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REED Vulva LA Tak Due 1-15-16 Vulvar Talk LA January 2016.Pptx 1 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 UW MEDICINE │ NAMS 2018 DISCLOSURES RECENT ADVANCES IN THE TREATMENT OF VASOMOTOR SYMPTOMS Disclosures: • Royalties from online UpToDate, Scientific American, and ACP Smart KNDy May Be the New Sweet Spot Medicine • Research funding from NIH, Bayer • No COI Trade Names: Every attempt made to present in a nonbiased fashion Definitions: • K = Kispeptin • N = Neurokinin B Istockphoto.com • Dy = dynorphin Susan D Reed, MD, MPH • PRKA = peripherally restricted Professor and Vice Chair kappa agonist Department of Obstetrics and Gynecology Program Director, Women’s Reproductive Health Research Center • NK3R = neurokinin 3 receptor University of Washington, Seattle • NK1R = neurokinin 1 receptor LEARNING OBJECTIVES KNDY NEURONS SECRETE NEUROPEPTIDES After this education, learners should be able to: Kisspeptin: G-protein coupled receptor ligand neuropeptide Describe the rationale for targeting the KNDy (gene kiss1) neuron complex for new therapeutic interventions for menopausal symptoms Neurokinin B: endogenous peptide ligand that belongs to the Understand potential side effects from KNDy family of tachykinin peptides neuron therapeutics (gene TAC) highest affinity NK3R Dynorphin: kappa opiod Describe what is known about drugs in the pipeline that target KNDy KNDy neurons are co-localized with > 95% of ER, PR, AR in arcuate nucleus 1 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 WORKING HYPOTHESIS KNDY NEURON PULSE GENERATOR Arcuate Thermoregulatory Centers Arcuate KNDy neurons are Nucleus (MnPO) Nucleus WSN KNDy Peripheral Effectors KNDy KNDy interconnected Neuron Neuron Neuron Hot Flashes Hyper-activation of KNDy neurons induces Hot Flashes 6 KNDY NEURON PULSE GENERATOR KNDY NEURON PULSE GENERATOR Arcuate KNDy neurons are Arcuate KNDy neurons are Nucleus Nucleus KNDy KNDy interconnected KNDy KNDy interconnected Neuron Neuron Neuron NKB NeuronDYN NKB NKB activates DYN DYN inactivates 7 8 2 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 SILENCING KNDY NEURONS CLINICAL APPLICATIONS OF KNDY Activation Activation NEURON MANIPULATIONS NKB agonists result in HF pre-MP (Jayasena, 2015) NKB NK3R- NKB antagonists suppress HF PMP (Prague, 2017) ANT NK3R NK3R Blocking the NK3R with NK3R - antagonist reduces Genetic variations in the gene that encodes NKB are KNDy Activity associated with variations in VMS frequency (Crandall 2017) OR Kappa antagonists ↑ LH pulsatility rats (Nakahara, 2013; Mosari, 2013) NKB Activation Activation A - Kappa agonists ↓ LH KOR pulsatility and ↓ HF (Oakley, 2015) DYN KOR KOR Stimulating the KOR receptor with KOR agonist increases the impact of the Dynorphin KNDy Inactivation pathway 9 KNDY HOT FLASH RX PIPELINE HISTORY NK3R ANTAGONIST DRUGS NK3R antagonists Osanetant SR-142, 801, NK3R antagonist, nonpeptide developed for schizophrenia and drug addiction ( blocked – MLE 4901 effects of cocaine in anima models) Emonds-Alt X. SR 142801, the first potent non-peptide antagonist of the tachykinin NK3 receptor. Life Sciences1995;56 (1): PL27–32. – ESN364 