The Combined Treatment With the FLT3-Inhibitor AC220 and the Complex I Inhibitor IACS-010759 Synergistically Depletes Wt- and FLT3-Mutated Acute Myeloid Leukemia Cells.

Xiyuan Lu,Marina Konopleva,Joseph R Marszalek,Stefano Tiziani,Meghan Collins,Alessia Lodi,Lina Han,Jonathan Busquets

doi:10.3389/fonc.2021.686765

Abstract

Acute myeloid leukemia (AML) is an aggressive hematologic malignancy with a high mortality rate and relapse risk. Although progress on the genetic and molecular understanding of this disease has been made, the standard of care has changed minimally for the past 40 years and the five-year survival rate remains poor, warranting new treatment strategies. Here, we applied a two-step screening platform consisting of a primary cell viability screening and a secondary metabolomics-based phenotypic screening to find synergistic drug combinations to treat AML. A novel synergy between the oxidative phosphorylation inhibitor IACS-010759 and the FMS-like tyrosine kinase 3 (FLT3) inhibitor AC220 (quizartinib) was discovered in AML and then validated by ATP bioluminescence and apoptosis assays. In-depth stable isotope tracer metabolic flux analysis revealed that IACS-010759 and AC220 synergistically reduced glucose and glutamine enrichment in glycolysis and the TCA cycle, leading to impaired energy production and de novo nucleotide biosynthesis. In summary, we identified a novel drug combination, AC220 and IACS-010759, which synergistically inhibits cell growth in AML cells due to a major disruption of cell metabolism, regardless of FLT3 mutation status.

Highlights

Acute myeloid leukemia (AML) is characterized by the uncontrolled proliferation of immature myeloid cells within the bone marrow and blood, preventing the growth and differentiation of normal hematopoietic cells [1]
FMS-like tyrosine kinase 3 (FLT3) inhibitors showed promising results with IACS-010759, all 21 drug candidates proceeded to the secondary screening in OCI-AML3 cells using a high-content stable isotope tracer direct infusion mass spectrometry (SITDIMS) analysis, for a comprehensive analysis and further selection of candidate combinations
AML prognoses vary widely depending on the presence or absence of recurrent gene mutations, such as those affecting FLT3, which occur in 30% of AML patients and are associated with poor clinical outcomes [41]

Summary

Introduction

Acute myeloid leukemia (AML) is characterized by the uncontrolled proliferation of immature myeloid cells within the bone marrow and blood, preventing the growth and differentiation of normal hematopoietic cells [1]. Several methods have been developed to quantify synergism in an ex vivo drug screening setting, such as the Bliss independence [8], Loewe [9], and highest single agent [10] models. Hypoxia, as a hallmark of the hematopoietic niche, has been shown to promote AML maintenance and progression through energetic and oxidative metabolism [17] and the negative regulation from the oncometabolite 2-hydroxyglutarate [18]. These factors are important metabolic manifestation of AML, and clinically relevant for identifying therapeutic interventions and targeted drug development [19, 20]. Using a nanoelectrospray ionization direct-infusion mass spectrometry (DIMS) technique [23], we capture and fingerprint drug-induced disturbances of metabolic states in AML screening models in vitro

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