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Esaxerenone: First Global Approval

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Esaxerenone: First Global Approval Drugs https://doi.org/10.1007/s40265-019-01073-5 ADISINSIGHT REPORT Esaxerenone: First Global Approval Sean Duggan1 © Springer Nature Switzerland AG 2019 Abstract Esaxerenone (MINNEBRO™)—a novel oral, non-steroidal, selective mineralocorticoid receptor blocker—is being developed by Daiichi Sankyo for the treatment of hypertension and diabetic nephropathies. In January 2019, based on positive results from a phase III trial conducted in Japan in patients with essential hypertension, esaxerenone received marketing approval in Japan for the treatment of hypertension. This article summarizes the milestones in the development of esaxerenone leading to this frst global approval for the treatment of hypertension. 1 Introduction 1.1 Company Agreements Daiichi Sankyo are developing esaxerenone (MINNE- In March 2006, Sankyo Co., Ltd, a subsidiary of Daiichi BRO™), a novel oral, non-steroidal, selective mineralocor- Sankyo, entered into a research collaboration agreement ticoid receptor blocker, for the treatment of hypertension and with Exelixis Inc. to develop and commercialise novel ther- diabetic nephropathies. Excessive mineralocorticoid recep- apies targeting the mineralocorticoid receptor [7]. Daiichi tor activation by endogenous ligands such as aldosterone has Sankyo obtained an exclusive, worldwide licence to certain been shown to play an important role in the development of intellectual property primarily relating to compounds that hypertension, as well as progression of nephropathy and car- modulate the mineralocorticoid receptor, including esaxer- diovascular disease [1–4]. Esaxerenone is thought to exert an enone [7, 8]. After completion of the research term, Sankyo antihypertensive efect by blocking mineralocorticoid recep- Co., Ltd has assumed responsibility for all further clinical tor activation. Esaxerenone was approved in Japan for the and regulatory development of the drug. In return, Exelixis treatment of hypertension on the 8th January 2019 [4, 5] on received a $US20 million upfront payment and will receive the basis of positive results from a phase III trial in Japa- research and development funding. nese patients with essential hypertension (NCT02890173; ESAX-HTN) [6]. The drug is available as 1.25, 2.5 and 5 mg tablets, with the recommended dosage of esaxerenone being 2 Scientifc Summary 2.5 mg once daily administered orally; if the efect is insuf- fcient, the dosage can be increased to 5 mg [4]. Clinical 2.1 Pharmacodynamics development of esaxerenone for the treatment of diabetic nephropathies is underway in Japan. Esaxerenone, a selective nonsteroidal mineralocorticoid receptor antagonist, has been shown to bind to mineralo- corticoid receptors, thereby inhibiting aldosterone binding and activation of the receptor [4, 9]. In preclinical studies, esaxerenone inhibited the binding of aldosterone to the min- AdisInsight This profle has been extracted and modifed from the eralocorticoid receptor with greater potency than spirono- database. AdisInsight tracks drug development worldwide through the entire development process, from discovery, through pre- lactone and eplerenone (IC50 9.4, 36 and 713 nmol/L, clinical and clinical studies to market launch and beyond. respectively) [9]. Esaxerenone blocked aldosterone-induced transcriptional activation of human mineralocorticoid * Sean Duggan receptor with greater potency than eplerenone and spirono- [email protected] lactone (IC50 3.7 vs 66 and 970 nmol/L, respectively) in a 1 Springer, Private Bag 65901, Mairangi Bay, 0754 Auckland, cell-based assay [9]. Esaxerenone had no agonistic efect New Zealand Vol.:(0123456789) S. Duggan Positive top-line results from Phase III trial ESAX- HTN announced (Sep) Phase I trials initiated (Dec 2010) NDA submitted in Japan (Feb) Approved in Japan for the Phase II trial in essential hypertension completed treatment of hypertension (NCT02345044; JapicCTI152772) [Aug] (Jan) 2015 2016 2017 2018 2019 NCT02722265 NCT02848170 NCT02890173 ESAX-HTN NCT02808026 Studies in essential hypertension NCT02807987 Studies in hypertension NCT02807974 Key milestones in the development of esaxerenone, focusing on phase III trials in hypertension. NDA new drug application on the mineralocorticoid receptor and did not show any 2.2 Pharmacokinetics antagonistic or agonistic efect on glucocorticoid, androgen and progesterone receptors even at 5 μM, unlike eplerenone The pharmacokinetic properties of esaxerenone have been and spironolactone [9]. evaluated in phase I, double blind, sequential, dose-escalation Esaxerenone-induced mineralocorticoid receptor studies in healthy Japanese subjects [2]. Once-daily oral esax- antagonism has been evaluated in in vivo animal models erenone generally