Biomarker: Clinical Validation for Intended Use

Joop van Gerven professor of clinical neuropsychopharmacology Centre for Human Drug Research Leiden The Netherlands

to the memory of Hermann Fuder Lecture Contents

What are biomarkers? question-based drug development What can you do with them? examples from GABA-ergic research Biomarker Definitions

A characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. (NIH Biomarkers Definitions Working Group, 2001) A quantitative measure that is on the causal path between drug administration and effect. (EU COST-B Biomarker Working Party, Danhof, 2005)

type 0 type 1 type 2 type 3 type 4 type 5 type 6 phenotype drug target target physiological patho- clinical genotype concentration occupancy activation response physiological response response

…the causal path…

A Practical Biomarker Definition: Tools to Answer Questions in Drug Development

population action site drug development is case building

pharmacology

clinical

window Question-Based Drug Development: main issues for early development

1. Does the drug reach its target? 2. Does the drug have pharmacological activity/-ies? 3. Does the drug affect intended (patho)physiological processes? 4. What is the window between desired and undesirable effects? Example 1

First-in-human study Fast- and short-acting benzodiazepines New sedative in anesthesia Two new compounds vs midazolam Question-Based Development: Action Site 1: does the drug reach its target? Question-Based Development: Action Site 1: does the drug reach its target?

Membrane Receptors/Ion Channels GABA-A-receptors glutamate NMDA channel L-type Ca2+ channel Membrane Transporters 5HT-transporter *18F-flumazenil dopamine-transporter p-Glycoprotein * Vesicular Transporters vesicular Monoamine Transporter-2 vesicular Acetylcholine Transporter Neurotransmitter Precursors F-DOPA Enzymes MAO-A, MAO-B acetylcholinesterase Question-Based Development: Action Site 1: does the drug reach its action site? single rising dose study of two novel benzodiazepines vs positive control

•1 mg •2 mg •3 mg •500 •midazolam •500

•450 •400

•400

•350 •SPV (deg/sec) •SPV •300 •SPV (deg/sec)

•300

•200 •250 •0 •60 •120 •180 •240 •300 •0 •50 •100 •150 •Time (min) •effect compartment concentration (µg/L) Ro 8684: shorter duration of Ro 6791: more potent than midazolam, action than midazolam equipotent at 3 mg (+20 µg/L)

Dingemanse J, Van Gerven JMA, Schoemaker HC et al. Integrated pharmacokinetics and pharmacodynamics of Ro 48-6791, a new benzo¬diazepine, in comparison to mida¬zolam during first administration to healthy male subjects. Br J Clin Pharmacol 1997;44:477 -486 Van Gerven JMA, Roncari G, Schoemaker HC et al. Integrated pharmacokinetics and pharmacodynamics of Ro 48-8684, a new benzo¬diazepine, in comparison to midazolam during first administration to healthy male subjects. Br J Clin Pharmacol 1997;44:487-493 Question-Based Development: Pharmacology 2: does the drug have a pharmacological effect? [C]

E

PK/PD Question-Based Development: Pharmacology 2: does the drug have a pharmacological effect?

GABAA

R concentration-related effects are pharmacological biomarkers! Question-Based Development: Pharmacology 2: how relevant are the pharmacological effects?

A. Can biomarkers show competitive (dis)advantage? B. Can biomarkers predict adverse effects? C. Can biomarkers predict therapeutic doses?

effect profiling positive controls NeuroCart: multimodal CNS-profiling in early drug development

• Saccadic and smooth pursuit eye movement • Memory testing • Adaptive tracking • Finger tapping • Body sway • Visual analogue scales • Psychometric questionnaires NeuroCart • Electroencephalography • Polysomnography • Other CNS function tests • Symbol Digit Substitution Test • Critical Flicker Fusion • Stroop Conflict Task • Neuroendocrine measures • Autonomic function tests

Data-Intensive Phase 1

ScreenCNS -180 -120 -75 -60 -45 0h 30 60 75 90 105 120 135 150 180 195 210 240 255 270 6h 8h 12h 21h FU practice Assessment Informed Consent X Demography X Incl./Exclusion X Medical history X Physical examination X Body Weight X Virology X Thyroid function test X Routine Lab +Urinalysis X X X

