Treating Multiple Myeloma by Targeting the NF-Kappa-B Pathway with Gadd45-Beta/MKK7 Inhibitors

Lead Research Organisation: Imperial College London
Department Name: Dept of Medicine

Abstract

Professor Guido Franzoso and his colleagues at Imperial College London have discovered a new way of tackling multiple myeloma, an incurable cancer of the white blood cells, which are normally responsible for producing 'antibodies,' that attacks and destroys bone, which could offer a cure for this disease. The treatments that currently exist for multiple myeloma have severe side effects that limit the doses that can be given to patients. The most recent treatment, bortezomib (Velcade), cannot completely destroy the cancer, allowing some of the cancer cells to escape this treatment and so, whilst the disease can be temporarily stabilised, relapse is unfortunately inevitable. Because of an increased number of antibody-producing white blood cells, patients generally have high levels of a single type of antibody called 'M-protein' in their blood and/or urine. These patients often also have reduced blood cell counts and decreased amounts of normal antibodies, which compromises their body's immune defenses against infection. As a result of these and other complications, most of the 110,000 people diagnosed each year with the disease in the US, Europe and Japan will die within about five years of diagnosis. This blood borne cancer cannot be treated using radiotherapy or surgery and so the options are restricted to chemotherapy or bone marrow transplant.

Prof. Franzoso's team discovered a new protein, called Gadd45-Beta, which forms one half of a crucial signalling point within cells. An enzyme called MKK7 controls traffic through a second signalling pathway (JNK) that forms the other half of this focal signalling point. When bound together, the two Gadd45-Beta and MKK7 proteins stop the signals that tell the cancerous cells to activate a form of cellular suicide known to specialists as 'apoptosis', thus allowing them to multiply uncontrollably.

The team has since developed a novel compound molecule, DTP3, which specifically disrupts the relationship and interaction between Gadd45-Beta and MKK7, and in so doing kills the cancerous cells effectively but, perhaps most importantly, completely lacks toxicity to the normal cells. This unique property makes DTP3 an exciting starting point in the search for a new effective drug therapy against multiple myeloma.

The goal of the research team is now to progress DTP3 to an early stage clinical study in patients suffering from multiple myeloma in order to test the drug in man and ultimately develop an effective therapy with no toxicity, alongside a diagnostic test, for multiple myeloma and potentially other cancers where the Gadd45-Beta and MKK7 proteins are responsible for keeping the tumour cells alive.

Technical Summary

The NF-kB pathway is aberrantly upregulated in many cancers, where it promotes survival. A paradigm of these cancers is Multiple Myeloma (MM), an incurable plasma cell malignancy. Existing MM treatments fail to induce lasting remissions, leading to relapse and/or refractory disease. NF-kB is a promising therapeutic target in MM. Despite the industry's long-standing pursuit of NF-kB inhibitors, however, no such inhibitor has been clinically approved to this day. Likewise, proteasome inhibitors with MM indication, such as bortezomib, inhibit NF-kB and other cellular functions, and do not specifically target cancer cells, resulting in low therapeutic indices and dose-limiting toxicities. We reasoned that an attractive alternative to globally targeting NF-kB would be to block the non-redundant, cancer-specific effectors of NF-kB-dependent survival. Recently, we identified the interaction between the NF-kB-regulated gene product, Gadd45b, and the JNK kinase, MKK7, as a novel therapeutic target in MM. Gadd45b is elevated in MM cells relative to healthy tissue and promotes survival therein by suppressing MKK7/JNK-induced apoptosis. Further, with MRC support, we developed a novel D-tripeptide, DTP3, which specifically disrupts the Gadd45b/MKK7 interaction, kills MM cells at low-nM concentrations and, importantly, completely lacks toxicity to normal cells. Due to this cancer-selective target specificity, DTP3 has similar anti-MM activity to bortezomib, but more than 100-fold higher therapeutic index in vitro. DTP3 also has excellent tolerability and far greater therapeutic index than bortezomib in vivo. Consequently, it virtually eradicates MM xenografts in mice without apparent side effects. We currently aim to progress DTP3 to a Phase 1 trial to deliver clinical PoC for a cancer-selective NF-kB-targeting strategy and an effective therapy with no preclusive toxicity, alongside a diagnostic test, for MM and potentially other cancers where NF-kB promotes survival via Gadd45b.

Planned Impact

Multiple myeloma is an incurable malignancy of plasma cells. At present, it accounts for 10% of all haematological malignancies and ~2% of all cancer deaths in the Western World. The median age at diagnosis is approximately 68 years, and the disease is more common in men than in women. Approximately 4,000 people are diagnosed with multiple myeloma in the UK and it affects 110,000 patients in US, Europe and Japan each year. The worldwide pharmaceutical market for multiple myeloma was valued at $4.4 billions in 2013 and is currently forecasted to reach $7 billions by 2017.

