The primary aim of drug development is to identify new therapies that effectively inhibit or stimulate a specific target (most often a protein) that is causally involved in the development or progression of a specific disease. Clinical trials focus on establishing whether the candidate drug is a) safe to use in terms of general toxicity and other potential side effects, and b) has sufficient efficacy in terms of improving patient health as measured by pre-defined clinical endpoints. The precise mode of action (MOA) for how a drug achieves its clinical aims (in terms of the cell types and biomolecules involved and their associated mechanistic pathways) may not be completely understood in many cases. Knowledge regarding MOA can be important for evaluating safety and establishing a more comprehensive picture of drug pharmacodynamics, and this is becoming increasingly relevant in the move towards precision medicine. Protein biomarker analysis of samples from clinical trials is increasingly being used to facilitate a better understanding of MOA for the drug being evaluated.
MOA of Empagliflozin in heart failure patients - the EMPEROR study
In a landmark MOA study of over 1100 heart failure patients from the EMPEROR program, Professor Faiez Zannad and colleagues used Olink® Explore 1536 to measure ~1500 plasma proteins longitudinally over the course of a 52-week trial of the SGLT2 inhibitor, empagliflozin. Comparing empagliflozin and placebo-treated patients, 32 proteins were differentially expressed (>10% change at an FDR of <1%). The 9 proteins showing the largest treatment effect (>15% change at an FDR of <1%) were IGFBP1, TfR1, CA2, EPO, TGM2, TMSB10, uMtCK, IGFBP4 & AFABP4. The functions of these proteins were most commonly related to the promotion of autophagic flux in the heart, kidney or endothelium (6 proteins), along with others linked to important biological processes in the heart and kidney. These findings in the clinical setting are consistent with those from previous experimental studies on the effects of SGLT2 inhibitors.
Zannad F, Ferreira JP, Butler J, et al. Effect of Empagliflozin on Circulating Proteomics in Heart Failure: Mechanistic Insights from the EMPEROR Program. (2022) European Heart Journal, DOI: 10.1093/eurheartj/ehac495
Professor Faiez Zannad discusses the wider aims of the EMPEROR program at the European Society of Cardiology Congress 2022 in Barcelona.
“Proteomics is rapidly emerging as an innovative approach to gaining potential insights into the mechanisms of disease and drug action.”
Zannad et al., (2022) Eur. Heart J.
Insights into MOA of ASN002 in the treatment of atopic dermatitis.
Protein biomarker analysis is increasingly used in the clinical trials setting to generate invaluable additional data beyond primary clinical endpoints, providing unique insights into the deeper biology of the therapeutics under investigation, including a better understanding of drug MOA. One example of this approach came from a successful phase I clinical trial for the oral dual inhibitor of Janus kinase and spleen tyrosine kinase, ASN002, for atopic dermatitis (AD) patients.
When plasma samples taken longitudinally over the course of treatment from patients treated with ASN002 were compared to those from placebo subjects in the trial using Olink, signiﬁcant reduction was seen in serum levels of individual markers of general inﬂammation, T-cell/B-cell markers, T-cell activation, innate immunity and T helper cell regulation. Further pathway enrichment analysis indicated that cytokine–cytokine-receptor interaction, cytokine, Th1–Th2, inflammatory, chemokine-receptor binding, chemokine signaling, JAK-STAT signaling and IL-23 signaling were the primary pathways affected by ASN002. One particularly interesting finding was that the drug significantly reduced the level of the known atherosclerosis marker, E-selectin. This raises the possibility that ASN002 could help protect against CVD risk, which is a known comorbidity in patients with AD.
Reduction of serum proteins in AD patients treated with ASN002 (Bissonnette et al., 2019)
Bissonnette R, Maai C, Forman S, Bhatia N, Lee M, Fowler J, Tyring S, Pariser D, Sofen H, Dhawn S, Zook M, Zammit D, Usansky H, Denis L, Rao N, Song T, Pavel A and Guttman-Yassky E. (2019) The oral Janus kinase/spleen tyrosine kinase inhibitor ASN002 demonstrates efficacy and improves associated systemic inflammation in patients with moderate‐to‐severe atopic dermatitis: results from a randomized double‐blind placebo‐controlled study. British Journal of Dermatology, Doi: 10.1111/bjd.17932
🔗Bracco Gartner TCL, Crnko S, Leiteris L, et al. Pirfenidone Has Anti-fibrotic Effects in a Tissue-Engineered Model of Human Cardiac Fibrosis. (2022) Frontiers in Cardiovascular Medicine, DOI: 10.3389/fcvm.2022.854314
🔗Dörner T, Tanaka Y, Dow ER, et al. Mechanism of action of baricitinib and identification of biomarkers and key immune pathways in patients with active systemic lupus erythematosus (2022) Annals of the Rheumatic Diseases, DOI: 10.1136/annrheumdis-2022-222335
🔗Paramel GV, Lindkvist M, Idosa BA, et al. Novel purine analogues regulate IL-1β release via inhibition of JAK activity in human aortic smooth muscle cells. (2022) European Journal of Pharmacology, DOI: 10.1016/j.ejphar.2022.175128
🔗Simats A, Ramiro L, Valls R, et al. Ceruletide and Alpha-1 Antitrypsin as a Novel Combination Therapy for Ischemic Stroke. (2022) Neurotherapeutics, DOI: 10.1007/s13311-022-01203-0
Proteomics at the heart of multiomics strategies
Systems biology approaches addressing multiple molecular and cellular components are adding vital insights into the dynamic biology underlying human health and disease.