Urine drug screen X X Concomitant Medications X X X

Breath alcohol test X Meals/snack X XXXX Drug administration X Verbal learning X Delayed recall X Cognitive testing X 2X X X XXX X Adaptive trackingX XXXXXXXXXXXXX PK/PD Saccadic eye movements X XXXXXXXXXXXXX Smooth pursuit X XXXXXXXXXXXXX Body sway X XXXXXXXXXXXXX VAS (Bond & Lader) X XXXXXXXXXXXXX VAS (Bowdle) X XXXXXXXXXXXXX EEG X X XX X X XX XX XXX NeuroCart

PK blood sampling X XXXX X X X X X XX X X Auricular temperature X X X XXX XXX Respiratory rate X X X Orthostatic BP/Pulse X X

Supine BP /Pulse X X X XXX XXX Resting 12-Lead ECG X X X AE follow up X X X X XXX XXX Discharge from unit X Multimodal Pharmacological Effect Profiling: PK/PD-analyses show drug-specific pharmacological effect profiles

VAS alertness SPV adaptive tracking body sway

40 5 3.2 660

20 )

% 0 3.0 e ( 600

0 manc or f -5 2.8 540 er ng P i k -20 (mm) Sway Log Body 2.6

ac -10 GABA-agonists 480 r Delta VAS Alertness (mm) a T t Saccadic Peak Velocity (deg/sec) Velocity Peak Saccadic

Del 2.4 -40 -15 420

2.2 -60 360 -20 -120 0 120 240 360 480 600 720 840 -120 0 120 240 360 480 600 720 840 -120 0 120 240 360 480 600 720 840-120 0 120 240 360 480 600 720 840 Time (min) Time (min) Time (min) Time (min)

6 70 3.2 600

3.0 0 550 ) 60 mm) ( 2.8 ay w 500 ance (% -6 S 2.6 ody 50 rform e B 450 -12 G VAS Alertness (mm) VAS Alertness ng P LO 2.4 Saccadic Peak Velocity (deg/sec) Velocity Peak Saccadic acki

M-antagonists r 40 T 400 -18 2.2

30 350 2.0 -24 -60 0 60 120 180 240 300 360 420 480 540 600 -60 0 60 120 180 240 300 360 420 480 540 600 -60 0 60 120 180 240 300 360 420 480 540 600-120 0 120 240 360 480 600 720 840 Time (min) Time (min) Time (min) Time (min)

590 4 3.2 80 580 570 3 560 3.0 550 540 2 530 2.8 CB1-agonists 60 520 1 510 500 2.6 0 490 480 LOG Body Sway (mm) Sway LOG Body 470 -1 2.4 40 VAS Alertness (mm) VAS Alertness 460 Saccadic peak velocity (deg/sec) velocity peak Saccadic 450 -2 440 2.2 430 -3 420 2.0 20 410 (%)(change) performance Tracking average -4 -60 0 60 120 180 240 300 360 420 480 540 600 -120 0 120 240 360 480 600 0 120 240 360 480 600 Time (min) 0246810 Time (min) Time (min) … Time (h) Multimodal Pharmacological Effect Profiling: effect profiles are drug-class-specific

