A Phase 1 study of the safety, tolerability, and pharmacokinetics of ALG-000184 (pevifoscorvir sodium), a novel Class E capsid assembly modulator, in healthy participants.

Population Pharmacokinetic Modeling of Different Formulations of Inclacumab Using Phase 1 Data in Healthy Participants

Multiple capsid assembly modulators (CAMs) are in clinical development for the treatment of chronic hepatitis B. The emergence of CAM-resistant HBV has resulted in the failure of CAM antiviral therapy in recent clinical trials. Because wild-type (WT) and CAM-resistant core protein (Cp) can co-assemble to form chimeric capsids, it is important to understand how CAMs modulate the assembly and disassembly of chimeric capsids and how CAM-resistant HBV variants emerge under CAM antiviral therapy. In addressing these questions, we found that in human hepatoma cells co-transfected with a serial molar ratio of WT and mutant HBV replicons expressing CAM-resistant Cp, expression of as few as 10% WT Cp conferred inhibition of nucleocapsid assembly by CAMs. However, 50% Cp with T33N substitution conferred complete resistance to the assembly of chimeric empty capsids induced by AB-506 but remained sensitive to GLS4, as determined in an in vitro capsid assembly assay and in transfected hepatoma cells. Moreover, the existence of approximately 50% WT Cp in chimeric nucleocapsids is required for CAMs to induce the disassembly of mature nucleocapsids and inhibit the infection of hepatocytes by HBV virions with chimeric nucleocapsids. Our results thus suggest that although disruption of nucleocapsid assembly requires only small numbers of CAM binding pockets at Cp dimer-dimer interfaces to be engaged, induction of mature nucleocapsid disassembly requires much larger numbers of CAM binding pockets to be occupied. The strong WT Cp dominance in CAM suppression of nucleocapsid assembly may slow down the emergence of CAM-resistant HBV variants under CAM therapy.

Hepatitis B virus (HBV) capsid assembly is a critical step in the propagation of the virus and is mediated by the core protein. Due to its multiple functions in the viral life cycle, core became an attractive target for new antiviral therapies. Capsid assembly modulators (CAMs) accelerate the kinetics of capsid assembly and prevent encapsidation of the polymerase-pregenomic RNA (Pol-pgRNA) complex, thereby blocking viral replication. CAM JNJ-632 is a novel and potent inhibitor of HBV replication in vitro across genotypes A to D. It induces the formation of morphologically intact viral capsids, as demonstrated by size exclusion chromatography and electron microscopy studies. Antiviral profiling in primary human hepatocytes revealed that CAMs prevented formation of covalently closed circular DNA in a dose-dependent fashion when the compound was added together with the viral inoculum, whereas nucleos(t)ide analogues (NAs) did not. This protective effect translated into a dose-dependent reduction of intracellular HBV RNA levels as well as reduced HBe/cAg and HBsAg levels in the cell culture supernatant. The same observation was made with another CAM (BAY41-4109), suggesting that mechanistic rather than compound-specific effects play a role. Our data show that CAMs have a dual mechanism of action, inhibiting early and late steps of the viral life cycle. These effects clearly differentiate CAMs from NAs and may translate into higher functional cure rates in a clinical setting when given alone or in combination with the current standard of care.

