Rezafungin—Mechanisms of Action, Susceptibility and Resistance: Similarities and Differences with the Other Echinocandins
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Journal of Fungi Review Rezafungin—Mechanisms of Action, Susceptibility and Resistance: Similarities and Differences with the Other Echinocandins Guillermo Garcia-Effron 1,2 1 Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, C.P. 3000 Santa Fe, Argentina; [email protected] or guillermo_garciaeff[email protected]; Tel.: +54-9342-4575209 (ext. 135) 2 Consejo Nacional de Investigaciones Científicas y Tecnológicas, C.P. 3000 Santa Fe, Argentina Received: 30 September 2020; Accepted: 22 October 2020; Published: 1 November 2020 Abstract: Rezafungin (formerly CD101) is a new β-glucan synthase inhibitor that is chemically related with anidulafungin. It is considered the first molecule of the new generation of long-acting echinocandins. It has several advantages over the already approved by the Food and Drug Administration (FDA) echinocandins as it has better tissue penetration, better pharmacokinetic/phamacodynamic (PK/PD) pharmacometrics, and a good safety profile. It is much more stable in solution than the older echinocandins, making it more flexible in terms of dosing, storage, and manufacturing. These properties would allow rezafungin to be administered once-weekly (intravenous) and to be potentially administered topically and subcutaneously. In addition, higher dose regimens were tested with no evidence of toxic effect. This will eventually prevent (or reduce) the selection of resistant strains. Rezafungin also has several similarities with older echinocandins as they share the same in vitro behavior (very similar Minimum Inhibitory Concentration required to inhibit the growth of 50% of the isolates (MIC50) and half enzyme maximal inhibitory concentration 50% (IC50)) and spectrum, the same target, and the same mechanisms of resistance. The selection of FKS mutants occurred at similar frequency for rezafungin than for anidulafungin and caspofungin. In this review, rezafungin mechanism of action, target, mechanism of resistance, and in vitro data are described in a comparative manner with the already approved echinocandins. Keywords: rezafungin; CD101; antifungal susceptibility; mechanism of action; mechanism of resistance; literature review 1. Introduction Over 1 billion individuals are affected by fungal infections worldwide. It is estimated that 11.5 million suffer serious infections and that more than 1.5 million people die from fungal diseases each year [1,2]. Since the beginning of this century, there have been great advances in medical mycology including an increased number of diagnostic tools, the development of reliable methods for assessing antifungal susceptibility, the increased knowledge in mechanisms of antifungal resistance and fungal virulence factors, and the development of new drugs [1,2]. One of the greatest improvements in this last area was the incorporation of echinocandins into the antifungal armamentarium. Until the appearance of this class of drugs, the therapeutic options for invasive mycoses were limited to polyenes, 5-fluorocytocin, and azoles, which have only two molecular targets, the fungal membrane and the synthesis of nucleic acids [3,4]. J. Fungi 2020, 6, 262; doi:10.3390/jof6040262 www.mdpi.com/journal/jof J. Fungi 2020, 6, x FOR PEER REVIEW 2 of 23 J. Fungi 2020, 6, 262 2 of 23 2. β-Glucan Synthase Inhibitors Family Tree There are different chemical classes of fungal glucan synthesis inhibitors including lipopeptides 2. β-Glucan Synthase Inhibitors Family Tree (pneumocandins and echinocandins), glycolipids (papulocandins) [5], and triterpenoids (ibrexafungerp)There are [6]. di ffSeveralerent chemicalcompounds classes were eval ofuated fungal to glucanestablish synthesis their antifungal inhibitors potency including and toxicitylipopeptides and even (pneumocandins some molecules and echinocandins),were subjected glycolipidsto clinical (papulocandins)trials. Some of the [5], most and triterpenoids promising molecules(ibrexafungerp) were arbocandins, [6]. Several papulacandins, compounds were enfumagungin, evaluated to establisharundifungin, their antifungaland cilofungin. potency [7–11]. and Onlytoxicity three and echinocandins even some moleculesare currently were in subjectedclinical use to while clinical the trials. safety Some and efficacy of the most of rezafungin promising (echinocandin)molecules were and arbocandins, ibrexafungerp papulacandins, (triterpenoid) enfumagungin, are being evaluated arundifungin, in different and clinical cilofungin trials [12]. [7–11 ]. OnlyThe three three echinocandins FDA-approved are echinocandin currently in drugs clinical are use semisynthetic while the safety derivatives and e ffiofcacy natural of