exhibited dose-proportional pharmacoki- using urinary sodium/potassium ratio concentrations as a netics following single (range 5–200 mg) [JapicCTI163473] biomarker for activity of the drug. In bilateral adrenalec- and multiple (10–100 mg/day for 10 days) [JapicCTI163476] tomized rats, administration of oral esaxerenone resulted dose regimens. Exposure reached steady state by day 4 in sub- in potent and long-lasting inhibition of an aldosterone- jects receiving oral esaxerenone 10–100 mg/day for 10 days; induced decrease in urinary sodium/potassium ratio [9]. the mean observed accumulation ratio was 1.36–1.98. Fol- Furthermore, esaxerenone dose-dependently increased the lowing a single oral administration of esaxerenone, the time urinary sodium/potassium concentration ratio in cynomol- to reach maximum plasma concentration was ≈ 3 h and the gus monkeys following a single-dose oral administration elimination half-life was ≈ 20 h; the pharmacokinetics of of the drug [4]. esaxerenone allow for a once-daily dosage regimen. In animal models of hypertension (DOCA/salt-induced The pharmacokinetics of esaxerenone are unafected by hypertensive rats and Dahl salt-sensitive hypertensive rats), food, with no diferences seen in Cmax and AUC following administration of esaxerenone resulted in dose-dependent a single oral esaxerenone 5 mg dose in healthy adult males and sustained antihypertensive efects [9–11], suppression of (n = 23) administered with or without a meal; the bioavail- renal injury development (e.g. proteinuria and renal hyper- ability of esaxerenone was 89% in those receiving esaxer- trophy) [10, 11] and inhibition of gene expression related to enone without food [4]. infammation, oxidative stress and fbrosis [10]. In healthy Japanese male subjects, administration of multiple doses of oral esaxerenone (10–100 mg/day HO for 10 days) resulted in dose-dependent changes in bio- O markers for the mineralocorticoid receptor in the plasma N HN S (increased plasma renin activity, active renin concentra- tion and plasma aldosterone concentration), providing O supportive evidence for the pharmacological activity of O esaxerenone (JapicCTI163476). An increased urinary F sodium/potassium concentration ratio was also observed in these patients following a single-dose administration F of esaxerenone; however, no obvious dose-response was F seen for this parameter when multiple doses of the drug were administered [2]. Chemical structure of esaxerenone Esaxerenone: First Global Approval Features and properties of esaxerenone Alternative names CS-3150; MINNEBRO; XL-550 Class Antihypertensives, pyrroles, small molecules, sulfones Mechanism of action Mineralocorticoid receptor blocker Route of administration Oral Pharmacodynamics Selectively binds to mineralocorticoid receptors (IC50 9.4 nmol/L), blocking aldosterone-induced transcriptional activation of the receptor (IC50 3.7 nmol/L) Pharmacokinetics Dose proportional exposure; time to maximum plasma concentration ≈3 h; elimination half-life ≈ 20 h Adverse events Most frequent ↑ Serum potassium, ↑ blood uric acids, hyperuricaemia ATC codes WHO ATC code A10X (other drugs used in diabetes); A16A (other alimentary tract and metabolism products); C01E-B (other cardiac preparations); C02K (other antihypertensives) EphMRA ATC code A10X (other drugs used in diabetes); A16A (other alimentary tract and metabolism products); C1X (all other cardiac preparations); C2A [antihypertensives (of non-herbal origin) plain] Chemical name (5P)-1-(2-Hydroxyethyl)-N-[4-(methanesulfonyl)phenyl]-4-methyl-5-[2-(trifuoromethyl)phenyl]-1H-pyrrole-3-car- boxamide In pharmacokinetic studies in healthy male subjects receiv- trough sSBP from baseline to the end of the treatment period ing a single oral dose of [14C]esaxerenone 20 mg (n = 6), the of − 13.7 and − 16.9 mmHg, respectively, compared with most abundant moiety in plasma was esaxerenone (40.8%) − 12.1 mmHg in eplerenone 50 mg/day recipients (n = 316); followed by metabolites O-glucuronide (M4) and acyl-glu- corresponding changes in trough sDBP from baseline were curonide of hydrolysate (M11) [21.4 and 8.0%, respectively]; − 6.8 and − 8.4 versus − 6.1 mmHg (primary endpoint anal- detection of several oxidized forms of metabolites in urine ysis) [4, 6]. According to noninferiority analyses, esaxer- and faeces suggest that multiple metabolic pathways exist for enone 2.5 mg/day was noninferior to eplerenone 50 mg/day esaxerenone, i.e. oxidation, glucuronidation, and hydrolysis in terms of the primary endpoint of change in trough sSBP/ [12]. In vitro metabolism studies demonstrated esaxerenone sDBP from baseline in the per protocol population [6]. Esax- is metabolized by CYP3A4, CYP3A5 and multiple UDP- erenone 5 mg/day was superior to esaxerenone 2.5 mg/day in glucuronosyltransferase isoforms. The total excretion
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