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Montalban X, Piasecka-Stryczynska K, Kuhle J, Benkert P, Arnold DL, Weber MS, Seitzinger A, Guehring H, Shaw J, Tomic D, Hyvert Y, Harlow DE, Dyroff M, Wolinsky JS. Efficacy and safety results after >3.5 years of treatment with the Bruton's tyrosine kinase inhibitor evobrutinib in relapsing multiple sclerosis: Long-term follow-up of a Phase II randomised clinical trial with a cerebrospinal fluid sub-study. Mult Scler 2024; 30:558-570. [PMID: 38436271 DOI: 10.1177/13524585241234783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
BACKGROUND Evobrutinib - an oral, central nervous system (CNS)-penetrant, and highly selective Bruton's tyrosine kinase inhibitor - has shown efficacy in a 48-week, double-blind, Phase II trial in patients with relapsing MS. OBJECTIVE Report results of the Phase II open-label extension (OLE; up to week 192 from randomisation) and a cerebrospinal fluid (CSF) sub-study. METHODS In the 48-week double-blind period (DBP), patients received evobrutinib 25 mg once-daily, 75 mg once-daily, 75 mg twice-daily or placebo (switched to evobrutinib 25 mg once-daily after week 24). Patients could then enter the OLE, receiving evobrutinib 75 mg once-daily (mean (± standard deviation (SD)) duration = 50.6 weeks (±6.0)) before switching to 75 mg twice-daily. RESULTS Of 164 evobrutinib-treated patients who entered the OLE, 128 (78.0%) completed ⩾192 weeks of treatment. Patients receiving DBP evobrutinib 75 mg twice-daily: annualised relapse rate at week 48 (0.11 (95% confidence interval (CI) = 0.04-0.25)) was maintained with the OLE twice-daily dose up to week 192 (0.11 (0.05-0.22)); Expanded Disability Status Scale score remained stable; serum neurofilament light chain fell to levels like a non-MS population (Z-scores); T1 gadolinium-enhancing lesion numbers remained low. No new safety signals were identified. In the OLE, evobrutinib was detected in the CSF of all sub-study patients. CONCLUSION Long-term evobrutinib treatment was well tolerated and associated with a sustained low level of disease activity. Evobrutinib was present in CSF at concentrations similar to plasma.
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Affiliation(s)
- Xavier Montalban
- Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Jens Kuhle
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Pascal Benkert
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx, Montreal, QC, Canada
| | - Martin S Weber
- Institute of Neuropathology, Department of Neurology, University Medical Center, University of Göttingen, Göttingen, Germany; Fraunhofer-Institute for Translational Medicine and Pharmacology ITMP, Göttingen, Germany
| | | | | | - Jamie Shaw
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | - Davorka Tomic
- Ares Trading SA, Eysins, Switzerland, an affiliate of Merck KGaA
| | | | - Danielle E Harlow
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | - Martin Dyroff
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX, USA
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Steinmaurer A, Riedl C, König T, Testa G, Köck U, Bauer J, Lassmann H, Höftberger R, Berger T, Wimmer I, Hametner S. The relation between BTK expression and iron accumulation of myeloid cells in multiple sclerosis. Brain Pathol 2024:e13240. [PMID: 38254312 DOI: 10.1111/bpa.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Activation of Bruton's tyrosine kinase (BTK) has been shown to play a crucial role in the proinflammatory response of B cells and myeloid cells upon engagement with B cell, Fc, Toll-like receptor, and distinct chemokine receptors. Previous reports suggest BTK actively contributes to the pathogenesis of multiple sclerosis (MS). The BTK inhibitor Evobrutinib has been shown to reduce the numbers of gadolinium-enhancing lesions and relapses in relapsing-remitting MS patients. In vitro, BTK inhibition resulted in reduced phagocytic activity and modulated BTK-dependent inflammatory signaling of microglia and macrophages. Here, we investigated the protein expression of BTK and CD68 as well as iron accumulation in postmortem control (n = 10) and MS (n = 23) brain tissue, focusing on microglia and macrophages. MS cases encompassed active, chronic active, and inactive lesions. BTK+ and iron+ cells positively correlated across all regions of interests and, along with CD68, revealed highest numbers in the center of active and at the rim of chronic active lesions. We then studied the effect of BTK inhibition in the human immortalized microglia-like HMC3 cell line in vitro. In particular, we loaded HMC3 cells with iron-dextran and subsequently administered the BTK inhibitor Evobrutinib. Iron treatment alone induced a proinflammatory phenotype and increased the expression of iron importers as well as the intracellular iron storage protein ferritin light chain (FTL). BTK inhibition of iron-laden cells dampened the expression of microglia-related inflammatory genes as well as iron-importers, whereas the iron-exporter ferroportin was upregulated. Our data suggest that BTK inhibition not only dampens the proinflammatory response but also reduces iron import and storage in activated microglia and macrophages with possible implications on microglial iron accumulation in chronic active lesions in MS.
