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Zhang P, Xiang S, Liu B, Wang X, Yang X, Ye C, Wang Z, Li Y, Zhou L, Wang C, Li H, Huang J, Peng A, Wang X, Wang D, Xiao J, Chen W, Cheng H, Mao N, Wang J, Yang L, Chen J. Randomized controlled trial of nalfurafine for refractory pruritus in hemodialysis patients. Ren Fail 2023; 45:2175590. [PMID: 36856148 PMCID: PMC9980412 DOI: 10.1080/0886022x.2023.2175590] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Background: Chronic kidney disease-associated pruritus (CKD-aP) is very common and sometimes refractory to treatment in hemodialysis patients. In a trial conducted in Japan, nalfurafine, effectively reduced itching of treatment-resistant CKD-aP. Our present bridging study aimed to evaluate the efficacy and safety of nalfurafine in Chinese cohort with refractory CKD-aP.Methods: In this phase III, multicenter bridging study conducted at 22 sites in China, 141 Chinese cases with refractory CKD-aP were randomly (2:2:1) assigned to receive 5 μg, 2.5 μg of nalfurafine or a placebo orally for 14 days in a double-blind manner. The primary end point was the mean decrease in the mean visual analogue scale (VAS) from baseline.Results: A total of 141 patients were included. The primary endpoint analysis based on full analysis set (FAS), the difference of mean VAS decrease between 5 μg nalfurafine and placebo group was 11.37 mm (p = .041); the difference of mean VAS decrease between 2.5 μg and placebo group was 8.81 mm, but not statistically significantly different. Both differences were greater than 4.13 mm, which met its predefined success criterion of at least 50% efficacy of the key Japanese clinical trial. The per protocol set (PPS) analysis got similar results. The incidence of adverse drug reactions (ADRs) was 49.1% in 5μg, 38.6% in 2.5 μg and 33.3% in placebo group. The most common ADR was insomnia, seen in 21 of the 114 nalfurafine patients.Conclusions: Oral nalfurafine effectively reduced itching with few significant ADRs in Chinese hemodialysis patients with refractory pruritus.
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Affiliation(s)
- Ping Zhang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China,Kidney Disease Center, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China,Kidney Disease Center, National Key Clinical Department of Kidney Diseases, Hangzhou, China,Institute of Nephrology, Zhejiang University, Hangzhou, China,Kidney Disease Center, Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Shilong Xiang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China,Kidney Disease Center, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China,Kidney Disease Center, National Key Clinical Department of Kidney Diseases, Hangzhou, China,Institute of Nephrology, Zhejiang University, Hangzhou, China,Kidney Disease Center, Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Bicheng Liu
- Department of Nephrology, ZhongDa Hospital, Southeast University, Chongqing, China
| | - Xiaohui Wang
- Department of Nephrology, Fifth Hospital in Wuhan, Wuhan, China
| | - Xiaoping Yang
- Department of Nephrology, The First Affiliated Hospital of Shihezi University School of Medicine, Shihezi, China
| | - Chaoyang Ye
- Department of Nephrology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zunsong Wang
- Department of Nephrology, Shandong Province QianFoshan Hospital, Jinan, China
| | - Yanlin Li
- Department of Nephrology, Zhongshan Traditional Chinese Medicine Hospital, Guangzhou, China
| | - Li Zhou
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Caili Wang
- Department of Nephrology, The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, China
| | - Hongbo Li
- Department of Nephrology, Wuhan No.1 Hospital, Wuhan, China
| | - Jian Huang
- Department of Nephrology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Ai Peng
- Department of Nephrology, Shanghai Tenth People’s Hospital, Shanghai, China
| | - Xiaoping Wang
- Department of Nephrology, The Central Hospital of Jinan, Jinan, China
| | - Deguang Wang
- Department of Nephrology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Jie Xiao
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenli Chen
- Department of Nephrology, The Central Hospital of Wuhan, Wuhan, China
| | - Hong Cheng
- Department of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Mao
- Department of Nephrology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Jianqin Wang
- Department of Nephrology, Lanzhou University Second Hospital, Lanzhou, China
| | - Lin Yang