The NF-kB pathway is arguably one of the most promising targets for drug development in multiple myeloma and other cancers. Despite the Biotech and pharmaceutical industries' aggressive pursuit of NF-kB inhibitors dating back to the early 90s, no such inhibitor has been clinically approved to this day. Proteasome inhibitors with clinical indication in multiple myeloma, such as bortezomib and more recently carfilzomib, do not specifically target cancer cells, resulting in dose-limiting toxicities and low therapeutic indices. Thus, whilst they show a clear clinical benefit, these and other drugs currently used for the treatment of myeloma patients, fail to induce lasting remissions, inevitably leading to relapse and/or refractory disease. These limitations reveal a need for a radically new therapeutic approach, one that is more specific, safer and, hence, more effective.

To deliver this urgent, unmet medical need, we have developed a novel D-tripeptidic compound, DTP3, which selectively targets a non-redundant and cancer-specific axis of the NF-kB pathway (i.e. the Gadd45b/MKK7 axis), rather than NF-kB globally. We have shown that DTP3 kills multiple myeloma cells very effectively and, importantly, lacks toxicity to normal cells, even when used at very high concentrations. Due to this cancer-selective target specificity, DTP3 displays similar potency to bortezomib, the current gold standard treatment, in multiple myeloma cells, but a more than 100-fold higher therapeutic index in vitro and far superior tolerability and therapeutic index in vivo.

DTP3 also has excellent physicochemical properties, such as high stability in serum and high aqueous solubility, favourable pharmacokinetic profile with good distribution to the bone marrow, the target tissue, and excellent tolerability in vivo.

With the current application, we aim to progress DTP3 to regulatory preclinical evaluation followed by a Phase 1 clinical trial in patients with advanced multiple myeloma in order to achieve clinical Proof of Concept for a therapeutic strategy to selectively target the NF-kB pathway in cancer by the use of Gadd45b/MKK7 inhibitors. Desirably, we also aim to progress a first-in-class candidate therapeutic targeting the Gadd45b/MKK7 axis towards development of a new, effective therapy for multiple myeloma and potentially other cancers where NF-kB promotes survival via Gadd45b.

Along with this trial, we propose to develop and validate a companion diagnostic test, based on a simple and cost-effective qRT-PCR assay, to establish a more informed approach to therapeutic strategy and improve clinical protocols with the aim of reducing unnecessary exposure to medicines' risk and enhancing clinical benefit.

On successful completion of clinical evaluation and market authorisation, we envisage DTP3 being used initially to treat hospitalised, relapsed and/or refractory myeloma patients for whom there is no alternative option, in order to extend remissions and improve quality of life, an area where existing therapies fail. Subsequently, we believe DTP3 may form the basis of a frontline multiple myeloma therapy used either alone or in combination with other therapies. Ultimately, DTP3 may find potential indication also in other areas on unmet need within oncology, such in diffuse large B cell lymphoma, and inflammatory and autoimmune diseases.

Publications


10 25 50
 
Title Established the PK / PD relation of DTP3 in vivo 
Description We have established the linear correlation of dose versus activity for DTP3 within the dose range of 2.5 mg/kg and 10 mg/kg in vivo. We have also established the correlation of PK profile and PD outcome in terms of JNK activation and apoptosis in the tumour tissue within this dose range. 
Type Of Material Model of mechanisms or symptoms - mammalian in vivo 
Provided To Others? No  
Impact This work enables the further development of DTP3 and supports the use of a bolus i.v. regimen in clinical studies. 
 
Title Identified a viable s.c. route of administration of DTP3 
Description We have established that a s.c. route of administration is capable of providing the same plasma exposure and PD effect in vivo as an i.v. bolus injection, over a range of DTP3 doses from 1 mg/kg to 50 mg/kg. 
Type Of Material Model of mechanisms or symptoms - mammalian in vivo 
Provided To Others? No  
Impact These data support a possible s.c. route of adminstration of DTP3 in the clinic and open up additional indications of this therapeutic beyond multiple myeloma. 
 
Title Safety, pharmacology, pharmacokinetics, biodistribution, metabolism, elimination, toxicology and selectivity of DTP3 in vitro and in vivo (mouse, rat, dog) 
Description We have established the high selectivity and low to no metabolism of DTP3 in vitro and vivo. We have established the PK profiles and maximum tolerated doses of DTP3 in rat and dog, and the very high safety margins of exposure of the drug in these species. 
Type Of Material Model of mechanisms or symptoms - mammalian in vivo 
Provided To Others? No  
Impact These activities have enabled us to obtain Medicines & Healthcare Products Regulatory Agency (MHRA) and ethics approval to initiate the first in human clinical study of DTP3 in patients with advanced multiple myeloma. 
 
