Tafamidis: A Novel Treatment for Transthyretin Amyloid Cardiomyopathy

Atomic Mechanisms of Transthyretin Tetramer Dissociation Studied by Molecular Dynamics Simulations

The dissociation of the transthyretin (TTR) tetramer into a monomer is closely related to various TTR amyloidoses in humans. While the tetramer dissociation has been reported to be the rate-limiting step for TTR aggregation, few details are known about the mechanism. Here, molecular dynamics (MD) simulations were performed by combining conventional MD and biased metadynamics to investigate the mechanism for the wild-type (WT) and mutant (T119M) structures. Both were found to have a great deal in common. Conventional MD simulations reveal that interfacial hydrophobic interactions contribute significantly to stabilize the tetramer. Interfacial residues including L17, V20, L110, and V121 with close contacts form a hydrophobic channel. Metadynamics simulations indicate that the mouth opening of the hydrophobic channel is the first and the most difficult step for dissociation. Interactions of V20 between opposing dimers lock four monomers into the tetramer, and disruption of the interactions is found to be involved in the final step. During the dissociation, an increasing extent of solvation was observed by calculating the radial distribution functions of water around interfacial hydrophobic residues, suggesting that water plays a role in driving the tetramer dissociation. Moreover, compared to T119, residue M119 has a longer side chain that extends into the hydrophobic channel, making solvation more difficult, consistent with a higher energy barrier for dissociation of the T119M tetramer. This result provides a good explanation for the protective role of the T119M mutation. Overall, this study can provide atomic-level insights to better understand the pathogenesis of TTR amyloidosis and guide rational drug design in the future.

Pharmacotherapy review: Emerging treatment modalities in transthyretin cardiac amyloidosis

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PURPOSE

This review aims to summarize the evidence and pharmacological characteristics of treatment options for transthyretin amyloid cardiomyopathy (ATTR-CM). Additionally, this review highlights the role of clinical pharmacists in helping to secure newly introduced therapies.

SUMMARY

ATTR-CM, a disease characterized by misfolded protein that is deposited in the myocardium and disrupts cardiac functioning, has historically been underdiagnosed due to the need for invasive biopsy and an illusion of rarity. Once diagnosed, limited treatment modalities for ATTR-CM have led providers to rely on nonpharmacological remedies or off-label use of medications with limited evidence of benefit. However, recent noninvasive diagnostic advancements and heightened disease state awareness have revealed increased prevalence of ATTR-CM. This has led to the introduction of several first-in-class pharmaceuticals with actions targeted at inhibiting the various phases of amyloidosis: TTR stabilizers include diflunisal and first-in-class, Food and Drug Administration (FDA)-approved tafamidis; TTR silencers include patisiran and inotersen; fibril disrupters include doxycycline with tauroursodeoxycholic acid; and alternative agents include green tea extract and curcumin.

CONCLUSION

ATTR-CM treatments have emerged and, despite current limited data, are continuing to evolve. Tafamidis, the only agent approved by FDA for ATTR-CM, shows promise to improve survival and quality of life in patients with ATTR-CM. Pharmacists can play a key role in assisting with agent selection for this disease state, as well as providing knowledge about current and future clinical trials evaluating the safety and efficacy of the available treatment modalities.

Repurposing a Cardiovascular Disease Drug of Cloridarol as hIAPP Inhibitor

Accumulating evidence have shown a strong pathological correlation between cardiovascular disease (CVD) and Type II diabetes (T2D), both of which share many common risk factors (e.g., hyperglycemia, hypertension, hypercoagulability, and dyslipidemia) and mutually contribute to each other. Driven by such strong CVD-T2D correlation and marginal benefits from drug development for T2D, here we proposed to repurpose a CVD drug of cloridarol as human islet amyloid peptide (hIAPP) inhibitor against its abnormal misfolding and aggregation, which is considered as a common and critical pathological event in T2D. To this end, we investigated the inhibition activity of cloridarol on the aggregation and toxicity of hIAPP_1-37 using combined experimental and computational approaches. Collective experimental data from ThT, AFM, and CD demonstrated the inhibition ability of cloridarol to prevent hIAPP aggregation from its monomeric and oligomeric states, leading to the overall reduction of hIAPP fibrils up to 57% at optimal conditions. MTT and LDH cell assays also showed that cloridarol can also effectively increase cell viability by 15% and decrease cell apoptosis by 28%, confirming its protection of islet β-cells from hIAPP-induced cell toxicity. Furthermore, comparative molecular dynamics simulations revealed that cloridarol was preferentially bound to the C-terminal β-sheet region of hIAPP oligomers through a combination of hydrophobic interactions, π-π stacking, and hydrogen bonding. Such multiple site bindings allowed cloridarol to disturb hIAPP structures, reduce β-sheet content, and block the lateral association pathway of hIAPP aggregates, thus explaining experimental findings. Different from other single-target hIAPP inhibitors, cloridarol is unique in that it works as both a CVD drug and hIAPP inhibitor, which can be used as a viable structural template (especially for benzofuran) for the further development of cloridarol-based or benzofuran-based inhibitors of amyloid proteins.