The application of safety biomarkers to risk assessment of ...toxikolog.se/wp-content/uploads/2013/05/Ina-SK-SFT-2013.pdf · The application of safety biomarkers to risk assessment

The application of safety

biomarkers to risk assessment of

drugs

Ina Schuppe KoistinenAstraZeneca Translational Science CentreScience for Life Laboratory

SFT Annual Meeting 2013-03-22

R&D | Innovative Medicines | Global Safety Assessment

Outline• What are the main reasons for attrition in drug R&D?

• What types of safety biomarkers do we need to develop innovative drugs

to treat diseases?

• Where are we today and where are the hurdles for safety biomarker

qualification?


Phase ‘Nonclinical’ Phase I Phase I-III Phase III/ Marketing

Post-Marketing

Post-Marketing

Information: Causes of attrition

Serious ADRs Causes of attrition

ADRs on label Serious ADRs Withdrawal from sale

Source: Car (2006) Sibille et al. (1998)

Olson et al. (2000)

BioPrint® (2006) Budnitz et al. (2006)

Stevens & Baker (2008)

Sample size: 88 CDs stopped 1,015 subjects 82 CDs stopped 1,138 drugs 21,298 patients 47 drugs

Cardiovascular: 27% 9% 21% 36% 15% 45%Hepatotoxicity: 8% 7% 21% 13% 0% 32%

Haematology/BM: 7% 2% 4% 16% 10% 9%Nervous system: 14% 28% 21% 67% 39% 2%

Immunotox; photosensitivity: 7% 16% 11% 25% 34% 2%Gastrointestinal: 3% 23% 5% 67% 14% 2%

Reprotox: 13% 0% 1% 10% 0% 2%Musculoskeletal: 4% 0% 1% 28% 3% 2%

Respiratory: 2% 0% 0% 32% 8% 2%Renal: 2% 0% 9% 19% 2% 0%

Genetic tox: 5% 0% 0% 0% 0% 0%

Carcinogenicity: 3% 0% 0% 1% 0% 0%

Other: 0% 0% 4% 16% 2% 2%

Adapted from Redfern WS et al. SOT 2010

1-9% 10-19% >20%0%

The various toxicity domains have been ranked first by contribution to products withdrawn from sale, then by attrition during clinical development.

Attrition in drug R&D


Safety Biomarkers (SBMs)What is wrong with the current ones?

• Not available

• Not qualified

• Not informative• Predictive vs diagnostic

• Adaptive vs adverse

• Mechanism vs damage

SBM test characteristics• Sensitivity (correct identification of cases)• Specificity (correct identification of controls)


Biomarker discovery using molecular profiling


Drug-induced kidney injury biomarkers

Adapted fromBonventre et al 2010 Nat. Biotech 28:436


Renal Biomarkers – A drug R&D example

• Monkey: 4-week study: no kidney pathology noted

• Rat: 4-week study: kidney tubular vacuolization and necrosis seen at all doses

• No BUN and serum creatinine elevations observed

• How do we proceed to humans in this case?


Application of Renal Biomarkers

Pre-clinicalC

linical

Tubular Toxicity confirmed at Histopathologyin one or more species including ratUrea and Crt in control range

Measure Urea, Crt, and new BMs (I.e.KIM-1, Alb)in urine samples of follow up rat GLP study.Show reversibility, with interim urine samples and periodic histopathology

BMs Diagnostic?

Phase I/II clinical trial:Monitor BM, urea, Crtand base decisionson best preclinical marker

No monitorable kidney tox:Delay trial until mechanistic understanding developed orhuman irrelevance shown

Yes No


In silicohERG

In vitroHigh throughput screen: hERG

In vivoSmall animal model; Monitoring in single & repeat-dose dog studies:QTc

ClinicalHigh resolution monitoring in Phase 1 and TQTS (threshold: mean >5 ms):QTc

Make

Test

Design

Confidence in predictive value of pre-clinical data = confidence in stop/go decision-making

Functional Cardiovascular Safety Biomarkers

Biomarker for In silico? In vitro? In vivo (acute)?

In vivo (chronic)?

Clinical? Predictivityassessment?

Threshold for

concern identified?