VAS ALERTNESS VAS EXTERNAL VAS INTERNAL SACCADIC PEAK VELOCITY SMOOTH PURSUIT ADAPTIVE TRACKING BODY SWAY SLEEP „ During night Sleep deprivation 1 night L-830409 0.25 mg PO L-830409 0.75 mg PO L-830982 0.5mg PO L-830982 1.5mg PO PARTIAL L-83982 2mg PO GABA A „ Bretazenil 0.5mg SL Diazepam 10mg PO Lorazepam 2 mg PO Lorazepam 2 mg PO Lorazepam 2mg PO Midazolam 0.1mg/kg IV Midazolam 0.1mg/kg IV GABA A „ Midazolam 0.1mg/kg IV Nitrazepam 5mg PO Nitrazepam 5mg PO (Jap) RO486791 10mg IV RO488684 10mg IV SL651498 2.5mg PO SL651498 25mg PO Temazepam IV Temazepam 20mg PO Temazepam IV Fast Zolpidem 10mg PO Breta 0.5mg SL+Ethanol 5.0% IV Diaz 10mg PO+Ethanol 0.6g/L TC Ethanol 0.6g/L TCI ETHANOL „ Ethanol 0.6g/L TCI Ethanol 0.6g/L TCI THC 2+4+6+6mg IH THC 2+4+6+8mg IH THC „ ORG 28611#6 IV ORG26828 #5 ug/kg IV AVE16255HTP 120 100mg mg PO 5HTP 100mg PO + Carbidopa 5HTP 100mg PO + Carbidopa 5HTP 200 mg PO + Carbidopa 5HTP 200mg PO 5HTP 200mg PO+Carb+Dom 10 mg 5HTP 200mg PO+Carb+Gran 2mg 5HTP 200mg PO+Carbidopa 5HTP „ 5HTP 300 mg PO + Carbidopa 5HT „ Dexfenfluramine 0.5mg/kg PO Amitriptyline 50mg PO 5HT ANT „ Rizatriptan 10mg PO Sumatriptan 50mg PO mCPP 0.1mg/kg IV mCPP 0.5mg/kg PO SB742457 50mg PO SB742457 50mg PO + Risper 2mg Risperidone 2mg PO DOPAMINE ANT „ Sulpiride 400 mg PO DOPAMINE „ Haloperidol 3mg PO Lisuride 0.2 mg PO GPI1 100 mg PO GPI1 300 mg PO GPI1 750 mg PO Scopolamine 0.5mg IV Scopolamine 0.5mg IV OTHER „ MK0869 160mg PO MK0869 160mg PO+Amitriptyline Talnetant 200mg PO Org25935 0.5mg PO R213129 30mg ACT-078573 1000mg PO ACT-078573 400mg PO O „ SPO2 80% 2 SPO2 90%

0 6 2 6 20 20 40 . . 0 0 0 0 0 0 0 0 0 0 0 5 -60 -40 - -0.4 -0.2 0.0 0.2 0.4 0 0.8-0.4 -0.2 0.0 0. 0.4 0 50 00 -5 5 -30 -20 -1 1 -30 -20 -1 10 . . .5 . . -1 -1 -0.5 0 0.5 1 1 2 2 EOD (5-95% CI) EOD (5-95% CI) EOD (5-95% CI) EOD (5-95% CI) EOD (5-95% CI) EOD (5-95% CI) EOD (5-95% CI) Example 2

First-in-human study New hypnotic Orexin antagonist vs zolpidem Question-Based Development: Pharmacology benchmarking biomarkers vs positive controls

a) Adapative tracking performance b) Saccadic peak velocity 10 40

20

5 0 first-in-man of orexin -20 0 -40

Placebo -60 Placebo -5 Zolpidem Zolpidem antagonist 1000 mg -80 1000 mg 400 mg 400 mg -100 Mean change from baseline (%) change from baseline Mean -10 200 mg 200 mg

100 mg (degree/s) baseline from change Mean 100 mg -120

-15 -140 0 2 4 6 8 10 12 0 2 4 6 8 10 12 single-ascending dose Time after administration (h) Time after administration (h) NeuroCart battery

c) Body sway d) Smooth pursuit 720 20 zolpidem as positive

600 Placebo Zolpidem 480 1000 mg 10 400 mg 360 200 mg control 100 mg 240 0 120

0 Placebo Zolpidem -10 -120 1000 mg Mean change from baseline (%) change baseline from Mean Mean change from baseline (mm) baseline from change Mean 400 mg -240 200 mg 100 mg -360 -20 0 2 4 6 8 10 12 almorexant 200-400 mg 0 2 4 6 8 10 12 Time after administration (h) Time after administration (h) similar to zolpidem 10 mg somewhat less postural e) Delta Pz −Oz f) Theta Pz−Oz 1.5 1.5 Placebo Placebo Zolpidem Zolpidem 1000 mg 1000 mg instability 1.0 1.0 400 mg 400 mg 200 mg 200 mg 100 mg 100 mg 0.5 0.5 almorexant effects lasted 0.0 0.0 Mean change from baseline (uV) baseline from change Mean -0.5 (uV) change baseline from Mean -0.5 longer

-1.0 -1.0 0 2 4 6 8 10 12 0 2 4 6 8 10 12 Time after administration (h) Time after administration (h) no signs of narcolepsy Question-Based Development: Pharmacology biomarkers can show competitive advantages Question-Based Development: Effects 3: does the drug affect (patho)physiology? Examples of (Patho)physiological Biomarkers

