Background of NHE-1 inhibition in DMD Fibrosis and Inflammation … · 2016. 10. 5. · PK profile...
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Translational Development of Rimeporide, a Sodium-Hydrogen Exchanger (NHE-1) Inhibitor, for Patients with Duchenne Muscular Dystrophy F. Porte-Thomé 1 , J.B. Su 2 , I. Barthelemy 3 , N.Blanchard Gutton 3 , C. Laveille 4 , G. Bkaily 5 , Q. Yu 6 , K. Nagaraju 6 , B. Ghaleh 2 , S. Blot 3 1 EspeRare Foundation, Geneva, Switzerland ([email protected]); 2 INSERM, Unité 955, Equipe 3, Créteil France; 3 Ecole Nationale Vétérinaire d’Alfort Laboratoire de Neurobiologie Maisons-Alfort France & IMRB, INSERM, Unité 955, Equipe 10, Créteil France; 4 Calvagone, France, 5 University of Medicine, Sherbrooke, Canada, 6 Children’s National Medical Center, Washington DC, USA. Background and rationale Significant reduction of fibrosis in the heart (above, -29%) & in diaphragm (-19%) , in mdx mice after a 9 M treatment) Phase II/III prerequisites 0 25 50 75 100 125 150 175 200 225 250 275 300 325 350 375 400 0.00 0.25 0.50 0.75 1.00 340 jours 100 30 jours AGE (Jours) Survie (%) Prevention of early death in cardiomyopathic hamsters Fibrosis and Inflammation in mdx mice BL10 Vehicle Mdx Vehicle Mdx-400ppm Mdx-800ppm + - Photon Intensity Significant reduction in inflammation in a large panel of skeletal muscles (forelimb & hindlimb) & diaphragm (-38%) Cardioprotection in CMH Hamsters Placebo GMRD moderate GMRD severe GLP Toxicology studies Rimeporide Clinical trial status update A complete safety & PK in healthy adults and congestive heart failure patients Ongoing Clinical development in patients with DMD (6 to 14 y) 2015 2016 2017 2021 Acknowledgements to patients & families , investigators and staff & patients organisations In cohort 1: 5 ambulant DMD patients aged 6 to 10 y, enrolled in France, received oral rimeporide for 4 W No treatment-related adverse events, no significant modification of safety lab & tolerability issues In cohort 2: 5 patients (6-10 y) in Italy, Spain & UK completed, safety analysis ongoing PK: Visual Predictive Check shows that the adult model, incorporating allometric scaling, adequately reflects the PK in children Clinical pharmacology studies in over 166 healthy and CHF patients: ‒ Single oral and IV administration ‒ Multiple oral doses administration ‒ Food interaction ‒ Drug Drug Interaction with Digoxin ‒ Safety, tolerability, PK in CHF patients with renal insufficiency Adverse events were mild in intensity with no clear dose dependency ‒ headache (15%), dizziness ( 5%), chest discomfort (10%), paresthesias, vaso-vagal attacks, local skin reactions. No clinically relevant changes in vital signs, ECGs, Laboratory. ‒ Similar events reported on Placebo and treated patients PK profile in Adults Predicted PK profile in Children Primary objective: Determine safety & tolerability of Rimeporide after 4 weeks oral treatment Secondary objective : Evaluate the PK profile of rimeporide in plasma Exploratory objectives: NMRI indices (T2, Muscle Mass, FF) & Serum Biomarkers 0 500 1000 1500 2000 2500 3000 0 6 12 18 24 30 36 42 48 54 60 66 72 EMD 87 580 plasma concentration [ng/mL] . mean 50 mg day1 mean 100mg day1 mean 200 mg day1 mean 50 mg day10 mean 100 mg day10 mean 200 mg day10 0 5 10 15 20 0 500 1000 1500 Rimeporide (µg/L) AGE=6yr AGE=12yr Extensive Toxicology package did show that Rimeporide was safe Repeated oral toxicity studies up to 26-week in rats and up to 39-week in dogs showed the main target organ in both species to be fundic parietal cells (reversible mild parietal cells alteration) No mutagenic activity nor teratogenic potential were shown No impairment of male and female fertility No skin sensitising properties No effect on cardiovascular hemodynamic parameters, no evidence of risk for any pro-arrhythmic effects No relevant effects on the central and peripheral nervous system, nor on the gastro-intestinal, renal and respiratory system Rimeporide [Na + ] i serves as a co-regulator of Ca 2+ influx through the NCX and NHE-1, (Burr et al, 2015) [Na + ] i overload was observed in DMD patients (Weber at al, 2012), is responsible for edema and a secondary increase in basal Ca 2+ levels leading to myofiber necrosis and muscles degeneration (Burr et al, 2015) NHE-1 inhibitors reduce [Na+] i , & indirectly [Ca2+] i (Iwata et al, 2007; Dorchies et al, 2015), reduce myocardial necrosis (Chahine et al, 2005), myofiber fibrosis (Nagaraju et al, 2015), inflammation (Yang et al 2013) and prevent early death (Bkaily et al, 2015) in CM hamsters . Rimeporide - Background of NHE-1 inhibition in DMD Translational GRMD Dogs studies Cohort 1 PK results Decreased heart necrosis, thrombosis, myolysis 20 animals (8 severe & 12 moderate) Blinded treatment with Rimeporide at 20 mg/kg/d or placebo started from 2 to 12 months Objectives: Contribute to the design of the clinical study by guiding dose selection, identifying novel non invasive biomarkers as well as cardiac outcome measures. GMRD moderate Simulated values in Children Observed values in children
Transcript of Background of NHE-1 inhibition in DMD Fibrosis and Inflammation … · 2016. 10. 5. · PK profile...
