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Arends EJ, Meziyerh S, Moes DJA, Kamerling SW, van der Kooy S, Ogando NS, Snijder EJ, van Hemert M, Visser LG, Feltkamp MC, Claas EC, Rabelink TJ, van Kooten C, de Vries AP, Teng YO. Voclosporin and the Antiviral Effect Against SARS-CoV-2 in Immunocompromised Kidney Patients. Kidney Int Rep 2023; 8:2654-2664. [PMID: 38106593 PMCID: PMC10719564 DOI: 10.1016/j.ekir.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Immunocompromised kidney patients are at increased risk of prolonged SARS-CoV-2 infection and related complications. Preclinical evidence demonstrates a more potent inhibitory effect of voclosporin on SARS-CoV-2 replication than tacrolimus in vitro. We investigated the potential antiviral effects of voclosporin on SARS-CoV-2 in immunocompromised patients. Methods First, we conducted a prospective, randomized, open-label, proof-of-concept study in 20 kidney transplant recipients (KTRs) on tacrolimus-based immunosuppression who contracted mild to moderate SARS-CoV-2 infection. Patients were randomized to continue tacrolimus or switch to voclosporin. Second, we performed a post hoc analysis on SARS-CoV-2 infections in 216 patients with lupus nephritis (LN) on standard immunosuppression who were randomly exposed to voclosporin or placebo as part of a clinical trial that was conducted during the worldwide COVID-19 pandemic. Results The primary end point was clearance of SARS-CoV-2 viral load and that did not differ between voclosporin-treated KTRs (median 12 days, interquartile range [IQR] 8-28) and tacrolimus-treated KTRs (median 12 days, IQR 4-16) nor was there a difference in clinical recovery. Pharmacokinetic analyses demonstrated that, when voclosporin trough levels were on-target, SARS-CoV-2 viral load dropped significantly more (ΔCt 7.7 [3.4-10.7]) compared to tacrolimus-treated KTRs (ΔCt 2.7 [2.0-4.3]; P = 0.035). In voclosporin-exposed patients with LN, SARS-CoV-2 infection was detected in 6% (7/116) compared to 12% (12/100) in placebo-exposed patients (relative risk [RR] 1.4 [0.97-2.06]). Notably, no voclosporin-exposed patients with LN died from severe SARS-CoV-2 infection compared to 3% (3/100) in placebo-exposed patients (RR 2.2 [1.90-2.54]). Conclusion This proof-of-concept study shows a potential positive risk-benefit profile for voclosporin in immunocompromised patients with SARS-CoV-2 infection. These results warrant further investigations on voclosporin to establish an equipoise between infection and maintenance immunosuppression.
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Affiliation(s)
- Eline J. Arends
- Department of Internal Medicine section Nephrology, Center of Expertise for Lupus-, Vasculitis and Complement- mediated Systemic Autoimmune Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Soufian Meziyerh
- Department of Internal Medicine section Nephrology, Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Dirk Jan A.R. Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Sylvia W.A. Kamerling
- Department of Internal Medicine section Nephrology, Center of Expertise for Lupus-, Vasculitis and Complement- mediated Systemic Autoimmune Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Sandra van der Kooy
- Department of Internal Medicine section Nephrology, Center of Expertise for Lupus-, Vasculitis and Complement- mediated Systemic Autoimmune Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Natacha S. Ogando
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eric J. Snijder
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn van Hemert
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leo G. Visser
- Department of Internal Medicine section Infectious diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Mariet C.W. Feltkamp
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eric C.J. Claas
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ton J. Rabelink
- Department of Internal Medicine section Nephrology, Center of Expertise for Lupus-, Vasculitis and Complement- mediated Systemic Autoimmune Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Cees van Kooten
- Department of Internal Medicine section Nephrology, Center of Expertise for Lupus-, Vasculitis and Complement- mediated Systemic Autoimmune Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Aiko P.J. de Vries
- Department of Internal Medicine section Nephrology, Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Y.K. Onno Teng
- Department of Internal Medicine section Nephrology, Center of Expertise for Lupus-, Vasculitis and Complement- mediated Systemic Autoimmune Diseases, Leiden University Medical Center, Leiden, the Netherlands
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Li X, Wang N, Liu Y, Li W, Bai X, Liu P, He CY. Backbone N-methylation of peptides: Advances in synthesis and applications in pharmaceutical drug development. Bioorg Chem 2023; 141:106892. [PMID: 37776681 DOI: 10.1016/j.bioorg.2023.106892] [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] [Received: 07/02/2023] [Revised: 09/16/2023] [Accepted: 09/25/2023] [Indexed: 10/02/2023]
Abstract
Peptide-based drugs have garnered considerable attention in recent years owing to their increasingly crucial role in the treatment of diverse diseases. However, the limited pharmacokinetic properties of peptides have hindered their full potential. One prominent strategy for enhancing the druggability of peptides is N-methylation, which involves the addition of a methyl group to the nitrogen atom of the peptide backbone. This modification significantly improves the stability, bioavailability, receptor binding affinity and selectivity of peptide drug candidates. In this review, we provide a comprehensive overview of the advancements in synthetic methods for N-methylated peptide synthesis, as well as the associated limitations. Moreover, we explore the versatile effects of N-methylation on various aspects of peptide properties. Furthermore, we emphasize the efforts dedicated to N-methylated peptide pharmaceuticals that have successfully obtained marketing approval.