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Affiliation(s)
- Anja Steinmaurer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christian Riedl
- Division of Neurochemistry and Neuropathology, Medical University of Vienna, Vienna, Austria
| | - Theresa König
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Giulia Testa
- Division of Neurochemistry and Neuropathology, Medical University of Vienna, Vienna, Austria
| | - Ulrike Köck
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Hans Lassmann
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neurochemistry and Neuropathology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Isabella Wimmer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Simon Hametner
- Division of Neurochemistry and Neuropathology, Medical University of Vienna, Vienna, Austria
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Scheible H, Schieferstein H, Schmidt R, Pusecker K, Gradhand U, Gopalakrishnan S, Iqbal K, Dong J, Jones R, Meli C, Bolleddula J, Dyroff M, Georgi K. Evobrutinib pathway to its major metabolite M463-2 and insights from a biotransformation and DDI perspective. Xenobiotica 2023; 53:547-558. [PMID: 37880944 DOI: 10.1080/00498254.2023.2272180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/14/2023] [Indexed: 10/27/2023]
Abstract
Evobrutinib is a highly selective, covalent, central nervous system-penetrant Bruton's tyrosine kinase (BTK) inhibitor, currently in Phase III trials for the treatment of relapsing multiple sclerosis. One major circulating metabolite of evobrutinib has been previously identified as the racemic dihydro-diol M463-2 (MSC2430422) in a Phase I human mass balance study.Phenotyping experiments were conducted to confirm the metabolic pathway of evobrutinib to M463-2. Ratio of the enantiomers was determined by enantioselective liquid chromatography with tandem mass spectrometry analysis of plasma samples from humans and preclinical species. Drug-drug interaction (DDI) characterisation, evaluation of pharmacological activity on BTK, and off-target screening experiments followed assessing safety of the metabolite.The biotransformation of evobrutinib to M463-2 was determined to be a two-step process with a CYP-mediated oxidation acting to form an epoxide intermediate, which was further hydrolysed by soluble and mitochondrial epoxide hydrolase. Only the (S)-enantiomer was determined to be a major metabolite, the (R)-enantiomer was minor. In vitro studies demonstrated the (S)-enantiomer lacked clinically relevant pharmacological activity, off-target effects and DDIs.The biotransformation of evobrutinib to its major metabolite has been elucidated, with the major (S)-enantiomer being shown to pose no on/off target or DDI risks.
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Affiliation(s)
| | | | - Ralf Schmidt
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | | | | | | | - Khalid Iqbal
- Quantitative Pharmacology Merck Healthcare KGaA, Darmstadt, Germany
| | - Jennifer Dong
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Reinaldo Jones
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Claudia Meli
- Merck Ltd, Piedmont, Italy, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Jayaprakasam Bolleddula
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Martin Dyroff
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
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Bar-Or A, Cross AH, Cunningham AL, Hyvert Y, Seitzinger A, Gühring H, Drouin EE, Alexandri N, Tomic D, Montalban X. Antibody response to SARS-CoV-2 vaccines in patients with relapsing multiple sclerosis treated with evobrutinib: A Bruton's tyrosine kinase inhibitor. Mult Scler 2023; 29:1471-1481. [PMID: 37626477 PMCID: PMC10580670 DOI: 10.1177/13524585231192460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Evobrutinib is an oral, central nervous system (CNS)-penetrant and highly selective covalent Bruton's tyrosine kinase inhibitor under clinical development for patients with relapsing multiple sclerosis (RMS). OBJECTIVE To investigate the effect of evobrutinib on immune responses in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccinated patients with RMS from a Phase II trial (NCT02975349). METHODS A post hoc analysis of patients with RMS who received evobrutinib 75 mg twice daily and SARS-CoV-2 vaccines during the open-label extension (n = 45) was conducted. Immunoglobulin (Ig)G anti-S1/S2-specific SARS-CoV-2 antibodies were measured using an indirect chemiluminescence immunoassay. RESULTS In the vaccinated subgroup, mean/minimum evobrutinib exposure pre-vaccination was 105.2/88.7 weeks. In total, 43 of 45 patients developed/increased S1/S2 IgG antibody levels post-vaccination; one patient's antibody response remained negative post-vaccination and the other had antibody levels above the upper limit of detection, both pre- and post-vaccination. Most patients (n = 36/45), regardless of pre-vaccination serostatus, had a 10-100-fold increase of antibody levels pre- to post-vaccination. Antibody levels post-booster were higher versus post-vaccination. CONCLUSION These results suggest evobrutinib, an investigational drug with therapeutic potential for patients with RMS, acts as an immunomodulator, that is, it inhibits aberrant immune cell responses in patients with RMS, while responsiveness to foreign de novo and recall antigens is maintained.