Title bioinformatics analysis of GADD45b expression in cancers other than multiple myeloma 
Description Using bioinformatics tools and publically available datasets of cancer patients, we have identified tumour subgroups in both haematological and solid malignancies displaying high expression levels of GADD45b. 
Type Of Material Model of mechanisms or symptoms - human 
Provided To Others? No  
Impact These studies may lead to the identification of additional indications for GADD45b/MKK7 targeting agents such as DTP3 within areas of unmet need within oncology, beyond multiple myeloma. 
 
Title engineered multiple myeloma cell lines 
Description several multiple myeloma cell lines expressing Gadd45b-specific or MKK7-specific sh-RNAs 
Type Of Material Cell line 
Provided To Others? No  
Impact these cell line have enabled us to establish the relevance of Gadd45b to multiple myeloma pathogenesis and the high target specificity of DTP3 for the Gadd45b/MKK7 complex. 
 
Title proof of concept in mice 
Description using mouse s.c. and orthotopic xenograft models, we have obtained proof of concept that DTP3 therapy will be safe and effective against multiple myeloma 
Type Of Material Model of mechanisms or symptoms - mammalian in vivo 
Provided To Others? No  
Impact These results supported the further development of DTP3 into clinical trials. In preparation for these trials, we have undertaken a parallel programme to develop new biomarkers enabling to predict patient responder populations and identify patient populations at higher risk of rapid disease progression in multiple myeloma. 
 
Description Development of prognostic biomarker in multiple myeloma 
Organisation Ealing Hospital NHS Trust
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Public 
PI Contribution We have worked in conjunction with the hematology clinics at KCL, West Middlesex Hospital, Ealing Hospital, Hillingdon Hospital and Imperial College to analyse bone marrow samples from myeloma patients and identify correlations between the expression of Gadd45b in MM cells and patient outcome, as well as correlation with the cell response to DTP3.
Collaborator Contribution The partners have recruited the patients and analysed the clinical data.
Impact Not yet in terms of publications, but the data were used as preliminary data to secure funding for Biomedical Grant MR/L005069/1.
Start Year 2015
 
Description Development of prognostic biomarker in multiple myeloma 
Organisation Imperial College Healthcare NHS Trust
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Hospitals 
PI Contribution We have worked in conjunction with the hematology clinics at KCL, West Middlesex Hospital, Ealing Hospital, Hillingdon Hospital and Imperial College to analyse bone marrow samples from myeloma patients and identify correlations between the expression of Gadd45b in MM cells and patient outcome, as well as correlation with the cell response to DTP3.
Collaborator Contribution The partners have recruited the patients and analysed the clinical data.
Impact Not yet in terms of publications, but the data were used as preliminary data to secure funding for Biomedical Grant MR/L005069/1.
Start Year 2015
 
Description Development of prognostic biomarker in multiple myeloma 
Organisation King's College London (KCL)
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Academic/University 
PI Contribution We have worked in conjunction with the hematology clinics at KCL, West Middlesex Hospital, Ealing Hospital, Hillingdon Hospital and Imperial College to analyse bone marrow samples from myeloma patients and identify correlations between the expression of Gadd45b in MM cells and patient outcome, as well as correlation with the cell response to DTP3.
Collaborator Contribution The partners have recruited the patients and analysed the clinical data.
Impact Not yet in terms of publications, but the data were used as preliminary data to secure funding for Biomedical Grant MR/L005069/1.
Start Year 2015
 
Description Development of prognostic biomarker in multiple myeloma 
Organisation The Hillingdon Hospitals NHS Foundation Trust
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Public 
PI Contribution We have worked in conjunction with the hematology clinics at KCL, West Middlesex Hospital, Ealing Hospital, Hillingdon Hospital and Imperial College to analyse bone marrow samples from myeloma patients and identify correlations between the expression of Gadd45b in MM cells and patient outcome, as well as correlation with the cell response to DTP3.
Collaborator Contribution The partners have recruited the patients and analysed the clinical data.
Impact Not yet in terms of publications, but the data were used as preliminary data to secure funding for Biomedical Grant MR/L005069/1.
Start Year 2015
 
Description Development of prognostic biomarker in multiple myeloma 
Organisation West Middlesex University Hospital NHS Trust
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Public 
PI Contribution We have worked in conjunction with the hematology clinics at KCL, West Middlesex Hospital, Ealing Hospital, Hillingdon Hospital and Imperial College to analyse bone marrow samples from myeloma patients and identify correlations between the expression of Gadd45b in MM cells and patient outcome, as well as correlation with the cell response to DTP3.
Collaborator Contribution The partners have recruited the patients and analysed the clinical data.
Impact Not yet in terms of publications, but the data were used as preliminary data to secure funding for Biomedical Grant MR/L005069/1.
Start Year 2015
 