- Department of Nephrology, Yichang Central People’s Hospital, Yichang, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China,Kidney Disease Center, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China,Kidney Disease Center, National Key Clinical Department of Kidney Diseases, Hangzhou, China,Institute of Nephrology, Zhejiang University, Hangzhou, China,Kidney Disease Center, Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China,CONTACT Jianghua Chen Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Yosipovitch G, Awad A, Spencer RH, Munera C, Menzaghi F. A Phase 2 Study of Oral Difelikefalin in Subjects With Chronic Kidney Disease and Moderate-to-Severe Pruritus. J Am Acad Dermatol 2023:S0190-9622(23)00586-8. [PMID: 37059302 DOI: 10.1016/j.jaad.2023.03.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 10/17/2022] [Revised: 03/03/2023] [Accepted: 03/15/2023] [Indexed: 04/16/2023]
Abstract
INTRODUCTION /Background: Chronic pruritus is burdensome for chronic kidney disease (CKD) patients. OBJECTIVE We evaluated difelikefalin efficacy and safety in reducing itch in subjects with non-dialysis-dependent (NDD)-CKD and those undergoing hemodialysis (HD). METHODS This phase 2, double-blind, randomized, placebo-controlled, dose-finding study enrolled NDD-CKD (stage 3-5) and HD subjects with moderate-to-severe pruritus. Subjects were equally randomized to oral difelikefalin (0.25, 0.5, 1.0 mg) or placebo once daily for 12 weeks. The primary endpoint was change in weekly mean Worst Itch Numeric Rating Scale (WI-NRS) score at week 12. RESULTS 269 subjects were randomized (mean [SD] baseline WI-NRS: 7.1 [1.2]). Difelikefalin 1.0 mg significantly reduced weekly mean WI-NRS scores versus placebo at week 12 (P=0.018), with numerical reductions observed with difelikefalin 0.25 and 0.5 mg. At week 12, 38.6% of subjects receiving difelikefalin 1.0 mg achieved complete response (WI-NRS 0-1) versus 14.4% receiving placebo. Difelikefalin resulted in ∼20% improvement in itch-related quality-of-life measures. The most common treatment-emergent adverse events were dizziness, fall, constipation, diarrhea, gastroesophageal reflux disease, fatigue, hyperkalemia, hypertension, and urinary tract infection. LIMITATIONS Study duration was 12 weeks. CONCLUSIONS Oral difelikefalin significantly reduced itch intensity in stage 3‒5 CKD subjects with moderate-to-severe pruritus, supporting continued development for this condition.
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Affiliation(s)
- Gil Yosipovitch
- Department of Dermatology and Cutaneous Surgery and Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL
| | - Ahmed Awad
- Kansas City Kidney Consultants, Kansas City, MO
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Inan S, Dun NJ, Cowan A. Antipruritic Effect of Nalbuphine, a Kappa Opioid Receptor Agonist, in Mice: A Pan Antipruritic. Molecules 2021; 26:5517. [PMID: 34576988 DOI: 10.3390/molecules26185517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022] Open
Abstract
Antipruritic effects of kappa opioid receptor (KOR) agonists have been shown in rodent models of acute and chronic scratching (itchlike behavior). Three KOR agonists, nalfurafine, difelikefalin, and nalbuphine, are in clinical studies for antipruritic effects in chronic itch of systemic and skin diseases. Nalfurafine (in Japan) and difelikefalin (in the USA) were approved to be used in the treatment of chronic itch in hemodialysis patients. The FDA-approved nalbuphine has been used in clinic for over 40 years, and it is the only narcotic agonist that is not scheduled. We aimed to study (a) antiscratch activity of nalbuphine against TAT-HIV-1 protein (controls HIV transcription)-, deoxycholic acid (DCA, bile acid)-, and chloroquine (CQ)-induced scratching in a mouse model of acute itch; and (b) whether the effect of nalbuphine is produced via KORs. First, dose-responses were developed for pruritogens. Mice were pretreated with nalbuphine (0.3-10 mg/kg) and then a submaximal dose of pruritogens were administered and the number of scratching bouts was counted. To study if the antiscratch effect of nalbuphine is produced via KOR, we used KOR knock out mice and pharmacologic inhibition of KORs using nor-binaltorphimine, a KOR antagonist. For this aim, we used CQ as a pruritogen. We found that: (a) TAT-HIV-1 protein elicits scratching in a dose-dependent manner; (b) nalbuphine inhibits scratching induced by TAT-HIV-1, DCA, and CQ dose-dependently; and (c) nalbuphine inhibits scratching induced by CQ through KORs. In conclusion, nalbuphine inhibits scratching elicited by multiple pruritogens.