Pavinetant MLE 4901 NK3R antagonist neuropeptide developed initially for schizophrenia, then HF, PCOS Dual NK1R/NK3R antagonist Talnetant SB-223,412 developed for schizophrenia and irritable bowel syndrome – NT-814 PRKA (peripherally restricted kappa agonists) 3 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 NK3R ANTAGONIST STRUCTURES MLE 4901, PAVINETANT Osanetant SR-142, 801 Oral twice daily selective NK3R antagonist Pavinetant MLE 4901 developed for schizophrenia, hot flashes (NCT02668185), PCO November 2017 Fezolinetant ESN364 (HF) Discontinued - Phase-II for Hot flashes in United Kingdom and Phase-II for Polycystic ovary syndrome in USA, Germany, United Kingdom Phase II trial for Hot flashes in United Kingdom showed the NT-814 (HF) clinical risks exceeded benefits Abnormal liver function Plan to reformulate and reintroduce ~ 3 yr http://adisinsight.springer.com/drugs/800038259 MLE 4901, PAVINETANT MLE 4901, PAVINETANT Frequency, severity, bother, interference Phase 2a study postmenopausal women Prague J, Lancet 2017 Prague J, Menopause 2018 16 4 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 ESN364, FEZOLINETANT ESN364, FEZOLINETANT Phase 1 studies healthy men and women - Selective NK3R antagonist RCT 6:2 blinded, N=64 men single ascending dose - Oral twice daily - 3, 6, 12, 23, 46, 90, 180 mg - Phase 1, 2a trials for menopause RCT 6:2, N=24 men, 10 days - Phase 2a trials PCOS - repeat dose 20, 60, 180 - Phase 2 trials uterine fibroids RCT 6:2, N=24 women, 21 days - repeat dose 20, 60, 180 Findings - Rapid absorption (tmax 3-4 hours repeat dosing) - Linear PK (no accumulation on repeat dosing) - Short half life (4.4-6.3 hr in women, repeat dosing) - Dose response effect on reproductive hormones (LH, E2, P, T) Fraser G. J Clin Endocrinol Metab 2016 - ↓endometrial thickening, delayed/impeded ovulation, Fraser G. Endocrinol 2015 prolonged cycle duration Fraser G. J Clin Endocrinol Metab 2016 https://bciq.biocentury.com/products/fezolinetant ESN364, FEZOLINETANT ESN364, FEZOLINETANT Phase 2 studies postmenopausal women Sleep Phase 2a, 12 week RCT, N=80 - moderate-severe HF Phase 2a 12 week RCT, N=80 - 90 mg bid - moderate-severe HF Findings - 90 mg bid - LH ↓ 50% (vs 16%), p <0.001 Findings - VMS frequency ↓93% (vs 54%), p <0.001 - sleep improved ESN364 (vs placebo) p<0.001 - VMS severity ↓ 94% (vs 46%), p <0.001 Safety no SAEs, AEs similar between groups Weight loss Phase 2b, 12- week RCT 1:6, N=352, NCT03192176 , 51 sites Cynomolgus monkeys, N=12, 12 weeks - 8 cohorts: Plcbo vs qd (4 doses) vs bid (4 doses) - RCT - dose range 30 - 180 mg/d - dose range 50 mg/kg/d vs vehicle control - ONGOING, anticipate completion August 2019 Findings - ESN364 1% ↑ total body weight (vs 12% ↑ control) Fraser G. ENDOABSTRACT 2017 Clinicaltrials.gov Fraser G. ENDOABSTRACTS 2017 . 