QT TdP Y Y Y Y Y Y Y*

Adapted from Chris Pollard, AstraZeneca

http://images.google.co.uk/imgres?imgurl=http://www.iusb.edu/~cted/summer/img/Computer.JPG&imgrefurl=http://www.iusb.edu/~cted/fall/computers.shtml&h=377&w=353&sz=20&hl=en&start=2&tbnid=JY0zA4972ttCLM:&tbnh=122&tbnw=114&prev=/images?q=computer&gbv=2&hl=en&sa=G


Cardiotoxicity: Structural safety biomarkers

• Cardiomyocyte damage- Cardiac troponins (cTn)- Heart fatty acid binding protein (fabp3)- Myosine light chains- Creatine kinase MB, myoglobulin- Glycogen phosphorylase BB

• Myocardial ischaemia- Ischaemia modified albumin- Unbound free fatty acids

• Inflammation• C-reactive protein• White blood cell count• Soluble CD40 ligand• Monocyte chemo-attractant protein1

• Myocardial dysfunction• B-type natiuretic peptide• N-terminal fragment of pro BNP• Endothelin


Trovafloxacin

1984Methaqualon

1991Triazolam

2004Rofecoxib

1962 Thalidomide

Terfenadine

Fenfluramine

AlosetronCisapride

Cerivastatin

1970

2001

1998

1997

2000

2006

2003

Iproniazid1967

1982 1985 1996

2005

2007

Withdrawals

1959

Oxyphenisatin

Ibufenac BenoxaprofenTicrynafen

Perhexiline Alpidem

TolcaponeTolrestat

Bromfenac

TroglitazoneAmineptine Nefazodone

Pemoline

Ximelagatran

Lumiracoxib

Drug withdrawals due to DILIReducing treatment options for key disease areas

Diabetes

Cardiovascular disorders

CNS disorders

RA/OAConstipationInfections

11Slide courtesy Michael Merz, Novartis


Drug-induced liver injury (DILI)

• New biomarker(s) should be more sensitive and specific for detection of DILI and give mechanistic information about the injury.

• Predicitive DILI biomarkers that signal liver injury before ALT has increased in patients.

• Prognostic DILI biomarkers that follow the development of injury and signal if a patient is recovering or developing acute liver failure.

• Susceptibility biomarkers for patient stratification to select patients at risk

What types of new DILI biomarkers are needed?


DILI biomarkers: Preclinical issues

Preclinical issues:

• ALT changes in the absence of histopathological evidence of injury

• Absence of preclinical liver signals that do appear in clinical trials

• Poorly or un-monitorable liver changes in preclinical species due to:

• Steatosis, hepatocellular proliferation, biliary epithelial hyperplasia,

hepatic fibrosis

Histopathology is

considered the golden

standard for detecting DILI


miR-122 has been shown to be highly liver specific

Zhang Yi. Clinical Chemistry 56:12, 1830-1838 (2010)

Example of a novel DILI biomarker: miR-122


HMGB1 and Cytokeratin 18Mechanism based biomarkers

Apoptosis:

• Keratin-18 – intermediate filament protein / structural integrity

• Is cleared by caspases

• Fragment released into blood

• Full length K18 passively released during necrosis

Necrosis and Inflammation:

• HMGB1 – chromatin binding protein

• Passive released by necrotic cells

• Active released by activated immune cells (hyper-acetylated (Lys NLS))

• Cytokine activity (TLR/RAGE)

Antoine DJ et al., 2010 Mol MedAntoine DJ et al., 2009 Toxicol Sci

Slide courtesy Neil French, MRC CDSS


Cytokeratin 18 and HMGB-1Mouse data

Mice injected with 530 mg/kg of acetaminophenCK18 and HMGB1 show better correlation to histopathology than ALT


Patients post acetaminophen overdose Markers for inflammation, necrosis, and apoptosis

Association with King‘s College Criteria for prognosis of acute liver failure

Based on Antoine DJ et al., 2012 J Hepat


Patients post acetaminophen overdoseHMGB1 as a potential prognostic marker

18

Antoine DJ et al., 2012 J Hepat


Key challenges for SBM qualification

• Large number of preclinical studies needed linking biomarker to histopathology

• Translatability across species incl humans

• Lack of access to human histopathology

• Multitude of patient populations need to be included (background variability)