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Yadav VD, Kumar L, Kumari P, Kumar S, Singh M, Siddiqi MI, Yadav PN, Batra S. Synthesis and Assessment of Fused β-Carboline Derivatives as Kappa Opioid Receptor Agonists. ChemMedChem 2021; 16:1917-1926. [PMID: 33599108 DOI: 10.1002/cmdc.202100029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 01/14/2021] [Revised: 02/17/2021] [Indexed: 12/17/2022]
Abstract
The synthesis of 5-formyl-6-aryl-6H-indolo[3,2,1-de][1,5] naphthyridine-2-carboxylates by reaction between 1-formyl-9H-β-carbolines and cinnamaldehydes in the presence of pyrrolidine in water with microwave irradiation is described. Pharmacophoric modification of the formyl group offered several new fused β-carboline derivatives, which were investigated for their κ-opioid receptor (KOR) agonistic activity. Two compounds 4 a and 4 c produced appreciable agonist activity on KOR with EC50 values of 46±19 and 134±9 nM, respectively. Moreover, compound-induced KOR signaling studies suggested both compounds to be extremely G-protein-biased agonists. The analgesic effect of 4 a was validated by the increase in tail flick latency in mice in a time-dependent manner, which was completely blocked by the KOR-selective antagonist norBNI. Moreover, unlike U50488, an unbiased full KOR agonist, 4 a did not induce sedation. The docking of 4 a with the human KOR was studied to rationalize the result.
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Affiliation(s)
- Veena D Yadav
- Medicinal and Process Chemistry Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India
| | - Lalan Kumar
- Medicinal and Process Chemistry Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India
| | - Poonam Kumari
- Neuroscience and Ageing Biology Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India
| | - Sakesh Kumar
- Neuroscience and Ageing Biology Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India.,Academy of Scientific and Innovative Research, CSIR-Human Resource Development Centre, CSIR-HRDC) Campus Sector 19, Kamla Nehru Nagar, Ghaziabad, 201002, Uttar Pradesh, India
| | - Maninder Singh
- Molecular and Structural Biology Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India
| | - Mohammad I Siddiqi
- Molecular and Structural Biology Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India.,Academy of Scientific and Innovative Research, CSIR-Human Resource Development Centre, CSIR-HRDC) Campus Sector 19, Kamla Nehru Nagar, Ghaziabad, 201002, Uttar Pradesh, India
| | - Prem N Yadav
- Neuroscience and Ageing Biology Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India.,Academy of Scientific and Innovative Research, CSIR-Human Resource Development Centre, CSIR-HRDC) Campus Sector 19, Kamla Nehru Nagar, Ghaziabad, 201002, Uttar Pradesh, India
| | - Sanjay Batra
- Medicinal and Process Chemistry Division, CSIR-Central Drug Research Institute Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, Uttar Pradesh, India.,Academy of Scientific and Innovative Research, CSIR-Human Resource Development Centre, CSIR-HRDC) Campus Sector 19, Kamla Nehru Nagar, Ghaziabad, 201002, Uttar Pradesh, India
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Denny L, Al Abadey A, Robichon K, Templeton N, Prisinzano TE, Kivell BM, La Flamme AC. Nalfurafine reduces neuroinflammation and drives remyelination in models of CNS demyelinating disease. Clin Transl Immunology 2021; 10:e1234. [PMID: 33489124 PMCID: PMC7811802 DOI: 10.1002/cti2.1234] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/22/2020] [Accepted: 12/14/2020] [Indexed: 12/31/2022] Open
Abstract