5 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 EFFICACY ON HOT FLASH FREQUENCY EFFICACY ON HOT FLASH SEVERITY ESN364, FEZOLINETANT ESN364, FEZOLINETANT * * * * * * * * 1 2 % ¯ 2 3 % ¯ 6 0 % ¯ 7 0 % ¯ Fraser G. ENDOABSTRACT 2017 Fraser G. ENDOABSTRACT 2017 With permission With permission 21 22 NT-814 NT-814 NK1R, NK3R ANTAGONIST NK1R, NK3R ANTAGONIST Phase 1 study healthy men - Selective NK1R, NK3R antagonist Single blind, RCT, N=14 - Oral once daily Doses: 10, 30, 60, 120, 160, 160-250 mg - Patent for “sex hormone dependent diseases” - Phase 1, 2a trials for menopause Findings - long t1/2 ~ 15 hr - Phase 2a trials PCOS - rapid absorption at doses < 60 mg, ~ 1 hr - doses > 120 mg, t max ~ 4-5 hours - NK1R occupancy, EC50 0.875 ng/mL - NK3R occupancy, EC50 8.75 ng/mL Safety: Increase somnolence, headache https://clinicaltrials.gov/ct2/show/NCT02865538 GSK1144814 compound https://www.gsk-clinicalstudyregister.com 6 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 NT-814 NT-814 NK1R, NK3R ANTAGONIST Phase 2a study postmenopausal women Phase 1 study healthy men and women Open label, 3-way cross over, N=16 Double blind RCT 14 days, N=80 Dose 100 mg, 200 mg, placebo (with food) Doses: 20 subjects each, placebo vs 50, 100, 150 and 200 mg Findings Primary outcome: pharmacokinetics - long t 1/2 ~ 26 hr - rapid absorption, t max ~ 1 hr, both doses Secondary outcome: VMS, LH serum Safety (42 doses across groups) concentration 9/42 somnolence (21%) vs 0/12 placebo 9/42 headache (21%) vs 5/12 placebo 2/42 dizziness (5%) vs 0/12 placebo GSK1144814 compound https://www.gsk-clinicalstudyregister.com https://clinicaltrials.gov/ct2/show/NCT02865538 26 NT-814, DAYTIME HOT FLASH FREQUENCY PERIPHERALLY RESTRICTED KAPPA AGONISTS The pulsatile activity of KNDy neurons is controlled by an interplay of NKB receptors and dynorphin receptors, acting in a reciprocal fashion Median Reduction in HF to generate pulsatile events—intermittently stimulated by NKB and Number of moderate and severe day time hot Frequency in Week 2 – All suppressed by dynorphin flashes recorded in a diary in the evening Doses BASELINE WEEK 1 WEEK 2 Placebo 50 mg 100 mg 150 mg 300 mg 0 Kappa agonists bind the dynorphin receptor (AKA kappa opioid -1 receptor, KOR), and inhibit LH pulses, presumably by interfering with 16 -2 15 -3 kisspeptin and GnRH signaling 14 -4 13 -5 12 -6 KOR receptor antagonists stimulate LH pulse frequency 11 -7 10 -8 9 Placebo -9 * * 8 * p<0.05 Pure kappa agonists cause dysphoria and nausea, peripherally 7 N=18 SE) Daily Frequemcy - ** p<0.01 restricted kappa agonists (PRKAs) do not - 6 Wilcoxon rank-sum 5 37% 4 test 3 KNDy neurons are located at the interface of the blood brain barrier Mean (+/ 2 1 and may be a target for PRKAs that do not pass the blood brain barrier 0 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 -8 -7 -6 -5 -4 -3 -2 -1 84% Hypothesis: PRKAs are effective in treating HF and have minimal Day 150 mg side effects Placebo 150mg N=15 Anderson R, With from Permission KaNDY Therapeutics 7 REED 9/25/18 Vulva LA Tak due 1-15-16 Vulvar Talk LA January 2016.pptx 1-11-2016 PERIPHERALLY RESTRICTED KAPPA AGONISTS THE BRAINS Clinical observations suggest postmenopausal women on methadone and some opioids may have ↓ hot flashes and opioid withdrawl ↑ hot flashes (Reed clinical experience) Kappa agonists bind to the opioid receptor in the hypothalamus and inhibit KNDy neuronal activity (Navarro, 2009; Wakabayashi, 2010) Peripherally restricted kappa receptor agonists
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