• Large number of biomarker candidates require substantial sample volumes

• Key target responses, i.e. specific ADRs, suitable and accessible for qualification are overall very rare or difficult to mimick in animals

• Regulators require broad scientific consensus for SBMs qualified for regulatory decision-making

Qualification cannot be achieved by onelaboratory/company alone


Qualification of SBM requires collaboration

http://www.fnih.org/


SAFE-T(Safer and faster evidence-based translation)

Objective- To qualify new specific and sensitive safety biomarkers for drug-induced kidney, liver and

vascular injuries to improve safety assessment during drug development

FDA

• Evidence-based decisionmaking

• More reliable causalityassessment

• Better mechanisticunderstanding

• Safer translation to clinical development

• Earlier and more specificsignal detection

• Enhanced clinicalmonitoring

Improved patient safety

Reduced attrition rates

Accelerated and safeapproval of innovative medicines

Project co-ordinator: Michael Merz (Novartis)

Scientific co-ordinator: Ina Schuppe Koistinen (AstraZeneca)

11 Pharma, 8 academic, 4 SME partners Budget 35.7 mio Euro


Identification of biomarker candidates

ACE 1IL-6IL-8IP-10ITACMCP-1MIGMIP-1aTGFbVEGFCRPICAMVCAM

E-SelectinP-SelectinThrombomodulinCaveolin 1H1-CalponinH-CaldesmonSM22/TransgelinSmooth muscle alpha actinSmoothelinCirculating endothelial cellsEndothelin 1

ESM-1Lipocalin-2 (NGAL)MIP-3bSDF-1Serum nitriteThrombospondin 1TIMP 1TNFR-1Von Willebrandfactor (VWF)Von Willebrandfactor propeptide(VWFpp)

Albumin mRNAMicroglobulin precursor (Ambp) mRNAMicro RNA 122Conjugated/unconjugated bile acidsHigh mobility group box 1 (HMGB1)Cytokeratin 18 (KRT18)Alpha fetoprotein (AFP)Arginase 1Colony stimulating factor receptor (CSF1R)F-protein (HPPD)Glutathione S transferase

alpha (GSTa)Leukocyte cell-derived chemotaxin 2 (LECT2)ST6Gal 1OsteopontinRatio Paraoxonase (PON1) / ProthrombinRegucalcin (RGN)ALT1/2Glutamate dehydrogenase(GLUD, GLDH)Malat dehydrogenase (MDH)Purine nucleoside phosphorylase (PNP)

Microalbumin/Albuminα-1 microglobulinCystatin C Urinary creatinineRetinol Binding Protein-4 (RBP-4)N-acetyl-β-D-glucosaminidase(NAG) Glutathione-S-transferase-α (GST-α)Glutathione-S-transferase-π (GST-π)Liver-type fatty acid binding protein (L-FABP)Collagen IVPodocinNephrin

Aquaporin-2Calbindin D28Kidney injury molecule-1 (KIM-1)ClusterinNeutrophil gelatinase associated lipocalin (NGAL)Trefoil Factor 3 (TFF3)OsteopontinTissue inhibitor of metalloproteinase-1 (TIMP-1)Connective Tissue Growth Factor (CTGF)Interleukin-18 (IL-18)Monocyte chemoattractantprotein-1 (MCP-1)

DILI

DIVI

DIKI

From a long list ofpotentially interestingmarkers, 79 have beenpicked for furtherassessment in exploratoryqualification studies


SAFE-T: Clinical biomarker qualification process

Q2 2009

Q1 2010

Q2 2011

Q2 2014


Many organ systems lack SBM to monitor drug-induced injuries


Enable personalized healthcareStratify patient groups

based on their likelihood foradverse drug reactions (ADRs)

Identify projects with safety liability earlyIdentify compounds with weak safety profiles and

elevated risk for causing future ADR,within a compound family early

Increase patient safetyUse common toxicity SBMs to

monitor clinical trials and discoverOrgan toxicity while damage is still

reversible

Impact

Enable launch of drugs that otherwise would have failed

Enable more competitivelaunches

Reduce level of uncertaintyat key decision points

Reduce level of late stagesafety related attrition

Increased safety for trialsubjects

Potential to stop compounds with safety issues early

Translational Safety Biomarkers: Scenarios for use


Animal welfare: 3 R´s

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