rezafunginproducts. In(echinocandin) 1974, the first andechinocandin-l ibrexafungerpike compound (triterpenoid) was are isolated being evaluatedfrom Aspergillus in different nidulans clinical var. trialsechinulatus [12]. [5,6]. TheIt was three named FDA-approved echinocandin echinocandin B and it drugsbecame are the semisynthetic precedent compound derivatives offor natural anidulafungin products. (LY303366)In 1974, the [5–7]. first echinocandin-like Fifteen year later, compound pneumocandin was isolated was isolated from Aspergillus from Lophium nidulans arboricolavar. echinulatus (homotypic[5,6 ]. synonym:It was named Zalerion echinocandin arboricola B) andand itit became became the the precedent compound compound leading for to anidulafungincaspofungin (MK991) (LY303366) [8].[5 –In7 ]. 1990,Fifteen three year small later, molecules pneumocandin with antifu wasngal isolated properties from Lophiumwere isolated arboricola from(homotypic Coleophoma synonym: empetri (homotypicZalerion arboricola synonym:) and Thabdostrimina it became the empetri compound). Of those, leading WF11899A to caspofungin side chain (MK991) was [8chemically]. In 1990, modifiedthree small to obtain molecules micafungin with antifungal [13]. Rezafungin properties (CD were101, formerly isolated fromSP3025,Coleophoma Cidara Therapeutics) empetri (homotypic is the newestsynonym: memberThabdostrimina of the echinocandin empetri). Of family those, and WF11899A it is the first side member chain was of the chemically second generation modified to of obtain this classmicafungin of antifungals. [13]. Rezafungin (CD101, formerly SP3025, Cidara Therapeutics) is the newest member of the echinocandin family and it is the first member of the second generation of this class of antifungals. 3. Chemistry Characteristics and Differences between Rezafungin and the First Generation Echinocandins:3. Chemistry Characteristics Stability, Stability, and Di andfferences Stability between Rezafungin and the First Generation Echinocandins: Stability, Stability, and Stability Lipopeptide antifungals are cyclic depsipeptides (oligopeptides that have at least one of its amideLipopeptide groups, -C(O)NHR-, antifungals arereplaced cyclic depsipeptidesby its ester, (oligopeptides-C(O)OR) with that different have at least side one chains of its amide[14]. Echinocandinsgroups, -C(O)NHR-, are lipopeptides replaced by with its ester,a cyclic -C(O)OR) hexapeptide with dicorefferent that sidecontains chains uncommon [14]. Echinocandins amino acids are inlipopeptides their structure with such a cyclic as hexapeptide 4-hydroxyproline, core that 3- containshydroxy-4-methilproline, uncommon amino acidsdihydroxyornithine, in their structure and such dihydroxyhomotyrosineas 4-hydroxyproline, 3-hydroxy-4-methilproline, [15]. The depsipeptide core dihydroxyornithine, is N-linked to different and dihydroxyhomotyrosine side chains in each of the [15 ]. drugs.The depsipeptide Caspofungin, core micafungin, is N-linked toand diff anidulafunginerent side chains have in each a fatty-acyl, of the drugs. an Caspofungin,isoxazole 3,5-diphenyl- micafungin, subtituted,and anidulafungin and alkoxytriphenyl have a fatty-acyl, side chains, an isoxazole respecti 3,5-diphenyl-subtituted,vely [10,15] (Figure 1). andWhen alkoxytriphenyl these side chains side arechains, removed respectively by deacetylation, [10,15] (Figure the1 ).cyclic When core these sh sideowed chains no areantifungal removed activity, by deacetylation, demonstrating the cyclic its essentialitycore showed for no echinocandin antifungal activity, activity demonstrating[6]. its essentiality for echinocandin activity [6]. Figure 1. Chemical structure of FDA-approved echinocandins (anidulafungin, caspofungin, Figure 1. Chemical structure of FDA-approved echinocandins (anidulafungin, caspofungin, and micafungin) and rezafungin. In black, the common chemical structure of the four molecules. In red J. Fungi 2020, 6, 262 3 of 23 and micafungin) and rezafungin. In black, the common chemical structure of the four molecules. In red and green, the caspofungin/micafungin and anidulafungin/rezafungin common structures, respectively. In blue, exclusive micafungin chemical structures. In light blue, the choline aminal ether of rezafungin that improves it stability (degradation less likely). Degradation of anidulafungin and rezafungin, modified from [16]. First-generation echinocandins share several pharmacological problems. They have poor oral absorption and average half-lives of 14 h (mouse model) [10], making daily intravenous administration mandatory [17–19]. These drugs also share chemical instability problems such as thermal and hydrolytic degradation for all three echinocandins [17–19] plus photodegradation for micafungin [16,17]. These last inconveniences imply manufacturing and storage