Animal studies report equal or greater clinical efficacy with once daily versus multiple daily aminoglycoside dosing; however, results are inconsistent. Extrapolation of these animal data to human data is difficult, since marked variability exists in terms of pharmacokinetic disposition of aminoglycosides. Human data suggest that once daily aminoglycoside dosing regimens are as effective as multiple dosing regimens. However, studies need to be performed assessing the efficacy of once daily aminoglycoside dosing for infectious sites other than intra-abdominal and the urinary tract. In addition, the results of these studies should not be extrapolated to those with renal dysfunction, the immunocompromised, or in patients with aminoglycoside treatment durations of greater than 8 days, as the efficacy of once daily dosing in these patient populations has not been proven. Animal studies assessing nephrotoxicity suggest that multiple daily aminoglycoside dosing results in more frequent or more severe nephrotoxicity compared to once daily dosing. Nine human studies have been published comparing the nephrotoxicity of once daily versus multiple daily aminoglycoside dosing. The majority of investigators have studied nonimmunocompromised patients with urinary tract infections. Netilmicin has been the most frequently used aminoglycoside, although other agents such as gentamicin, amikacin, and sisomicin have been studied. The most common netilmicin dosage regimen has ranged from approximately 4 to 6 mg/kg administered once daily. Eight of the nine trials performed have documented no significant differences in serial serum creatinine concentrations between once daily and multiple daily aminoglycoside dosing regimens, by the end of the study period. In conclusion, preliminary data suggest that once daily aminoglycoside dosing in nonimmunocompromised patients is equally efficacious and nephrotoxic compared to multiple daily dosing regimens.

Objectives:Previous studies have examined renal safety of once daily intravenous tobramycin in individuals with cystic fibrosis. This has been mainly in combination with ceftazidime in an adolescent or adult population. In this report, we describe our institutional experience of once daily intravenous tobramycin in combination with a variety of second anti-pseudomonal antibiotics in children with cystic fibrosis.Methods:We present a retrospective review including children with cystic fibrosis, who were admitted for a pulmonary exacerbation from January 2009 to December 2011, and treated using intravenous tobramycin. A literature review of once daily intravenous aminoglycoside dosing in cystic fibrosis was performed to compare our results to existing literature.Results:A total of 35 subjects were divided into once daily dosing (n = 20) versus multiple daily dosing (n = 15) groups. Mean age was 11.3 years (± 5.7) for the once daily dosing group and 13.1 years (± 4.4) for the multiple daily dosing group (p = 0.34). All subjects had normal baseline serum creatinine at admission (once daily dosing 0.49 ± 0.14 mg/dL vs multiple daily dosing 0.62 ± 0.23 mg/dL, p = 0.07). All subjects received intravenous tobramycin, and most received piperacillin-tazobactam as their second anti-pseudomonal antibiotic (once daily dosing 45% and multiple daily dosing 40%). There was no significant change in serum creatinine in either group during antibiotic treatment (once daily dosing 0.08 ± 0.12 mg/dL vs. multiple daily dosing 0.06 ± 0.10 mg/dL, p = 0.43). All subjects had significant improvement in lung function following intravenous antibiotic therapy.Conclusion:We show that both once daily dosing and multiple daily dosing of intravenous tobramycin in combination with a variety of second anti-pseudomonal antibiotics were safe in terms of nephrotoxicity in children with cystic fibrosis. These findings are important given existing literature mainly examines once daily tobramycin in combination with ceftazidime, a cephalosporin, and the majority of our patients were on tobramycin with piperacillin-tazobactam, an extended spectrum penicillin plus beta-lactam. This contributes new information not previously examined in a pediatric cystic fibrosis population.

