Review Article CLINICAL INVESTIGATION Selectively targeting TGF-β with Trabedersen/OT-101 in treatment of evolving and mild ARDS in COVID-19 Abstract Fatih M Uckun1,2*, Based on the role of TGF- β in the immunopathology of ARDS, we and others have proposed the use of Larn Hwang1, Vuong Trieu1 TGF-β inhibitors for the treatment of COVID-19 pneumonia and ARDS. TGF-targeting is employed as a strategy to stimulate the immune system of advanced-stage cancer patients in an attempt to overcome the 1Immuno-Oncology Program, Oncotelic immunosuppression and T-cell exhaustion within the tumor microenvironment. Nevertheless, we do not Inc., Agoura Hills, CA 91301, USA anticipate any worsening of existing ARDS or Cytokine Storm/Cytokine Release Syndrome (CRS) of COVID-19 patients as a treatment-emergent complication with our contemplated use of the anti-TGF-β RNA therapeutic 2COVID-19 Task Force, Worldwide Clinical OT-101. That is because (i) inhibitors of TGF-β signaling are not associated with ARDS, Cytokine Storm/CRS, Trials, Wayne, PA 19087, USA or systemic capillary leak, (ii) OT-101 did not cause any pulmonary toxicity, non-infectious pneumonitis, CRS, systemic or pulmonary capillary leak or ARDS in any of the 61 patients with advanced solid tumors enrolled *Author for correspondence: in Phase I/II study (ClinicalTrials.gov identifier: NCT00844064) who received much longer periods of OT-101 [email protected] therapy, and (iii) OT-101 did not cause in human subjects an elevation of TNF-α, IL-6 or IL-10 levels associated with CRS and ARDS in COVID-19 patients-likewise, OT-101 did not induce production of these inflammatory cytokines in cultures of human white blood cells. We postulate that because of the significance of the TGF-β pathway on the development of ARDS and T cell exhaustion, treatment with OT-101 may prevent the progression of evolving or mild ARDS and help facilitate the recovery of lymphocytopenia and T-cell exhaustion in COVID-19 patients. Keywords: COVID-19 • TGF-β • ARDS • cytokine release syndrome Submitted: 19 May 2020; Accepted: 26 May 2020; Published online: 31 May 2020 Introduction drug candidates have caused CRS/Cytokine Storm, systemic capillary leak, or ARDS [1]. Clinical use of TGF-β pathway inhibitors are not associated with the systemic capillary leak, Fresolimumab is a pan-specific, recombinant, β cytokine release syndrome/cytokine storm, or fully human anti- TGF- monoclonal antibody. ARDS No patient experienced a systemic capillary leak, β cytokine release syndrome/cytokine storm, or ARDS The signaling of TGF- can be modulated when treated in Phase 1 clinical trials for renal cell through three distinct strategies: using anti- β carcinoma, melanoma, or glioma [1]. Galunisertib sense nucleotides that block TGF- an mRNA is a small-molecule selective inhibitor of TGFβR1 (Trabedersen/AP 12009-also known as OT-101), (ALK5), the receptor that binds both TGF-β1 and β using monoclonal antibodies to block TGF isoforms TGF-β2. No patient enrolled in the open-label Phase (lerdelimumab, metelimumab) or using inhibitors of II study in hepatocellular carcinoma (ClinicalTrials. β the TGF- receptor. Several small molecules as well gov: NCT01246986), experienced a systemic capillary as large molecule inhibitors (e.g. neutralizing anti- leak, cytokine release syndrome/cytokine storm, TGF antibodies) of TGF-β signaling have been and or ARDS [2]. The observed treatment-emergent are being evaluated in clinical trials. None of these adverse events included fatigue, anemia, peripheral Clinical-Investigation.1000166 © 2020 Clin. Invest. (Lond.) (2020) 10(2), 167-176 ISSN 2041-6792 167 Review Article Uckun, Hwang & Trieu edema, and abdominal pain and neutropenia, anemia, cytokine implicated in COVID-19 associated CRS embolism, high bilirubin, and low albumin levels were and ARDS [7]. Detectable serum SARS-CoV-2 viral encountered as Grade 3-Grade 4 treatment-related load (RNAaemia) is closely correlated with markedly Adverse Events (AEs). In another Phase II clinical elevated IL-6 levels in critically ill COVID-19 study of Galunisertib in patients with myelodysplasia patients [11]. Diao et al. reported the serum cytokine (ClinicalTrials.gov, number NCT02008318), fatigue, concentration from inpatient data of patients with diarrhea, fever, and emesis (5/41, 12%) were observed COVID-19 in Wuhan, admitted to hospital from as treatment-emergent AEs. No patient experienced December 2019 to January 2020, and healthy controls, a systemic capillary leak, cytokine release syndrome/ who came to the hospitals for routine evaluation. cytokine storm, or ARDS [3]. AVID200 is a IL-6 levels, along with IL-10 and TNF-α levels were rationally designed first-in-class receptor ectodomain β β markedly elevated [12]. Xu et al. also reported that trap that inhibits TGF- 1 and TGF- 3. Phase I IL-6 and TNF-α levels were increased in COVID-19 studies of AVID200 were performed in patients patients [13]. Subsequently, several