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Affiliation(s)
- Xuefei Li
- Key Laboratory of Basic Pharmacology of Ministry of Education, Key Laboratory of Biocatalysis & Chiral Drug Synthesis of Guizhou Province, Zunyi Medical University, Zunyi, Guizhou 563000, China; Central Research Institute, United-Imaging Healthcare Group Co., Ltd, Shanghai, China
| | - Ningchao Wang
- Central Research Institute, United-Imaging Healthcare Group Co., Ltd, Shanghai, China
| | - Yuhang Liu
- Central Research Institute, United-Imaging Healthcare Group Co., Ltd, Shanghai, China
| | - Weipiao Li
- Key Laboratory of Basic Pharmacology of Ministry of Education, Key Laboratory of Biocatalysis & Chiral Drug Synthesis of Guizhou Province, Zunyi Medical University, Zunyi, Guizhou 563000, China
| | - Xinyu Bai
- Key Laboratory of Basic Pharmacology of Ministry of Education, Key Laboratory of Biocatalysis & Chiral Drug Synthesis of Guizhou Province, Zunyi Medical University, Zunyi, Guizhou 563000, China
| | - Ping Liu
- Key Laboratory of Basic Pharmacology of Ministry of Education, Key Laboratory of Biocatalysis & Chiral Drug Synthesis of Guizhou Province, Zunyi Medical University, Zunyi, Guizhou 563000, China
| | - Chun-Yang He
- Key Laboratory of Basic Pharmacology of Ministry of Education, Key Laboratory of Biocatalysis & Chiral Drug Synthesis of Guizhou Province, Zunyi Medical University, Zunyi, Guizhou 563000, China.
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Mejia-Vilet JM, Turner-Stokes T, Houssiau F, Rovin BH. Kidney involvement in systemic lupus erythematosus: From the patient assessment to a tailored treatment. Best Pract Res Clin Rheumatol 2023; 37:101925. [PMID: 38151362 DOI: 10.1016/j.berh.2023.101925] [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: 05/03/2023] [Accepted: 12/10/2023] [Indexed: 12/29/2023]
Abstract
In the last few years, several studies have provided new evidence for the diagnosis, management, and follow-up of patients with lupus nephritis. Evidence showing dissociation between clinical and histological findings has prompted reevaluation of the role of the kidney biopsy as a tool for diagnosis and follow-up. In therapeutics, four immunosuppressive schemes now have supporting evidence for use as initial therapy. Current challenges include individualized selection of the best immunosuppressive regimen, an unmet need for non-invasive biomarkers of disease activity to inform treatment responses and guide subsequent therapy, holistic patient management in this complex, multisystem disease, and ultimately the development of more targeted therapies directed at specific effector pathways driving glomerular inflammation and damage in order to improve treatment response. In this communication, we review the diagnostic and therapeutic approach to lupus nephritis, as well as evaluation of response to therapy and disease control.
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Affiliation(s)
- Juan M Mejia-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Tabitha Turner-Stokes
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Frederic Houssiau
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Service de Rhumatologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University, Columbus, OH, United States.