Introduction Despite multiple new drug advancements for patients with heart failure in recent years (specifically, sodium-glucose co-transporter-2 and sacubitril/valsartan), morbidity and mortality remain high. AZD5462 is a selective RXFP1 agonist which mimics the pregnancy hormone relaxin and its actions on systemic hemodynamics and kidney function. Purpose To assess the safety, tolerability, and pharmacokinetics (PK) of AZD5462 in a first-in-human study following single ascending dose (SAD) and multiple ascending dose (MAD) administration in healthy participants. Methods This was a phase 1 randomized, double-blind, placebo-controlled study. The SAD evaluated doses of 20, 80, 400, 750, and 1000 mg across 7 cohorts, with 2 cohorts comprising solely participants of Japanese descent. The MAD evaluated doses of 40, 120, 250, and 500 mg BID for 10 days across 5 cohorts, with 1 cohort of Japanese descent. There were approximately 8 participants in each cohort, randomized 6:2 to AZD5462 or placebo. AZD5462 was administered as an oral liquid solution. Results Overall, 98 participants were randomized and 92 completed the study (56 of 56 in SAD; 36 of 42 in MAD). The majority of participants randomized were male, and the median age was 39 years in the SAD and 36 years in the MAD. There were no major safety and tolerability concerns up to the highest dose administered (1000 mg SAD; 500 mg BID MAD). Pre-specified study stopping criteria were not met. There were no deaths or other serious adverse events. AEs were more common in the pooled AZD5462 group than placebo (approximately 40% for AZD5462 and 20% for placebo). The most common AEs were GI disorders (nausea, abdominal pain, vomiting), headache, medical device site dermatitis, and orthostatic heart rate response increase, but without clear relationship to dose. Three participants discontinued the MAD due to dizziness, supraventricular tachycardia, and positive COVID-19 test. There was no clear pattern in the effect on SBP with 120 mg and higher doses in the MAD. There was a trend for DBP decrease but no signs of hypotension. HR increased in all cohorts, which was dose-dependent in SAD but without clear relationship to dose in MAD. Treatment with AZD5462 led to a dose-dependent increase in plasma renin in all but the lowest SAD dose. AZD5462 was rapidly absorbed with a median Tmax between 0.53 hr and 1.75 hr. Plasma concentrations declined in a biphasic manner, with a geometric mean terminal half-life after a single dose between 3 h and 6 h. The exposure to AZD5462 increased more than proportionately with dose. Conclusions AZD5462 was generally well tolerated at all dose levels in this phase 1 study. These data pave the way for development of a chronic oral relaxin therapy for patients with heart failure.

An effective approach in the development of novel antivirals is to target the assembly of viral capsids using capsid assembly modulators (CAMs). CAMs targeting hepatitis B virus (HBV) have two major modes of function: they can either accelerate nucleocapsid assembly, retaining its structure, or misdirect it into non-capsid-like particles. Previous molecular dynamics (MD) simulations of early capsid-assembly intermediates showed differences in protein conformations for apo and bound states. Here, we have developed and tested several classification machine learning (ML) models to better distinguish between apo-tetramer intermediates and those bound to accelerating or misdirecting CAMs. Models based on tertiary structural properties of the Cp149 tetramers and their inter-dimer orientation, as well as models based on direct and inverse contact distances between protein residues, were tested. All models distinguished the apo states and the two CAM-bound states with high accuracy. Furthermore, tertiary structure models and residue-distance models highlighted different tetramer regions as important for classification. Both models can be used to better understand structural transitions that govern the assembly of nucleocapsids and to assist the development of more potent CAMs. Finally, we demonstrate the utility of classification ML methods in comparing MD trajectories and describe our ML approaches, which can be extended to other systems of interest.

An effective approach in the development of novel antivirals is to target the assembly of viral capsids by using capsid assembly modulators (CAMs). CAMs targeting hepatitis B virus (HBV) have two major modes of function: they can either accelerate nucleocapsid assembly, retaining its structure, or misdirect it into noncapsid-like particles. Previous molecular dynamics (MD) simulations of early capsid-assembly intermediates showed differences in protein conformations for the apo and bound states. Here, we have developed and tested several classification machine learning (ML) models to better distinguish between apo-tetramer intermediates and those bound to accelerating or misdirecting CAMs. Models based on tertiary structural properties of the Cp149 tetramers and their interdimer orientation, as well as models based on direct and inverse contact distances between protein residues, were tested. All models distinguished the apo states and the two CAM-bound states with high accuracy. Furthermore, tertiary structure models and residue-distance models highlighted different tetramer regions as being important for classification. Both models can be used to better understand structural transitions that govern the assembly of nucleocapsids and to assist in the development of more potent CAMs. Finally, we demonstrate the utility of classification ML methods in comparing MD trajectories and describe our ML approaches, which can be extended to other systems of interest.