Translational Development of Rimeporide, a Sodium-Hydrogen Exchanger (NHE-1) Inhibitor, for Patients with Duchenne Muscular Dystrophy
F. Porte-Thomé1, J.B. Su2, I. Barthelemy3 , N.Blanchard Gutton3, C. Laveille4, G. Bkaily5, Q. Yu6, K. Nagaraju6, B. Ghaleh2, S. Blot3
1EspeRare Foundation, Geneva, Switzerland ([email protected]); 2INSERM, Unité 955, Equipe 3, Créteil France; 3Ecole Nationale Vétérinaire d’Alfort Laboratoire de Neurobiologie Maisons-Alfort France & IMRB, INSERM, Unité 955, Equipe 10, Créteil France; 4Calvagone, France, 5University of Medicine, Sherbrooke, Canada, 6Children’s National Medical Center, Washington DC, USA.
Background and rationale
Significant reduction of fibrosis in the heart (above, -29%) & in diaphragm (-19%) , in mdx mice after a 9 M treatment)
Phase II/III prerequisites
0 25 50 75 100 125 150 175 200 225 250 275 300 325 350 375 400
0.00
0.25
0.50
0.75
1.00
Control EMD
EMD 87580
340 jours
100
30 jours
AGE (Jours)
Su
rv
ie
(%)
Prevention of early death in cardiomyopathic hamsters
Fibrosis and Inflammation in mdx mice
BL10 Vehicle Mdx Vehicle Mdx-400ppm Mdx-800ppm
+
-Photon
Intensity
Significant reduction in inflammation in a large panel of skeletal muscles (forelimb & hindlimb) & diaphragm (-38%)
Cardioprotection in CMH Hamsters
Placebo
GMRD moderate
GMRD severe
GLP Toxicology studies
Rimeporide Clinical trial status update
A complete safety & PK in healthy adults and congestive heart failure patients Ongoing Clinical development in patients with DMD (6 to 14 y)
2015 2016 2017 2021
Acknowledgements to patients & families , investigators and staff & patients organisations
In cohort 1: 5 ambulant DMD patients aged 6 to 10 y, enrolled in
France, received oral rimeporide for 4 W No treatment-related adverse events, no significant
modification of safety lab & tolerability issues In cohort 2: 5 patients (6-10 y) in Italy, Spain & UK
completed, safety analysis ongoing
PK: Visual Predictive Check shows that the adult model,
incorporating allometric scaling, adequately reflects the PK in children
Clinical pharmacology studies in over 166 healthy and CHF patients:
‒ Single oral and IV administration‒ Multiple oral doses administration ‒ Food interaction ‒ Drug Drug Interaction with Digoxin‒ Safety, tolerability, PK in CHF patients with renal insufficiency
Adverse events were mild in intensity with no clear dose dependency
‒ headache (15%), dizziness ( 5%), chest discomfort (10%), paresthesias, vaso-vagal attacks, local skin reactions. No clinically relevant changes in vital signs, ECGs, Laboratory.
‒ Similar events reported on Placebo and treated patients
PK profile in Adults Predicted PK profile in Children
Primary objective: Determine safety & tolerability of Rimeporide after 4 weeks oral treatment Secondary objective : Evaluate the PK profile of rimeporide in plasma Exploratory objectives: NMRI indices (T2, Muscle Mass, FF) & Serum Biomarkers
0
500
1000
1500
2000
2500
3000
0 6 12 18 24 30 36 42 48 54 60 66 72
time [h]
EM
D 8
7 5
80
pla
sma c
on
cen
trati
on
.
[n
g/m
L]
.
mean 50 mg day1
mean 100mg day1
mean 200 mg day1
mean 50 mg day10
mean 100 mg day10
mean 200 mg day10
0 5 10 15 20
050
010
0015
0020
00
Temps (h)
Rim
epor
ide
(µg/
L)
AGE=6yr
AGE=12yr
Extensive Toxicology package did show that Rimeporide was safe
Repeated oral toxicity studies up to 26-week in rats and up to 39-week in dogs showed the main target organ in both species to be fundicparietal cells (reversible mild parietal cells alteration)
No mutagenic activity nor teratogenic potential were shown No impairment of male and female fertility No skin sensitising properties No effect on cardiovascular hemodynamic parameters, no evidence of
risk for any pro-arrhythmic effects No relevant effects on the central and peripheral nervous system, nor
on the gastro-intestinal, renal and respiratory system
Rimeporide
[Na+]i serves as a co-regulator of Ca2+ influx through the NCX and NHE-1, (Burr et al, 2015)
[Na+]ioverload was observed in DMD patients (Weber at al, 2012), is responsible for edema and a secondary increase in basal Ca2+ levels leading to myofiber necrosis and muscles degeneration (Burr et al, 2015)
NHE-1 inhibitors reduce [Na+]i, & indirectly [Ca2+]i (Iwata et al, 2007; Dorchies et al, 2015), reduce myocardial necrosis (Chahine et al, 2005), myofiber fibrosis (Nagaraju et al, 2015), inflammation (Yang et al 2013) and prevent early death (Bkaily et al, 2015) in CM hamsters .
Rimeporide -
Background of NHE-1 inhibition in DMD
Translational GRMD Dogs studies
Cohort 1 PK results
Decreased heart necrosis, thrombosis, myolysis
20 animals (8 severe & 12 moderate) Blinded treatment with Rimeporide at
20 mg/kg/d or placebo started from 2 to 12 months
Objectives: Contribute to the design of the
clinical study by guiding dose selection, identifying novel non invasive biomarkers as well as cardiac outcome measures.
GMRD moderate
Simulated values in ChildrenObserved values in children