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Abdel-Kahaar E, Keller F. Clinical Pharmacokinetics and Pharmacodynamics of Voclosporin. Clin Pharmacokinet 2023; 62:693-703. [PMID: 37133755 PMCID: PMC10182160 DOI: 10.1007/s40262-023-01246-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Voclosporin is an approved option for the long-term treatment of lupus nephritis. We aimed to provide a narrative review of the pharmacokinetics and pharmacodynamics of voclosporin. In addition, we derived values for pharmacokinetic and pharmacodynamic parameters by graphical analysis of published diagrams. Compared with cyclosporin, low-dose voclosporin is associated with a lower nephrotoxicity risk and, compared to tacrolimus, with a lower diabetes risk. After repetitive dosing of 23.7 mg twice daily and at target trough concentrations of 10-20 ng/mL, the dominant or effect-indicative half-life is estimated at 7 hours. Compared with the pharmacodynamics of cyclosporin, the potency of voclosporin is stronger, with a lower concentration CE50 of 50 ng/mL already producing the half-maximum immunosuppressive effect. The Hill coefficient can be predicted to be low at H = 1.3, indicating a concentration-dependent effect on the immune system. The corresponding effect bisection time of 10 hours allows for dosing every 12 hours. Accordingly, the trough concentration will be above the threshold concentration that produces 5% of the maximum effect of 5.2 ng/mL for immunosuppression but below both the predicted threshold of 30 ng/mL for nephrotoxicity and the predicted threshold of 40 ng/mL for new-onset diabetes. The pharmacokinetic and pharmacodynamic properties suggest the use of low-dose voclosporin combined with mycophenolate and low-dose glucocorticoids for immunosuppressive maintenance therapy.
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Affiliation(s)
- Emaad Abdel-Kahaar
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University Hospital Ulm, Helmholtzstrasse 20, 89081, Ulm, Germany
- Department of Pharmacology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
- , Ulm, Germany
| | - Frieder Keller
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University Hospital Ulm, Helmholtzstrasse 20, 89081, Ulm, Germany.
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Yuan S, Wang DS, Liu H, Zhang SN, Yang WG, Lv M, Zhou YX, Zhang SY, Song J, Liu HM. New drug approvals for 2021: Synthesis and clinical applications. Eur J Med Chem 2022; 245:114898. [DOI: 10.1016/j.ejmech.2022.114898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
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Gelder T, Lerma E, Engelke K, Huizinga RB. Voclosporin: a novel calcineurin inhibitor for the treatment of lupus nephritis. Expert Rev Clin Pharmacol 2022; 15:515-529. [PMID: 35763288 DOI: 10.1080/17512433.2022.2092470] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Lupus nephritis (LN) is a severe manifestation of systemic lupus erythematosus. Standard-of-care immunosuppressive therapies achieve poor complete renal response (CRR) rates, with considerable toxicity. This article reviews voclosporin, a novel oral calcineurin inhibitor (CNI) approved for treatment of adults with active LN by the US Food and Drug Administration (the FDA) in January 2021. AREAS COVERED : This review summarizes the chemical properties, pharmacokinetics, and pharmacodynamics of voclosporin, and its efficacy and safety in LN, based on literature review covering PubMed searches, manufacturers' websites and documents produced by the FDA. EXPERT OPINION : Voclosporin is a CNI with a consistent pharmacokinetic-pharmacodynamic relationship resulting from enhanced calcineurin binding and reduced drug and metabolite load. This profile permits therapeutic efficacy in LN at a dose associated with relatively low calcineurin inhibition, and therefore a potentially improved safety profile. Pivotal trials demonstrated a significant benefit of adding voclosporin to standard therapy, with rapid reduction in proteinuria, and a clinically meaningful and significantly higher CRR rate at 1 year. At approved doses for LN, potential advantages of voclosporin versus historical experience with CNIs include lack of need for therapeutic drug monitoring, benign metabolic, lipid and electrolyte profile, and no impact on mycophenolate mofetil levels.
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Affiliation(s)
- Teun Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago College of Medicine/Advocate Christ Medical Center, Chicago, IL, USA
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Chaudhari S, Pham GS, Brooks CD, Dinh VQ, Young-Stubbs CM, Shimoura CG, Mathis KW. Should Renal Inflammation Be Targeted While Treating Hypertension? Front Physiol 2022; 13:886779. [PMID: 35770194 PMCID: PMC9236225 DOI: 10.3389/fphys.2022.886779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
Despite extensive research and a plethora of therapeutic options, hypertension continues to be a global burden. Understanding of the pathological roles of known and underexplored cellular and molecular pathways in the development and maintenance of hypertension is critical to advance the field. Immune system overactivation and inflammation in the kidneys are proposed alternative mechanisms of hypertension, and resistant hypertension. Consideration of the pathophysiology of hypertension in chronic inflammatory conditions such as autoimmune diseases, in which patients present with autoimmune-mediated kidney inflammation as well as hypertension, may reveal possible contributors and novel therapeutic targets. In this review, we 1) summarize current therapies used to control blood pressure and their known effects on inflammation; 2) provide evidence on the need to target renal inflammation, specifically, and especially when first-line and combinatory treatment efforts fail; and 3) discuss the efficacy of therapies used to treat autoimmune diseases with a hypertension/renal component. We aim to elucidate the potential of targeting renal inflammation in certain subsets of patients resistant to current therapies.
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