Oral small molecule inhibitors of tumor necrosis factor alpha (TNFα) are emerging as attractive therapeutic agents for the treatment of various autoimmune diseases. Balinatunfib (SAR441566), a novel oral inhibitor of tumor necrosis factor receptor 1 (TNFR1) signaling, changes the configuration of the soluble TNFα (sTNFα) trimer and prevents its heterotrimerization with TNFR1 but not TNFR2, thereby blocking TNFR1 signaling. Herein, we report the results from a first‐in‐human (FIH) study that evaluated the safety, pharmacokinetics (PK), and pharmacodynamics (PD) following single ascending doses (SAD) and multiple ascending doses (MAD) of balinatunfib in healthy male participants. Single (5–600 mg) and multiple (100–600 mg total daily dose for up to 14 days) oral doses of balinatunfib were well‐tolerated in all participants. Consistent PK data were obtained across the studies, with a median tmax of 2.5–5 hours, a mean terminal half‐life of 22–30 hours, and a time to steady state of 5–6 days. A supra‐proportional exposure increase was observed in both SAD and MAD studies, which was less pronounced at doses ≥ 180 mg. Food had no relevant effects on the PK characteristics of balinatunfib. As the main PD read‐out, complete TNFα occupancy was shown at all tested time points after the treatment started. Balinatunfib, as the first clinically tested oral TNFR1 signal inhibitor, demonstrated a good safety profile along with favorable PK/PD characteristics that allowed both once and twice daily dosing, confirming a successful preclinical‐to‐clinical translation and guiding dose selection for further clinical efficacy studies.

ALG-000184 (pevifoscorvir sodium) monotherapy in participants with chronic HBV infection: a phase 1, multicentre, randomised, dose escalation trial.

Rational design, synthesis, and evaluations of HBV capsid assembly modulators featuring a core of 2-amino-5-(2-amino-2-oxoacetyl)-4-methylthiophene-3-carboxamide.

ABSTRACTThe hepatitis B virus (HBV) core protein serves multiple essential functions in the viral life cycle, and antiviral agents that target the core protein are being developed. Capsid assembly modulators (CAMs) are compounds that target core and misdirect capsid assembly, resulting in the suppression of HBV replication and virion production. Besides HBV DNA, circulating HBV RNA has been detected in patient serum and can be associated with the treatment response. Here we studied the effect of HBV CAMs on the production of extracellular HBV RNA using infected HepaRG cells and primary human hepatocytes. Representative compounds from the sulfonamide carboxamide and heteroaryldihydropyrimidine series of CAMs were evaluated and compared to nucleos(t)ide analogs as inhibitors of the viral polymerase. The results showed that CAMs blocked extracellular HBV RNA with efficiencies similar to those with which they blocked pregenomic RNA (pgRNA) encapsidation, HBV DNA replication, and Dane particle production. Nucleos(t)ide analogs inhibited viral replication and virion production but not encapsidation or production of extracellular HBV RNA. Profiling of HBV RNA from both culture supernatants and patient serum showed that extracellular viral RNA consisted of pgRNA and spliced pgRNA variants with an internal deletion(s) but still retained the sequences at both the 5′ and 3′ ends. Similar variants were detected in the supernatants of infected cells with and without nucleos(t)ide analog treatment. Overall, our data demonstrate that HBV CAMs represent direct antiviral agents with a profile differentiated from that of nucleos(t)ide analogs, including the inhibition of extracellular pgRNA and spliced pgRNA.