Hypertension Serotonergic blood pressure 5HT2 cortisol temperature Diabetes Mellitus Cholinergic oral glucose tolerance M1 pupil diameter glucose clamping memory

Hypercholesterolaemia Norepinephrine cholesterol metabolism MHPG

Hyperthyroidism Dopaminergic TSH, FT4 D2 prolactin

Cardiac arrhythmias QTc Example 3

Early phase I studies New anxiolytics

Partial subtype selective GABAA-agonists vs lorazepam Early Development of New Class of Anxiolytics:

Partial Subtype Selective GABAA-agonists

α2,3 subtype selective compounds: TPA023, MK-0343, SL65.1498 sedation, memory postural instability anxiolysis disturbance α1 α2 α3 α5

TPA023 0 11 21 5

MK-0343 18 23 45 18

SL65.1498 45 115 83 48

in vitro efficacies relative to full agonist Saccadic Peak Velocity sensitive biomarker for anxiolytic GABA -agonists A

Saccadic Peak Velocity vs VAS Calmness for different anxiolytics and sedatives - shock threat

0 diphenhydramine R2 = 0.09

-25

-50

pregabalin VAS Calmness (mm) R2 = 0.83 -75

alprazolam R2 = 0.83 -100 -101234567 SPV (deg/sec) Saccadic Peak Velocity, Binding Affinity and Anxiolytic Dose

80 16 250

200 Quazepam 70 Temazepam 14 150

100

50 60 12 (deg/sec) SPV in Change 0 010203040 Quazepam Dose Temazepam (mg) 50 10 Temazepam Bromazepam 40 8 Midazolam

30 6 Diazepam

20 4 Bromazepam

Alprazolam Diazepam Kd at benzodiazepine sitebinding (nM)

10 po/daily)(mg dose maintenance Lowest 2 Midazolam Lorazepam Lorazepam Alprazolam 0 0 0246810120 2 4 6 8 10 12 SPV dose equivalence (10 mg Temazepam) SPV dose equivalence (10 mg Temazepam) Question-Based Development: Effects 3: biomarkers can show physiological selectivity

Saccadic Peak Velocity (SPV)

5050

0

-50

∆ lorazepam

-100 ○ TPA023 1.5 mg □ TPA023 0.5 mg ● placebo

Saccadic Peak Velocity; change from baseline (deg/sec) Saccadic Peak Velocity; -150-150 00 120 240 360 480 600600 Time (minutes) Body Sway postural instability Question-Based Development: Effects 3: biomarkers can show physiological selectivity

∆ lorazepam Body sway ○ TPA023 1.5 mg 1.001.00

mm) □ TPA023 0.5 mg

log ● placebo

0.50 ed; change from baseline ( ed; change from baseline

0.00

Body Sway Eyes Clos -0.50-0.50

log 00 120 240300 360 480 600600 Time (minutes) Visual Analogue Scales for alertness, mood and calmness

(English original version) VISUAL ANALOGUE SCALES

(As described in : Bond A, Lader M. The use of analogue scales in rating subjective feelings. Br J Med Psychol 1974;47:211-18)

1. Please rate the way you feel in terms of the dimensions given below. 2. Regard the line as representing the full range of each dimension. 3. Rate your feelings as they are at the moment. 4. Mark clearly and perpendicularly across each line.

1 Alert ______Drowsy

2 Calm ______Excited

3 Strong ______Feeble

4 Confused ______Clear-headed

5 Well-coordinated______Clumsy

6 Lethargic ______Energetic

7 Contented ______Discontented

8 Troubled ______Tranquil

9 Mentally slow ______Quick-witted

10 Tense ______Relaxed

11 Attentive ______Dreamy alertness 12 Incompetent ______Proficient

13 Happy ______Sad

14 Antagonistic ______Amicable

15 Interested ______Bored

16 Withdrawn ______Gregarious

(*Line numbers refer to VAS-item definition in the ProMaSys study database) Question-Based Development: Effects 3: biomarkers can show physiological differences

