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Brase C, Kanefendt F, Loewen S, Himmel H, Schmitz S. No Influence of Asundexian on Cardiac Repolarization. Clin Pharmacol Drug Dev 2024; 13:265-280. [PMID: 38224232 DOI: 10.1002/cpdd.1366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/28/2023] [Indexed: 01/16/2024]
Abstract
Inhibition of activated factor XI reduces thrombogenesis while maintaining physiological hemostasis, with the expectation of reduced bleeding risk compared with standard of care in the clinical setting. Asundexian (BAY 2433334), an activated factor XI inhibitor, is in clinical development for the prevention of thromboembolic events. The effect of asundexian and its plasma metabolite M10 on cardiac repolarization and potential interactions with the hNav1.5 sodium, hCav1.2 calcium, and human ether-à-go-go-related gene (hERG) potassium channels was investigated in vitro. Additionally, asundexian effects on cardiac parameters and electrocardiogram were examined in telemetered beagle dogs. A randomized, placebo-controlled, 4-way crossover, thorough QT study in healthy adults evaluated the influence of 50 and 150 mg of asundexian on the corrected QT interval, including 400 mg of moxifloxacin as positive control. Across all studies, asundexian and M10 were not associated with any effects on cardiac repolarization. The largest in vitro effects of asundexian (approximately 20% inhibition) were seen for hCav1.2 and hERG. Throughout the thorough QT study, the upper limits of the one-sided 95% confidence interval of placebo-corrected mean changes from baseline in Fridericia corrected QT for 50 and 150 mg of asundexian were below Δ = 10 milliseconds. Asundexian demonstrated favorable safety and tolerability profiles.
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Affiliation(s)
| | | | | | - Herbert Himmel
- Research & Development, Pharmaceuticals Safety Pharmacology, Bayer AG, Wuppertal, Germany
| | - Sebastian Schmitz
- Research and Early Development, Statistics, Bayer AG, Wuppertal, Germany
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Kramer A, Patti G, Nielsen-Kudsk JE, Berti S, Korsholm K. Left Atrial Appendage Occlusion and Post-procedural Antithrombotic Management. J Clin Med 2024; 13:803. [PMID: 38337496 PMCID: PMC10856063 DOI: 10.3390/jcm13030803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation for stroke prevention in atrial fibrillation. Antithrombotic therapy is used in the post-procedural period to prevent device-related thrombosis (DRT). The risk of DRT is considered highest in the first 45-90 days after device implantation, based on animal studies of the device healing process. Clinically applied antithrombotic regimens vary greatly across studies, continents, and centers. This article gives an overview of the evidence behind current antithrombotic regimens, ongoing randomized trials, and future post-procedural management.
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Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, 13100 Vercelli, Italy;
- Department of Thoracic and Cardiovascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Sergio Berti
- Department of Interventional and Diagnostic Cardiology, Fondazione CNR-Regione Toscana G, Monasterio, Ospedale del Cuore, 54100 Massa, Italy;
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
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Roehrig S, Ackerstaff J, Jiménez Núñez E, Teller H, Ellerbrock P, Meier K, Heitmeier S, Tersteegen A, Stampfuss J, Lang D, Schlemmer KH, Schaefer M, Gericke KM, Kinzel T, Meibom D, Schmidt M, Gerdes C, Follmann M, Hillisch A. Design and Preclinical Characterization Program toward Asundexian (BAY 2433334), an Oral Factor XIa Inhibitor for the Prevention and Treatment of Thromboembolic Disorders. J Med Chem 2023; 66:12203-12224. [PMID: 37669040 PMCID: PMC10510402 DOI: 10.1021/acs.jmedchem.3c00795] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Indexed: 09/06/2023]
Abstract
Activated coagulation factor XI (FXIa) is a highly attractive antithrombotic target as it contributes to the development and progression of thrombosis but is thought to play only a minor role in hemostasis so that its inhibition may allow for decoupling of antithrombotic efficacy and bleeding time prolongation. Herein, we report our major efforts to identify an orally bioavailable, reversible FXIa inhibitor. Using a protein structure-based de novo design approach, we identified a novel micromolar hit with attractive physicochemical properties. During lead modification, a critical problem was balancing potency and absorption by focusing on the most important interactions of the lead series with FXIa while simultaneously seeking to improve metabolic stability and the cytochrome P450 interaction profile. In clinical trials, the resulting compound from our extensive research program, asundexian (BAY 2433334), proved to possess the desired DMPK properties for once-daily oral dosing, and even more importantly, the initial pharmacological hypothesis was confirmed.
