune cell co-receptor checkpoints • Prevent inhibitory T-cell co-receptor/ligand signaling – AGENTS - PD-1, CTLA-4, LAG-3, A2aR blockers (OX40* is stimulatory) Immunometabolic checkpoint modifications • Regulate immune cell differentiation and function by pathway controlled cellular metabolism, e.g., to enhance Th1/TH17 and memory CD8+ T cell responses - AGENTS - AMPK, sirtuin1/HIF-1α, mTOR inhibition* VACCINE potentiation * Used in combination for vaccine potentiation - animals 2) Block Suppressor cell induction (Indirect effect on Mtb-reactive cells) • Tregs, MDSCs, M2 polarized macrophages induced by Mtb and BCG vaccination - AGENTS – IDOi, ATRA, TKIs, PDE-5i, bisphosphonates, others Leveraging the exciting advances in precision medicine for the development of innovative next-generation HDTs may lead to entirely new paradigms for treatment and prevention of tuberculosis and other infectious diseases. BACK-UPS Targeting Immunometabolic Cell Regulatory Pathways to improve Vaccine Responses AMPK Stimulation • Regulates CD4 T cell responses to infection by control of a glucose-sensitive metabolic checkpoint for Th1 and Th17 development • Controls metabolic transition of active/glycolytic effector CD8 T lymphocytes to quiescent T cells to support CD8 T-cell memory development Sirtuin1/HIF1a signaling • Sirtuin1 inhibition enhances HIF1a activity in DCs to improve Th1 T cell differentiation and to decrease Tregs • HIF1a activity stabilizing agents improve Th1 responses by inhibiting HIF-PHs (HypoxiaInducible Factor prolyl hydroxylases – PHDs) mTORC inhibition – including with BCG vaccination • Improves memory CD8+ T cell generation in animal models – see “Beyond Adjuvants: Immunomodulation Strategies to enhance T-cell immunity” Vaccine 33S (2015) B21-28. PAMP or DAMP PRR RTK β-AR Adenylate Cyclase cAMP PI3K PKA SR ROS ATP ERK PTEN AKT OxLDL JNK Oxidative Stress mTOR OxLDL ER STRESS PDE Autophagy AMPK DAMPs PARP Foamy Macrophage M2 NF-κB Antiinflammatory SIRT PRO-inflammatory And Cell Death Metformin • Decreases glycolation (pyridoxamine and buformin may be better) reacts with dicarbonyls • Decreased TNF and other inflammatory CKs by inhibiting ERK/EGR-1 pathway and suppressing scavenger receptors (CD36 and SR-A) • AMPK activation – Inhibits mTOR – enhances autophagy in TB infected macrophages mediated by PPAR-gamma – Inhibits PARP activation and activates Bcl-6 – Decreases effects of RAGE signaling on some cells and inhibits HMGB1 release – Decreases NF-kB expression/Suppresses ROS formation 20 Statins HIGHLY PLEIOTROPHIC EFFECTS • AGE/RAGE effects – Decrease MPO-dependent AGE generation – Control AGE-mediated histone modification – Displaces RAGE from membrane – Decrease RAGE expression by inhibition of Rac-1 • Decreases LOX-1 effects • Enhance Efflux pumps for lipids • Matrix metalloproteinase down-regulation And Others - Will all of these be sufficiently additive to significantly impact TB-DM treatment outcomes? 21 Metabolic pathways in T cell fate and function Immunometabolism: linking metabolism and immune function Trends in Immunology April 2012, Vol. 33, No. 4 T-cell Activation Immune Checkpoints Checkpoints for development of effective cellular immunity T cell Co-receptors • Blocking PD-1 and CTLA-4 checkpoints with antibodies improves antigenspecific T cell functions – reverses senescence • The next generation of immune checkpoint blockade for clinical evaluation will include oral A2aR antagonists. Some are in trials (e.g., oral istradefylline) to increase immune responses to tumors (by T-cells, macrophages, NK cells) • TB connection - Journal of Infectious Diseases 2014;210:824–33 “… a role for the purinergic pathway in the host response to M. tuberculosis. Dampening inflammation through signaling via the adenosine A2A receptor may limit tissue damage but may also favor bacterial immune escape.” Myeloid-derived Suppressor Cells (MDSCs) MDSCs are immunosuppressive lesion-infiltrating cells • Tumor-associated MDSCs are being targeted in cancer vaccine and other immunotherapies to improve host immune responses • Large numbers of MDSCs develop during active TB in humans and BCG infection recruits MDSCs • In a mouse model, BCG-induced MDSCs blocked T cell proliferation and dampened Ag-specific priming in lymph nodes Interventions - MDSC suppression or conversion to improve cancer immunoRx by • Sirtuin1 inhibition directs a switch to a M1 lineage by glycolytic activation of cells through enhanced HIF1a function • All-trans retinoic acid, PDE-5 and c-KIT inhibition (sunitilib), bisphosphonate… Innovative New Research Tools for Use at Single Cell Level High through-put assays to define effects of molecular drivers of disease on individual cell regulation and to identify intervention targets • Epigenomic assays – defining the regulome • ChIP (Chromatin Immunoprecipitation)-based assays (acetyl, methyl, TF