VAS sedation

10 diff vs PLAC 95%CI p TPA 0.5 mg 1.35 (-0.37 / 3.08) 0.119

TPA 1.5 mg -0.33 (-2.05 / 1.39) 0.698

LOR 2 mg -1.8 (-3.52 /-0.08) 0.041

mm) ln

5

0 ∆ lorazepam ○ TPA023 1.5 mg

VAS Alertness above baseline ( VAS Alertness above baseline □ TPA023 0.5 mg ln ● placebo -5 0 120 240 360 480 600 Time (minutes) Question-Based Development: Pharmacology 3: less sedation with partial GABA -Agonists A

10 10 SL65.1498 0 TPA023 0

-10 -10

-20 -20

-30 ● lorazepam 2 mg -30 ● lorazepam 2 mg VAS Alertness: change from baseline VAS Alertness: change □ TPA023 1.5 mg VAS Alertness: change from baseline □ SL65.1498 25 mg -40 -40 -120 -100 -80 -60 -40 -20 0 20 -120 -100 -80 -60 -40 -20 0 20 SPV: change from baseline SPV: change from baseline

10 10

0 MK-0343 0

-10 -10

-20 -20 zolpidem

-30 ● lorazepam 2 mg -30 ● lorazepam 2 mg VAS Alertness: change from baseline VAS Alertness: change □ MK-0343 0.75 mg baseline VAS Alertness: change from □ zolpidem 10 mg -40 -40 -120 -100 -80 -60 -40 -20 0 20 -120 -100 -80 -60 -40 -20 0 20 SPV: change from baseline SPV: change from baseline VAS alertness vs SPV Log Body Sway: change from baseline Log Body Sway: change from baseline 3: lessposturalinstability withpartialGABA -0.2 -0.2 0.0 0.2 0.4 0.6 0.8 0.0 0.2 0.4 0.6 0.8 10-0 8 6 4 2 20 0 -20 -40 -60 -80 -100 -120 10-0 8 6 4 2 20 0 -20 -40 -60 -80 -100 -120 MK-0343 TPA023 tt Tt Question-Based Development: Effects SPV: changefrombaseline SPV: change frombaseline L ● ● □ □ TPA023 1.5mg MK-0343 0.75mg lorazep lorazep TPACMP2 Body sway a a m m 2 2 mg mg

Log Body Sway: change from baseline Log Body Sway: change from baseline

-0.2 vs -0.2 0.0 0.2 0.4 0.6 0.8 0.0 0.2 0.4 0.6 0.8 10-0 8 6 4 2 20 0 -20 -40 -60 -80 -100 -120 10-0 8 6 4 2 20 0 -20 -40 -60 -80 -100 -120 SPV SL65.1498 SPV: chan SPV: change frombaseline ● □ g SL65.1498 25mg lorazep e frombaselin ● □ A zo lorazep -Agonists Zolpidem a lp e m idem 2

mg a m 10 mg 2 mg

Question-Based Development: Window 4: biomarkers predict improved adverse effect profile

• less sedation • less postural stability • less memory impairment

30 7 Number correct Reaction time correct ‡ ‡ 6 † † 5 ‡ 20 Placebo

‡ 4 TPA023 0.5mg

‡ TPA023 1.5mg 3 Lorazepam 2mg 10 2

1

0 0 RFSE RFSI RWSE RWSI RFSE RFSI RWSE RWSI Question-Based Development: Window 4: biomarkers predict anxiolytic efficacy

Week of study 1234 0 PBO/Drug 48/43 45/37 36/33 60/61 -1

-2

-3

-4 Change in HAM-A, TPA023 vs. placebo * -5 *** *

Atack JR. Subtype-selective GABAA receptor modulation yields a novel pharmacological profile: the design and development of TPA023. Adv Pharmacol. 2009;57:137-85. Conclusions (1)

Biomarkers are essential tools to answer questions during drug development ‘proof-of-action-site penetration’ ‘proof-of-pharmacological activity’ Best answers are obtained with biomarkers that: have well-established relationships with mechanism of drug action and/or pathophysiology show good concentration/effect relationships have excellent test characteristics including frequent repeatability Conclusions (2)

Combinations of biomarkers can create informative effect profiles: drug-class specific ‘fingerprints’ relationships with underlying mechanisms of action potential competitive advantage (duration of action, window etc) Positive controls can provide clinical benchmarks for effects of new drug indications for pharmacological selectivity impression of functional (adverse) effects