Cytisine’s lower potency at 5-HT3 receptors may explain its lower incidence of and than

Lummis, SCR1, Price, KL1, Clarke A2.

1 Department of Biochemistry, University of Cambridge, United Kingdom 2 Achieve Life Sciences, Inc., Seattle, United States Disclosures

▪ Study was part of a larger project to examine the

5-HT3 receptor binding of and some semi- synthetic analogues generated in a project managed by Achieve Life Sciences ▪ Performed at Department of Biochemistry, University of Cambridge by Prof Sarah Lummis and Dr Kerry Price ▪ Prof Lummis and Dr Price were not paid to conduct this work ▪ Dr Clarke is a full-time, paid employee and shareholder of Achieve Life Sciences

2 (-)-Cytisine

▪ (-)-Cytisine is a naturally-occurring substance extracted from Cytisus laburnum (Golden chain) and other botanical sources ▪ USAN (U.S. Approved Name) is cytisinicline ▪ Used as an aid to cessation in Central & Eastern Europe for many years ▪ Traditional dosing of 1.5 mg tablets using a downward titration over 25 days ▪ Recent trial results suggest a simplified regimen of a 3 mg tablet 3 times daily is effective and well tolerated

3 Nausea in Clinical Trials

Latest Cochrane review reported 32 randomised trials comparing varenicline (Champix/Chantix®) with placebo

Nausea Subjects Placebo 596 7,034 8.5% Varenicline 2,207 7,929 27.8% RR = 3.1

Routine use of cytisine is associated with a low incidence of nausea. Analysis based on 4 randomised trials comparing cytisine with placebo

Nausea Subjects Placebo 16 582 2.7% RR = 1.2 Cytisine 30 733 4.1% 4 Neuronal Nicotinic Receptors

▪ Neuronal nicotinic acetylcholine receptors (nACHRs) • Composed on 5 sub-units • Belong to the Cys-loop family of ligand gated ion channel receptors

▪ Cytisine and varenicline act primarily as partial at a4b2 nAChRs

▪ Both drugs also have activity at other nAChRs to varying degrees

5 5-HT3 Receptors

▪ 5-HT3 receptor also belongs to the Cys-loop family of ligand gated ion channel receptors

▪ 5-HT3 receptor activation causes nausea and vomiting

▪ Drugs that block 5-HT3 receptors ameliorate nausea and vomiting - especially chemotherapy and post-operative induced - by binding to the 5-HT binding site

Walstab 2010 6 5-HT3 Receptors

▪ Previous study demonstrated that varenicline is a

potent and full at 5-HT3 receptors and binds to the 5-HT site ▪ This study was to determine the activity of cytisine

compared with varenicline at 5-HT3 receptors

7 Methods

▪ Human embryonic kidney (HEK) 293 cells were maintained on 90 mm tissue culture plates at 37°C and 7% CO2 in a humidified atmosphere

▪ Transfected with 5-HT3A receptor subunit cDNA ▪ Cells were incubated 2 to 3 days before harvesting ▪ Transfected HEK293 cell membranes were incubated for 1 h at 4°C in 0.5 mL of HEPES pH 7.4 buffer containing 3 ▪ 5-HT3 [ H]-GR65630 (0.1 nM) ▪ ± Cytisine / ± Varenicline ▪ Nonspecific binding was determined using 1 mM quipazine ▪ Data were analyzed by iterative curve fitting using Prism software 8 Results – Displacement Curves

% Specific Binding % Specific Varenicline

log [varenicline] M 9 Results – Displacement Curves

Cytisine

% Specific Binding % Specific Varenicline

log [compound] M 10 Results – IC50

Mean displacement of [3H]-GR65630

Human 5-HT3A Varenicline Cytisine

IC50 0.25 mM 0.50 mM

Ki 83 nM 170,000 nM

11 Ki (nM) Varenicline Cytisine Ratio

Human 5-HT3A 83 170,000 2,048 Present study a4b2 nAChR 0.06 0.17 2.8 a3b4 nAChR 240 840 3.5 Coe et al, 2005 a7 nAChR 322 2,400 7.5

▪ Displacement of varenicline and cytisine were in a different order of magnitude for 5-HT3 but are similar for nAChR

▪ Ki ratio cytisine:varenicline at 5-HT3 receptor is approximately 2000

▪ Cytisine is a very weak agonist at 5-HT3 receptors 12 Head-to-head comparing varenicline and cytisine ▪ See Natalie Walker’s presentation this afternoon ▪ Session: “ dependence and specialist groups: health inequalities and disadvantage” ▪ “Is cytisine at least as effective as varenicline for ? Findings from a non-inferiority trial in indigenous New Zealanders and their extended family” ▪ Details of the incidence of nausea associated with varenicline and cytisine will be presented ▪ Results are consistent with the previously reported clinical trial results ▪ Results also consistent with the current in vitro binding outcomes

13 ▪ The incidence of nausea associated with varenicline is high ▪ The incidence for cytisine is much lower ▪ Cytisine’s agonist activity is 2000-fold less potent than varenicline at the human 5-HT3 receptor ▪ Differences in the incidence of nausea and vomiting for varenicline and cytisine might be explained by the differences in human 5-HT3 receptor agonist activity

14 Summary Thank you

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