binding, etc.) • Chromatin accessibility assays (ATAC-seq, FAIRE-seq, …) • DNA methylation sequencing – bisulfite methylation sequencing (BMS) • Advanced proteomics, metabolomics… • Combined for simultaneous use – interactomes • DNA + RNAseq, CHiP + DNAseq, ChIP + BMS, Chip+proteomics, etc. • Sensitive detection of histone-altering gene polymorphisms (acetylation ChiP-DNAseq to find haQTL SNPs) – on a genome-wide basis using cohorts < 100, MAF ’s < 1% Results: Correlating changes in specific cell’s signaling (and influence of genetics, epigenetics) gene expression (transcription/translation/post-translational modifications) effects on cell metabolism and defense functions (phenotype) “Signaling Network Modeling” for Outcomes Single cell methods are key to this modeling • With a sufficient signaling database for a specific cell type – develop mathematical modeling for effects of signaling changes on cellular outcomes -- gene expression cell metabolism/function • Adaptive – modify model as new data becomes available • In silico study of network dynamics to predict “network nodes” of most vulnerability to intervention • Modeling can predict effect of targeted drug interventions and if combination therapy would be significantly more effective • After drug intervention – include dosing effects to determine minimal effective dose for a drug The future of therapeutic development for most diseases Immune Protection vs. Inflammatory Damage Immune reaction regulation will need to change over the time course of an evolving immune reaction to pathogens Initially • Enhance robust and usually highly inflammatory reaction to first control and then kill and begin to remove the pathogen -- or react to vaccine • HDT’s best use may be to reverse pathogen immune disruptive effects Later - ? Exactly when • Inflammatory down-regulation must INCREASE as the immune process evolves in order to limit tissue damage and implement tissue repair • NOW- HDT role may be to help modulate inflammation/damage – also to improve access and function of immune cells and antibiotics Timing/context of use of different HDTs may be crucial Key Cellular Regulatory Signaling Pathways Core pathways • PARP family • mTOR • Sirtuin family • AMPK Other key pathways – with known links to TB pathogenesis • Cellular Kinase networks (and Phosphatases) • MAPK and cascades • Kinases – TKs – (e.g., abl, c-kit, VEGF, JAK/STAT) and MANY more classes • Small molecule GTPases • Wnt/beta-catenin family • Hedgehog, Notch1/SOCS3…. Implicated in BCG-induced suppression of immune responses Drug Class/Target Tyrosine kinase inhibitors c-abl, c-kit JAK/STAT VEGF Src/FAK Ser-thr Kinase SIK inhibition AMPK activators MAPK Cascade inhibitors RAF-B MEK ERK JNK PI3K-, AKT-, mTOR Pathway mTOR Small GTPase inhibitors Ras (-RAF-MEK-ERK) Rho/ROCK PARP inhibitors Examples * Imatinib and others Tofactinib* Ruxolitinib* Pazopanib* Bevacizumab Dasatinib*, Bosutinib* Metformin*, AICAR and AZD-769662 Berberine* ,Resveratrol* ASA* Vemurafenib*, Dabrafenib Trametinib* SCH772984. VTX11e (pre) CC-930 Idelalisib*, Hispidulin, Afuresertib, Perifosine, MK-2206, Triciribine, Ridaforolimus Oxidative Stress Reduction Tipifarnib+Statin, Salirasib Fasudil# Statins, metformin NAM*, NR*, NMN*, Tetracylcines*, Olaparib* Resveratrol* Statins* Metformin Berberine Disulfiram Silymarin Tanshinone Angiotensin II receptors telmisartan* Sirtuin activators * US FDA-approved or available OTC Drug Class/Target Examples Inflammasome inhibitors Phenylbutyrate* Ursolic acid* Fasudil# Tauroursodeoxycholic acid Βeta-hydroxybutyrate, MCC950 Dipeptide dipeptiase-4 inhibitors Sitagliptin* GSK-3β Inhibitors CHIR98014, KICG1338 Cathelicidin Inducers Vitamin D, Phenylbuturate, Lithocholic acid, curcumin, nicotinamide, reseveratrol, pterostilbene Curcumin*, Imatinib*/TKIs,, Metformin*, Statins*, Verapamil*, SRIs*, Carbamazepine*, Berberine*, rapalogues ERS/UPR Reduction Autophagy Inducers (46) Mevalonate metabolism modulation ERK signaling inhibition through RAS farnesylation γδ T cell activation Highly Pleiotropic CombinationsVEGFR Inhibitors # Approved in other countries with stringent regulatory authorities Tipifarnib+Statin Amino-bisphophonates* Metformin, statins, phenylbutyrate, telmisartan, fasudil#, berberine, dimethyl fumatate* Benfotiamine Fasudil and Statins (ROCK) Vitamin D and Phenylbutyrate (AMPs) Metformin and disulfiramPazopanib Bold: Preclinical testing against MTB being performed HDT CAVEATS • May not work – PK/PD issues - delivery to site of action in active form with sufficient exposure – Extrapolation from different disease models/states – In vitro and animal model (rodent) data not translating – Actions depend on “tissue/cellular context” – Complexity of regulation/signaling – counter-reactions – ETC. • Could cause harm – Worsen TB disease course – Increase lung damage – Impact on HIV co-infection