Preclinical Evaluation of the Stability, Safety, and Efficacy of CD101, A
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crossmark Preclinical Evaluation of the Stability, Safety, and Efficacy of CD101, a Novel Echinocandin Voon Ong,a Grayson Hough,a Michael Schlosser,a Ken Bartizal,a James M. Balkovec,a Kenneth D. James,b B. Radha Krishnanb Cidara Therapeutics, Inc., San Diego, California, USAa; Seachaid Pharmaceuticals, Durham, North Carolina, USAb Fungal infections pose a significant public health burden with high morbidity and mortality. CD101 is a novel echinocandin un- der development for the treatment and prevention of systemic Candida infections. Preclinical studies were conducted to evalu- ate the metabolic stability, plasma protein binding, pharmacokinetics, toxicity, and efficacy of CD101 at various dose levels. CD101 was stable to biotransformation in rat, monkey, and human liver microsomes and rat, monkey, dog, and human hepato- cytes. In vitro studies suggest minimal interaction with recombinant cytochrome P450 enzymes (50% inhibitory concentrations Downloaded from [IC50s] of >10 M). Similar to anidulafungin, CD101 bound avidly (>98%) to human, mouse, rat, and primate plasma proteins. In a 2-week repeat-dose comparison study, CD101 was well tolerated in rats (no effects on body weight, hematology, coagula- tion, or urinalysis). In contrast, administration of anidulafungin (at comparable exposure levels) resulted in reduced body weight, decreases in red blood cell, hemoglobin, hematocrit, mean cell volume, mean corpuscular hemoglobin, platelet, and re- ticulocyte counts, increases in neutrophil and eosinophil counts, polychromasia, and decreased activated partial thromboplastin time. Elevated plasma transaminases, total bilirubin, cholesterol, and globulin, dark and enlarged spleens, and single-cell hepa- tocyte necrosis were also observed for anidulafungin but not CD101. Hepatotoxicity may be due to the inherent chemical lability of anidulafungin generating potentially reactive intermediates. A glutathione trapping experiment confirmed the formation of a http://aac.asm.org/ reactive species from anidulafungin, whereas CD101 did not exhibit instability or reactive intermediates. CD101 showed anti- fungal activity against Candida and Aspergillus infections in neutropenic mice. These preclinical studies demonstrated that CD101 is chemically and metabolically stable, well tolerated with no hepatotoxicity, and efficacious as an antifungal agent. erious fungal infections pose a significant public health bur- while retaining the antifungal activity of an echinocandin. CD101 Sden with high morbidity and mortality. Candidemia, in par- has demonstrated excellent stability in human plasma, with 93% ticular, carries a 35% mortality rate in the first 12 weeks after remaining after 44 h, compared with 7% remaining for anidula- diagnosis (1). Since 2009, echinocandins have been increasingly fungin (10). on October 21, 2016 by guest recommended as a first-line treatment for invasive fungal infec- The preclinical studies described herein were conducted to tions, such as candidemia, and as empirical therapy for suspected evaluate the metabolic stability and pharmacokinetics of CD101 candidiasis in both neutropenic and nonneutropenic patients (2, and to compare the antifungal effects and toxicities of CD101 and 3). Echinocandins prevent fungal growth through inhibition of anidulafungin. In particular, the plasma protein binding charac- glucan synthase, which catalyzes synthesis of 1,3--D-glucan, a teristics, reactive metabolite profile, and hepatotoxicity of each major component of cell walls in fungi but not mammals (4–6). antifungal agent were assessed at comparable exposure levels. Our Three echinocandins—caspofungin, micafungin, and anidula- findings support the further development of CD101 as a treatment fungin—are currently approved for the once-daily treatment of of invasive fungal infections. candidemia and various manifestations of invasive candidiasis by the U.S. Food and Drug Administration. MATERIALS AND METHODS Polyenes and azoles have also demonstrated efficacy in the All studies of CD101 (Cidara Therapeutics, Inc., San Diego, CA) that involved animals received approval from an Institutional Animal Care treatment of systemic fungal infections. However, associated ad- and Use Committee, and all work was performed with appropriate local verse effects and drug interactions, such as nephrotoxicity follow- health regulations and ethical approval. Unless otherwise noted, stock ing amphotericin B treatment and cytochrome P450 (CYP450) solutions for in vitro studies were prepared in dimethyl sulfoxide (DMSO) enzyme inhibition by azoles, preclude their use in many clinical and subsequently diluted into the appropriate buffer/medium for each situations. Caspofungin, micafungin, and