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Affiliation(s)
- Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne H Cross
- Department of Neurology, Center for Neuroimmunology and Neuroinfectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Anthony L Cunningham
- Centre for Virus Research, The Westmead Institute for Medical Research, The University of Sydney, Westmead, NSW, Australia
| | | | | | | | - Elise E Drouin
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | | | - Davorka Tomic
- Ares Trading SA, Eysins, Switzerland, an affiliate of Merck KGaA
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d’Hebron, Barcelona, Spain
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Peterson S, Jalil A, Beard K, Kakara M, Sriwastava S. Updates on efficacy and safety outcomes of new and emerging disease modifying therapies and stem cell therapy for Multiple Sclerosis: A review. Mult Scler Relat Disord 2022; 68:104125. [PMID: 36057173 DOI: 10.1016/j.msard.2022.104125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
Multiple Sclerosis (MS) is a chronic neurodegenerative autoimmune disorder of the central nervous system (CNS) and the most common cause of serious physical disability in working-age adults. Drug development and research in this field have rapidly evolved over the past two decades, leading to the broad array of treatment options available today. These disease-modifying therapies (DMTs) work through distinct mechanisms of action and exhibit varying safety and efficacy profiles to help manage symptoms and reduce exacerbations in MS patients. Our extensive understanding of this condition has also led to novel approaches, such as the discovery of specific biomarkers that allow us to monitor the therapeutic response towards DMTs. The development of new DMTs continues to progress quickly today, and it can be difficult for clinicians to remain up to date on the most recent advancements and new treatment options for their patients. In this comprehensive review, we provide an outline of current MS medications in the pipeline including emerging DMTs and stem cell therapy, as well as the unique characteristics of these medications, including their indications, pharmacokinetic effects, and the relevant advancements.
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Affiliation(s)
- Sarah Peterson
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amaris Jalil
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Katherine Beard
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Mihir Kakara
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, USA; Depratment of Neurology, Wayne State University, Detroit, MI, USA
| | - Shitiz Sriwastava
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Depratment of Neurology, Wayne State University, Detroit, MI, USA; West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA; Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA.
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6
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Torke S, Pretzsch R, Häusler D, Haselmayer P, Grenningloh R, Boschert U, Brück W, Weber MS. Inhibition of Bruton's tyrosine kinase interferes with pathogenic B-cell development in inflammatory CNS demyelinating disease. Acta Neuropathol 2020; 140:535-548. [PMID: 32761407 PMCID: PMC7498502 DOI: 10.1007/s00401-020-02204-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022]
Abstract
Anti-CD20-mediated B-cell depletion effectively reduces acute multiple sclerosis (MS) flares. Recent data shows that antibody-mediated extinction of B cells as a lasting immune suppression, harbors the risk of developing humoral deficiencies over time. Accordingly, more selective, durable and reversible B-cell-directed MS therapies are needed. We here tested inhibition of Bruton's tyrosine kinase (BTK), an enzyme centrally involved in B-cell receptor signaling, as the most promising approach in this direction. Using mouse models of MS, we determined that evobrutinib, the first BTK inhibiting molecule being developed, dose-dependently inhibited antigen-triggered activation and maturation of B cells as well as their release of pro-inflammatory cytokines. Most importantly, evobrutinib treatment functionally impaired the capacity of B cells to act as antigen-presenting cells for the development of encephalitogenic T cells, resulting in a significantly reduced disease severity in mice. In contrast to anti-CD20, BTK inhibition silenced this key property of B cells in MS without impairing their frequency or functional integrity. In conjunction with a recent phase II trial reporting that evobrutinib is safe and effective in MS, our mechanistic data highlight therapeutic BTK inhibition as a landmark towards selectively interfering with MS-driving B-cell properties.
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Affiliation(s)
- Sebastian Torke
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Roxanne Pretzsch
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Darius Häusler
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Philipp Haselmayer
- Translational Innovation Platform Immunology, Merck KGaA, Darmstadt, Germany
| | | | - Ursula Boschert
- Ares Trading S.A., An Affiliate of Merck Serono S.A., Eysins, Switzerland
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Martin S Weber
- Institute of Neuropathology, University Medical Center, Göttingen, Germany.
- Department of Neurology, University Medical Center, Göttingen, Germany.
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