Objectives Multiple sclerosis (MS) is a neurodegenerative disease characterised by inflammation and damage to the myelin sheath, resulting in physical and cognitive disability. There is currently no cure for MS, and finding effective treatments to prevent disease progression has been challenging. Recent evidence suggests that activating kappa opioid receptors (KOR) has a beneficial effect on the progression of MS. Although many KOR agonists like U50,488 are not suitable for clinical use because of a poor side‐effect profile, nalfurafine is a potent, clinically used KOR agonist with a favorable side‐effect profile. Methods Using the experimental autoimmune encephalomyelitis (EAE) model, the effect of therapeutically administered nalfurafine or U50,488 on remyelination, CNS infiltration and peripheral immune responses were compared. Additionally, the cuprizone model was used to compare the effects on non‐immune demyelination. Results Nalfurafine enabled recovery and remyelination during EAE. Additionally, it was more effective than U50,488 and promoted disease reduction when administered after chronic demyelination. Blocking KOR with the antagonist, nor‐BNI, impaired full recovery by nalfurafine, indicating that nalfurafine mediates recovery from EAE in a KOR‐dependent fashion. Furthermore, nalfurafine treatment reduced CNS infiltration (especially CD4+ and CD8+ T cells) and promoted a more immunoregulatory environment by decreasing Th17 responses. Finally, nalfurafine was able to promote remyelination in the cuprizone demyelination model, supporting the direct effect on remyelination in the absence of peripheral immune cell invasion. Conclusions Overall, our findings support the potential of nalfurafine to promote recovery and remyelination and highlight its promise for clinical use in MS.
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Affiliation(s)
- Lisa Denny
- School of Biological Sciences Victoria University of Wellington Wellington New Zealand.,Centre for Biodiscovery Victoria University of Wellington Wellington New Zealand
| | - Afnan Al Abadey
- School of Biological Sciences Victoria University of Wellington Wellington New Zealand.,Centre for Biodiscovery Victoria University of Wellington Wellington New Zealand
| | - Katharina Robichon
- School of Biological Sciences Victoria University of Wellington Wellington New Zealand.,Centre for Biodiscovery Victoria University of Wellington Wellington New Zealand
| | - Nikki Templeton
- School of Biological Sciences Victoria University of Wellington Wellington New Zealand.,Centre for Biodiscovery Victoria University of Wellington Wellington New Zealand
| | - Thomas E Prisinzano
- Department of Pharmaceutical Sciences University of Kentucky Lexington KY 40536 USA
| | - Bronwyn M Kivell
- School of Biological Sciences Victoria University of Wellington Wellington New Zealand.,Centre for Biodiscovery Victoria University of Wellington Wellington New Zealand
| | - Anne C La Flamme
- School of Biological Sciences Victoria University of Wellington Wellington New Zealand.,Centre for Biodiscovery Victoria University of Wellington Wellington New Zealand.,Malaghan Institute of Medical Research Wellington New Zealand
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6
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Fishbane S, Mathur V, Germain MJ, Shirazian S, Bhaduri S, Munera C, Spencer RH, Menzaghi F. Randomized Controlled Trial of Difelikefalin for Chronic Pruritus in Hemodialysis Patients. Kidney Int Rep 2020; 5:600-610. [PMID: 32405581 PMCID: PMC7210745 DOI: 10.1016/j.ekir.2020.01.