anidulafungin are asso- experiment. ciated with far fewer adverse effects and drug interactions, yet there is room for improvement in these currently available echi- nocandins. All have demonstrated liver function test abnormali- Received 28 March 2016 Returned for modification 29 May 2016 ties and hepatotoxicity (5–7), and all undergo nonenzymatic Accepted 4 August 2016 chemical degradation to a ring-opened product under neutral to Accepted manuscript posted online 12 September 2016 basic pH conditions (6, 8, 9). Caspofungin, in particular, has been Citation Ong V, Hough G, Schlosser M, Bartizal K, Balkovec JM, James KD, Krishnan shown to generate two potentially reactive intermediates follow- BR. 2016. Preclinical evaluation of the stability, safety, and efficacy of CD101, a novel echinocandin. Antimicrob Agents Chemother 60:6872–6879. ing spontaneous chemical degradation (5). doi:10.1128/AAC.00701-16. CD101, a novel echinocandin being developed as a high-expo- Address correspondence to Voon Ong, [email protected]. sure, once-weekly intravenous (i.v.) formulation for the treat- Copyright © 2016 Ong et al. This is an open-access article distributed under the ment and prevention of systemic fungal infections, was designed terms of the Creative Commons Attribution 4.0 International license. to be chemically and metabolically stable to avoid hepatotoxicity 6872 aac.asm.org Antimicrobial Agents and Chemotherapy November 2016 Volume 60 Number 11 Stability, Safety, and Efficacy of CD101, a Novel Echinocandin Antifungal susceptibility testing. MIC and minimal effective concen- plasma). The percentage extraction recovery values were calculated based tration (MEC) assays were performed according to the Clinical and Lab- on the total (free and bound) concentration as a percentage of theoretical oratory Standards Institute (CLSI) broth microdilution guidelines (11– spiked concentration (1 M CD101 and 1 g/ml warfarin). 13), with the exceptions that test compounds were made up at 50ϫ the CYP450 inhibition (17). Serial dilutions of the CD101 stock solution final assay concentration (100% DMSO) and 100-l assay volumes were (test concentrations of 0.03 to 30 M) were prepared in a 9:1 solution of used. MIC and MEC assays were read following 24 h of incubation at 35°C acetonitrile-dimethyl sulfoxide (DMSO) for CYP450 inhibition testing. for all drugs, except for amphotericin B, which was read at 48 h. MIC The final DMSO content in the reaction mixture was equal in all solutions values for C. albicans were reported as the lowest concentration resulting used within an assay and was less than 0.2%. The test articles were incu- in prominent growth inhibition (ϳ50%). MEC assays were read with the bated at 7 increasing concentrations in duplicate with human liver micro- aid of a microscope, and values were reported as the lowest drug concen- somes in the presence of 2 mM NADP (NADPH) in 100 mM potassium tration at which rounded/compact hyphal morphology was observed. phosphate (pH 7.4) containing 5 mM magnesium chloride and a probe Enumeration of MIC and MEC assay inoculum viable counts was per- substrate, in a 200-l assay final volume. The probe substrates were amo- formed by plating aliquots of the starting assay inoculum on Sabouraud diaquine (5 M) for CYP2C8 and midazolam (2.5 M) and testosterone dextrose agar. (50 M) for CYP3A4/5. Selective CYP inhibitors were screened alongside Metabolic stability. Metabolic stability was determined as described the test agents as a positive control, including quercetin (CYP2C8) and in reference 14. CD101 (1 M) was incubated with liver microsomes and ketoconazole (CYP3A4/5). After incubation for 5 min at 37°C, the reac- Downloaded from hepatocytes from Sprague-Dawley rats, cynomolgus monkeys, and hu- tions were terminated by addition of methanol-containing internal stan- mans or hepatocytes only from dogs with appropriate cofactors for up to dard (propranolol) for analytical quantification. The quenched samples 2 h at 37°C. Following incubation, samples were quenched with ice-cold were incubated at 4°C for 10 min and centrifuged at 4°C for 10 min. The methanol or acetonitrile (ACN), containing an appropriate internal stan- supernatant was removed, and the probe substrate metabolite was ana- dard and centrifuged to remove precipitated protein, and the superna- lyzed by LC-MS/MS using an Agilent 6410 mass spectrometer coupled tants were analyzed to quantitate the remaining parent. Samples from in with an Agilent 1200 HPLC and a CTC PAL autosampler. A decrease in vitro experiments were analyzed either by liquid chromatography-tandem the formation of the metabolite compared to vehicle control was used to mass spectrometry (LC-MS/MS) using an Agilent 6410 mass spectrome- calculate a 50% inhibitory concentration (IC50 [the test concentration ter coupled with