To date, hepatitis B virus (HBV) capsid assembly modulators (CAMs), which target the viral core protein and induce the formation of non-functional viral capsids, have been identified and characterized in microtiter plate-based biochemical or cell-based in vitro assays. In this work, we developed an automated microfluidic screening assay, which uses convection-dominated Taylor-Aris dispersion to generate high-resolution dose-response curves, enabling the measurements of compound EC50 values at very short incubation times. The measurement of early kinetics down to 7.7 seconds in the microfluidic format was utilized to discriminate between the two different classes of CAMs known so far. The CAM (-N), leading to the formation of morphologically normal capsids and the CAM (-A), leading to aberrant HBV capsid structures. CAM-A compounds like BAY 41-4109 and GLS4 showed rapid kinetics, with assembly rates above 80% of the core protein after only a 7 second exposure to the compound, whereas CAM-N compounds like ABI-H0731 and JNJ-56136379 showed significantly slower kinetics. Using our microfluidic system, we characterized two of our in-house screening compounds. Interestingly, one compound showed a CAM-N/A intermediate behavior, which was verified with two standard methods for CAM classification, size exclusion chromatography, and anti-HBc immunofluorescence microscopy. With this proof-of-concept study, we believe that this microfluidic system is a robust primary screening tool for HBV CAM drug discovery, especially for the hit finding and hit-to-lead optimization phases. In addition to EC50 values, this system gives valuable first information about the mode of action of novel CAM screening compounds.

Introduction and Objective: CK-0045 is a novel long-acting IL-22 receptor agonist with great potential for treatment of patients with metabolic diseases based on preclinical data. Here we present the results of a randomized, double-blind, placebo-controlled, Phase 1 study investigating safety, tolerability, and pharmacokinetics of CK-0045 in healthy participants with and without obesity. Methods: A total of 40 healthy participants were randomized 3:1 to a single subcutaneous dose of 1 - 30 µg/kg CK-0045 or placebo in 5 cohorts in the single ascending dose (SAD) part. In the multiple ascending dose (MAD) part, a total of 36 otherwise healthy participants with obesity (BMI 30 - 39.9) received once-weekly subcutaneous doses of CK-0045 (1.25, 2.5 or 5 µg/kg) or placebo (3:1 ratio) for 6 weeks. Results: CK-0045 was safe at all doses tested, and well-tolerated up to 10 µg/kg in the SAD and 2.5 µg/kg in the MAD. All adverse events were mild or moderate, with dry skin, dry lips, and pruritus being the most frequently reported adverse drug reactions. There were no clinically significant adverse trends in labs, electrocardiograms, or vital signs. CK-0045 treatment resulted in dose-proportional increases in exposure and in target engagement biomarkers. Body weight reductions at week 6 were not dose-dependent but did demonstrate an exposure-dependent relationship when analyzed by CK-0045 exposure tertile (+0.8%, -1.1%, and -1.6%). The weight loss in the highest exposure tertile at week 6 was significantly greater (p=0.04) than in the placebo group (-0.3%). Significant reductions in cholesterol levels were also observed as well as non-significant signals of efficacy on several other metabolic parameters. Conclusion: This Phase 1 study of the novel lipidated IL-22 agonist CK-0045 identified safe and tolerable doses with promising exploratory efficacy trends despite high baseline variability and short treatment duration. Disclosure M. van de Bunt: Employee; Cytoki Pharma. C. Friis: Employee; Cytoki Pharma. F. Cauwberghs: None. R. Jorgensen: Employee; Cytoki Pharma. A. Kjølbye: Employee; Cytoki Pharma.

Hepatitis B virus (HBV) remains a major health concern with 260 million people having been infected globally, and approximately 680,000 deaths have occurred annually from cirrhosis and liver cancer. The modulation of HBV capsid assembly has emerged as a promising therapeutic approach for curing chronic HBV infection. Small-molecule capsid assembly modulators (CAMs) can broadly be classified as heteroaryldihydropyrimidines and sulfamoylbenzamides (SBAs). SBAs are capsid activators that inhibit viral replication by achieving capsid assembly before polymerase encapsulation. Herein, we report a novel series of HBV CAMs based on NVR 3-778, a potent CAM belonging to the SBA class. The lead compound (KR-26556) exhibited improved pharmacological activity and was examined through molecular docking studies.