Description development of prognostic biomarker in multiple myeloma 
Organisation Imperial College Healthcare NHS Trust
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Hospitals 
PI Contribution We have worked in conjunction with the hematology clinics at the University of Turin and Imperial College to analyse bone marrow samples from myeloma patients and identify correlations between the expression of Gadd45b in MM cells and patient outcome, as well as correlation with the cell response to DTP3
Collaborator Contribution the partners have recruited the patients and analysed the clinical data
Impact not yet in terms of publications, but the data were used as preliminary data to secure funding for Biomedical Grant MR/L005069/1
Start Year 2009
 
Description development of prognostic biomarker in multiple myeloma 
Organisation University of Turin (Università degli Studi di Torino UNITO)
Country Italy, Italian Republic 
Sector Academic/University 
PI Contribution We have worked in conjunction with the hematology clinics at the University of Turin and Imperial College to analyse bone marrow samples from myeloma patients and identify correlations between the expression of Gadd45b in MM cells and patient outcome, as well as correlation with the cell response to DTP3
Collaborator Contribution the partners have recruited the patients and analysed the clinical data
Impact not yet in terms of publications, but the data were used as preliminary data to secure funding for Biomedical Grant MR/L005069/1
Start Year 2009
 
Title DTP3 
Description Local approvals have been received to allow Imperial College, Barts, UCLH, Royal Marsden and King's College Hospitals to start to identify patients. Three patients have been recruited and treated with DTP3 at the Hammersmith site. Individual patients have received 0.5 mg/kg, 1.0 mg/kg and 2 mg/kg as part of the dose escalation phase of the study. 
Type Therapeutic Intervention - Drug
Current Stage Of Development Refinement. Clinical
Year Development Stage Completed 2016
Development Status Under active development/distribution
Clinical Trial? Yes
Impact Patient 001 (0.5 mg/kg) has had no SAE, with evidence of cancer-selective therapeutic target engagement, and was withdrawn from the study after completion of Cycle 1, due to disease progression. Patient 002 (1.0 mg/kg) has had no SAE, with evidence of cancer-selective therapeutic target engagement, and was declared by the TDSMC as having stable disease. The patient continued on DTP3 and completed 3 cycles of treatment. He was subsequently withdrawn from the study, due to disease progression. Patient 003 (3.0 mg/kg) has had no SAE and no evidence of therapeutic target engagement. The patient was withdrawn from the study after completion of Cycle 1, due to disease progression. A preliminary qRT-PCR analysis of CD138+ cells from this patient revealed low/no GADD45B expression. This finding will be confirmed at completion of the dose escalation phase, when all patients in this phase will be profiled by qRT-PCR. In parallel with this, we have reinforced the current biomarker strategy for patient stratification by demonstrating a statistically significant correlation in primary human multiple myeloma cells between GADD45B expression levels and response to DTP3, ex vivo. We aim to preliminarily validate this correlation at completion of the dose escalation phase of the study, and then again at completion of the expansion phase. Additionally, we have continued to monitor the stability of the DTP3 API and vialled drug product (DP). Both the API (frozen) and DP (stored at 2-8oC) continue to show acceptable stability in the ongoing ICH studies. The current shelf life has now been extended to 24 months for both the API and DP. 
 
Title Further validation of peptides trargetting the Gadd45b/MKK7 interaction 
Description Current funding is MRC Biomedical Catalyst grant MR/L005069/1. Current stage is Initial Development. The intervention is a peptide drug designed to block the Gadd45b/MKK7 interaction to treat multiple myeloma. 
Type Therapeutic Intervention - Drug
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2011
Development Status Under active development/distribution
Impact This product is currently in development. Whilst very promising, it has not currently been in patients. 
 
Title Manufacture of large scale GMP clinical material for DTP3 
Description We have successfully completed the manufacture and characterisation of 6.4Kg of GMP material of DTP3 to support both the GLP toxicology and safety pharmacology, pharmacokinetics and ADME studies in rat and dog and the clinical trial of DTP3 in patients with multiple myeloma. 
Type Therapeutic Intervention - Drug
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2014
Development Status Under active development/distribution
Impact We have established the manufacture and characterisation process and demonstrated the high stability of the drug product under refrigerated conditions. 
 
Company Name Kesios Therapeutics Ltd 
Description Spinout company formed by Imperial Innovations focussed on the development of therapeutics targeting the novel Gadd45beta/MKK7 interaction for multiple myeloma, haematological cancers and other indications. 
Year Established 2012 
Impact In October 2014, Imperial Innovations has completed an aggregate seed investment of £1.85million into Kesios Therapeutics Ltd. In October 2015, Kesios Therapeutics Ltd. secured an additional aggregate Series A investment of £19 million