additional groups with advanced cancers (ClinicalTrials.gov Identifiers: likewise reported that IL-6 and TNF-α levels were NCT03834662; NCT03094169). Diarrhea and increased in COVID-19 patients [14-19]. Early elevation of the pancreas enzyme lipase were reported data from a single-arm, 21-patient Chinese trial as drug-related Grade 3 AE but no patient experienced indicated an anti-IL6 receptor monoclonal antibody a systemic capillary leak, cytokine release syndrome/ cytokine storm, or ARDS [4]. Pliant Therapeutics’ may have significant clinical benefit in COVID-19 proprietary small molecule PLN-74809 is an oral pneumonia patients. China has approved the use dual selective inhibitor of the tissue-specific αVβ6 of that antibody in severe forms of COVID-19. In and αVβ1 integrins blocking integrin-mediated an open-label Phase 2 study (ClinicalTrials.gov β stimulation of the TGF- pathway . The compound Identifier: NCT04317092), Tocilizumab is being was well-tolerated in a randomized, double-blind, evaluated in patients with COVID-19 pneumonia placebo-controlled study with no evidence of CRS/ and in a related randomized study (ClinicalTrials.gov cytokine storm, systemic capillary leak, or ARDS [5]. Identifier: NCT04306705), it is being evaluated for its efficacy in CRS associated with COVID-19. It is also being evaluated in combination with Favipiravir The safety of the anti-TGF-β anti-sense (ClinicalTrials.gov Identifier: NCT04310228). Oligonucleotide Trabedersen (OT-101) was Likewise, Sarilumab (Kevzara), another monoclonal evaluated in Phase 1 and Phase 2 studies in cancer antibody that binds to the IL-6 receptor, is being patients. In Phase I/II study (ClinicalTrials.gov evaluated in a Phase 2/3 study in hospitalized identifier: NCT00844064), a total of 61 patients were COVID-19 patients (ClinicalTrials.gov Identifier: treated with continuous intravenous (IV) infusion of NCT04315298). Based on the role of TGF-β in OT-101 as 2nd to 4th-line therapy in escalating doses the immunopathology of ARDS, we and others 40 mg/m2/day up to 330 mg/m2/day. Overall, OT- have proposed the use of TGF-β inhibitors for the 101 was well-tolerated and no patient experienced a treatment of COVID-19 pneumonia and ARDS systemic capillary leak, cytokine release syndrome/ [20-22]. cytokine storm, non-infectious pneumonitis, or OT-101 does not increase IL-6 or TNF-α levels in ARDS [6]. Thrombocytopenia, gastrointestinal human subjects when used at doses comparable hemorrhage, and fever were observed as related to those proposed for the COVID-19 patient /possibly related treatment-emergent AEs. population Interleukin 6 (IL-6) as the signature pro- inflammatory cytokine associated with cytokine Cytokine levels of clinical plasma samples of 12 storm/cytokine release syndrome (CRS) and ARDS pancreatic cancer patients of the P001 study of OT- in COVID-19 101 in advanced solid tumor patients were measured. These 12 pancreatic cancer patients were from the last IL-6 is a pro-inflammatory cytokine that plays cohort of the P001 study, with OT-101 treatment at a pivotal role in the development, progression, and 140 mg/m2/day on 4-days-on, 10-days-off schedule. severity of CRS as well as its complications, including The daily dose level of OT-101 was comparable to the Disseminated Intravascular Coagulopathy (DIC) and contemplated dose level of OT-101 for the proposed multiorgan failure [7-10]. It is the main signature COVID-19 study (viz: 150 mg/m2 on day 1, 100 mg/ 168 Clin. Invest. (Lond.) (2020) 10(2) Selectively targeting TGF-β with Trabedersen/OT-101 in treatment of evolving and mild ards in COVID-19 Review Article m2 on days 2-7; the selected dose level of 150 mg/m2 2 day 1 (time point 6), Cycle 2 day 2 (time point 7), on day 1 and 100 mg/m2 on days 2-7 is lower than Cycle 2 day 5 (time point 8), final visit (time point 9), the MTD of 160 mg/m2/day when OT-101 was exit period Cycle 3 day 5 (time point 11). As shown in administered via intravenous infusion according to Table 1, displaying the scatter plots for absolute IL-6 a 7 day on, 7 day off schedule in the P001 patient concentrations measured at different time points, OT- population and caused no SAEs). The evaluated 101 therapy was not associated with any significant cytokine panel included IL-6, TNFα, IFNγ, MIP- treatment-emergent increase in IL-6 levels. Examining 1α, IL-10, IL-1β, IL-12p40, IL-17A, IL-2, and IL- the parameter estimates of mixed ANCOVA model 8. Samples analyzed were acquired before the onset across time points to identify individually affected of OT-101 therapy and at selected 23-time points cytokines showed that only Epidermal Growth during the therapy. Most on-therapy samples were Factor (EGF) increased significantly across time. In α obtained at the following time points: Cycle 1 day particular, neither IL-6 or TNF- levels showed an 2 (time point 2), Cycle 1 day 5 (time point 3), Cycle increase in response to OT-101 therapy (Figure 1).