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 01/13/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction There is an unmet medical need for pruritus associated with chronic kidney disease, a distressing complication characterized by generalized and persistent itch affecting 20% to 40% of patients undergoing hemodialysis. Here we report the results of a phase 2 trial evaluating the efficacy and safety of a novel peripherally restricted kappa opioid receptor agonist, difelikefalin, in adult patients undergoing hemodialysis with pruritus. Methods In this study, 174 hemodialysis patients with moderate-to-severe pruritus were randomly assigned to receive difelikefalin (0.5, 1.0, or 1.5 μg/kg) or placebo intravenously thrice weekly after each hemodialysis session for 8 weeks in a double-blind, controlled trial. The primary endpoint was the change from baseline at week 8 in the weekly mean of the 24-hour Worst Itching Intensity Numerical Rating Scale score. The secondary efficacy endpoint was the change in itch-related quality of life measured by the Skindex-10 questionnaire. Other endpoints included safety, sleep quality, and additional measures including the 5-D itch scale. Results A significant reduction from baseline in itch intensity scores at week 8 favored all difelikefalin doses combined versus placebo (P = 0.002). Difelikefalin also showed improvement over placebo in Skindex-10, 5-D itch, and sleep disturbance scores (P ≤ 0.005). Overall, 78% of patients receiving difelikefalin reported treatment-emergent adverse events versus 42% of patients given placebo, with diarrhea, dizziness, nausea, somnolence, and fall being the most frequent (≥5%). Conclusion In this trial, difelikefalin effectively reduced itching intensity and improved sleep and itch-related quality of life.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | | | - Michael J Germain
- Baystate Medical Center and Tufts University, Springfield, Massachusetts, USA
| | - Shayan Shirazian
- Columbia University Medical Center, Division of Nephrology, Department of Medicine, College of Physicians and Surgeons at Columbia University, New York, New York, USA
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Harland AA, Pogozheva ID, Griggs NW, Trask TJ, Traynor JR, Mosberg HI. Placement of Hydroxy Moiety on Pendant of Peptidomimetic Scaffold Modulates Mu and Kappa Opioid Receptor Efficacy. ACS Chem Neurosci 2017; 8:2549-2557. [PMID: 28796483 PMCID: PMC5691919 DOI: 10.1021/acschemneuro.7b00284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
![]()
In
an effort to expand the structure–activity relationship (SAR)
studies of a series of mixed-efficacy opioid ligands, peptidomimetics
that incorporate methoxy and hydroxy groups around a benzyl or 2-methylindanyl
pendant on a tetrahydroquinoline (THQ) core of the peptidomimetics
were evaluated. Compounds containing a methoxy or hydroxy moiety in
the o- or m-positions increased
binding affinity to the kappa opioid receptor (KOR), whereas compounds
containing methoxy or hydroxy groups in the p-position
decreased KOR affinity and reduced or eliminated efficacy at the mu
opioid receptor (MOR). The results from a substituted 2-methylindanyl
series aligned with the findings from the substituted benzyl series.
Our studies culminated in the development of 8c, a mixed-efficacy
MOR agonist/KOR agonist with subnanomolar binding affinity for both
MOR and KOR.
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Affiliation(s)
- Aubrie A. Harland
- Department of Medicinal Chemistry, College of Pharmacy, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Irina D. Pogozheva
- Department of Medicinal Chemistry, College of Pharmacy, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Nicholas W. Griggs
- Department of Pharmacology, Medical School, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Tyler J. Trask
- Department of Pharmacology, Medical School, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - John R. Traynor
- Department of Pharmacology, Medical School, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Henry I. Mosberg
- Department of Medicinal Chemistry, College of Pharmacy, University of Michigan, Ann Arbor, Michigan 48109, United States
- Interdepartmental Program in Medicinal Chemistry, University of Michigan, Ann Arbor, Michigan 48109, United States
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