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Affiliation(s)
- Susanne Roehrig
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | | | | | | | | | | | - Stefan Heitmeier
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Adrian Tersteegen
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Jan Stampfuss
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Dieter Lang
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | | | | | - Kersten M. Gericke
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | | | - Daniel Meibom
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Martina Schmidt
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Christoph Gerdes
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Markus Follmann
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
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D'Allesandro N, Cave B, Hough A. Asundexian: an oral small molecule factor XIa inhibitor for the treatment of thrombotic disorders. Future Cardiol 2023; 19:477-486. [PMID: 37830334 DOI: 10.2217/fca-2023-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Abstract
Oral anticoagulants, including warfarin and direct oral anticoagulants, are the standard of care for thrombosis prevention and treatment; however, concerns of bleeding often dictate treatment decisions. Inhibition of the intrinsic coagulation system via factor XIa may allow for selective inhibition of the coagulation cascade without significantly impacting hemostasis after injury. Asundexian is an oral small molecule factor XIa inhibitor that, via this novel mechanism, may prove to be a safe and effective option compared with available anticoagulants. Early clinical data for asundexian was promising as a safer alternative to current therapies and prompted further analysis in certain patient populations at increased thrombotic risk. Currently, studies are ongoing to evaluate the safety and efficacy in stroke prevention in atrial fibrillation and in patients following an acute noncardioembolic ischemic stroke or high-risk transient ischemic attack.
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Affiliation(s)
- Nicasia D'Allesandro
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
| | - Brandon Cave
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
| | - Augustus Hough
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
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Piel I, Engelen A, Lang D, Schulz SI, Gerisch M, Brase C, Janssen W, Fiebig L, Heitmeier S, Kanefendt F. Metabolism and Disposition of the Novel Oral Factor XIa Inhibitor Asundexian in Rats and in Humans. Eur J Drug Metab Pharmacokinet 2023:10.1007/s13318-023-00838-4. [PMID: 37365440 DOI: 10.1007/s13318-023-00838-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Current anticoagulants pose an increased risk of bleeding. The development of drugs targeting factor XIa, like asundexian, may provide a safer treatment option. A human mass‑balance study was conducted to gain a deeper understanding of the absorption, distribution, metabolism, excretion, and potential for drug-drug interaction of asundexian. Additionally, an overview of the biotransformation and clearance pathways for asundexian in humans and bile-duct cannulated (BDC) rats in vivo, as well as in vitro in hepatocytes of both species, is reported. METHODS The mass balance, biotransformation, and excretion pathways of asundexian were investigated in six healthy volunteers (single oral dose of 25 mg [14C]asundexian) and in BDC rats (intravenous [14C]asundexian 1 mg/kg). RESULTS Overall recovery of radioactivity was 101% for humans (samples collected up to 14 days after dosing), and 97.9% for BDC rats (samples collected in the 24 h after dosing). Radioactivity was mainly excreted into feces in humans (80.3%) and into bile/feces in BDC rats (> 94%). The predominant clearance pathways in humans were amide hydrolysis to metabolite M1 (47%) and non-labeled M9 with subsequent N-acetylation to M10; oxidative biotransformation was a minor pathway (13%). In rats, hydrolysis of the terminal amide to M2 was the predominant pathway. In human plasma, asundexian accounted for 61.0% of total drug-related area under the plasma concentration-time curve (AUC); M10 was the major metabolite (16.4% of the total drug-related AUC). Excretion of unmetabolized drug was a significant clearance pathway in both species (human, ~ 37%; BDC rat, ~ 24%). The near-complete bioavailability of asundexian suggests negligible limitations on absorption and first-pass metabolism. Comparison with radiochromatograms from incubations with human or rat hepatocytes indicated consistency across species and a good overall in vitro/in vivo correlation. CONCLUSIONS Similar to preclinical experiments, total asundexian-derived radioactivity is cleared quantitatively predominantly via feces. Excretion occurs mainly via amide hydrolysis and as the unchanged drug.
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Affiliation(s)
- Isabel Piel
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Anna Engelen
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Dieter Lang
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Simone I Schulz
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Michael Gerisch
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | | | - Wiebke Janssen
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Lukas Fiebig
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
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