Eteplirsen

Eteplirsen
Systematic (IUPAC) name
(P-deoxy-P-(dimethylamino)](2',3'-dideoxy-2',3'-imino-2',3'-seco)(2'a→5')(C-m5U-C-C-A-A-C-A-m5U-C-A-A-G-G-A-A-G-A-m5U-G-G-C-A-m5U-m5U-m5U-C-m5U-A-G),5'-(P-(4-((2-(2-(2-hydroxyethoxy)ethoxy)ethoxy)carbonyl)-1-piperazinyl)-N,N-dimethylphosphonamidate) RNA
Clinical data
Routes of
administration		 Intravenous infusion
Legal status
Legal status
  • Investigational
Identifiers
CAS Number 1173755-55-9
ATC code None
ChemSpider 34983391
UNII AIW6036FAS YesY
Chemical data
Formula C364H569N177O122P30
Molar mass 10305.738

Eteplirsen, also called AVI-4658, is an experimental drug, currently in clinical trials. It is designed for treatment of some mutations that cause Duchenne muscular dystrophy (DMD), a genetic degenerative muscle disease. Eteplirsen is a product of Sarepta Therapeutics Inc. Eteplirsen only targets mutations in a region implicated in 13% of DMD cases.[1]

Mechanism of action

Duchenne muscular dystrophy is caused when a mutation in the DMD gene changes the DMD RNA so that it no longer codes for functional dystrophin protein, usually due to a mutation that alters the reading frame of the RNA downstream of the mutation. If an exon with an appropriate number of bases lies near the mutation, by removing that exon the downstream reading frame can be corrected and production of partially functional dystrophin can be restored. This is the general strategy used for designing exon-skipping oligos for DMD; as there are 79 exons in the longest splice form of the dystrophin transcript, many different oligos are needed to address the range of mutations present in the population of people with DMD.

Eteplirsen is a morpholino antisense oligomer which triggers excision of exon 51 during pre-mRNA splicing of the dystrophin RNA transcript. Skipping exon 51 changes the downstream reading frame of dystrophin;[2] giving eteplirsen to a healthy person would result in production of dystrophin mRNA which would not code for functional dystrophin protein but, for DMD patients with particular frameshifting mutations, giving eteplirsen can restore the reading frame of the dystrophin mRNA and result in production of functional (although modified by having an internal deletion consisting of both the patient's original defect, as well as the therapeutically skipped exon) dystrophin.[3] Eteplirsen is given by intravenous infusion for systemic treatment of DMD.

Clinical studies

Several clinical trials have been conducted to test eteplirsen, one in the UK involving local injection to the foot,[4][5] one in the UK involving systemic injection at low doses[6][7] and one in the USA at higher systemic doses[8] that progressed to a rollover extension study.[9][10] In the phase II study of 12 boys, dystrophin production was increased in 72% of the participants. It is questioned whether increasing the dose - which is feasible due to the lower toxicity of eteplirsen compared to drisapersen - would benefit the non responders and whether this could result in any increased side effects. A phase III study has begun in the USA.[11]

In 2011, in a UK study Eteplirsen(AVI-4658) was given to 19 children with Duchenne muscular dystrophy; researchers found that higher doses of the drug led to an increase in dystrophin. Researchers believe that drugs which are designed to make the body “skip over” mutations in this way could be used to treat approximately 83% of Duchenne muscular dystrophy cases. Eteplirsen only targets mutations in a region implicated in 13% of cases. This study demonstrated the potential of this approach for increasing the levels of dystrophin in the short term. The trial’s principal aim was to work out the appropriate dosages of the drug, therefore the drug’s safety profile and effects will need to be confirmed in larger, longer-term studies, particularly as patients would need to take it for the rest of their lives (or until a better treatment is available).[1]

A similar drug is also in clinical trials, drisapersen, which is a 2'-O-methyl phosphorothioate antisense oligo that, like eteplirsen, triggers skipping of dystrophin exon 51. In January 2016, the FDA rejected drisapersen (Kyndrisa) largely on the basis of toxicity, effectively shifting focus to eteplirsen.[12]

Current status

Both eteplirsen and the similar drug drisapersen have filed a New Drug Application (NDA) for review with the US Food and Drug Administration (FDA).[13] The Prescription Drug User Fee Act (PDUFA) goal dates for these are December 27, 2015 for drisapersen and February 26, 2016 for eteplirsen. Following FDA rejection of drisapersen, the agency announced a three-month time extension for its review of eteplirsen. The agency is now scheduled to make a decision on approval of eteplirsen by May 26, 2016. On April 25, 2016, FDA advisers voted against approval.[14]

References

  1. 1 2 Cirak, Sebahattin; Arechavala-Gomeza, Virginia; Guglieri, Michela; Feng, Lucy; Torelli, Silvia; Anthony, Karen; Abbs, Stephen; Garralda, Maria Elena; Bourke, John; Wells, Dominic J; Dickson, George; Wood, Matthew JA; Wilton, Steve D; Straub, Volker; Kole, Ryszard; Shrewsbury, Stephen B; Sewry, Caroline; Morgan, Jennifer E; Bushby, Kate; Muntoni, Francesco (2011). "Exon skipping and dystrophin restoration in patients with Duchenne muscular dystrophy after systemic phosphorodiamidate morpholino oligomer treatment: an open-label, phase 2, dose-escalation study". The Lancet 378 (9791): 595–605. doi:10.1016/S0140-6736(11)60756-3. PMC 3156980. PMID 21784508. Lay summary – NHS Choices (July 25, 2011).
  2. ↑ Anthony, Karen; Feng, Lucy; Arechavala-Gomeza, Virginia; Guglieri, Michela; Straub, Volker; Bushby, Katherine; Cirak, Sebahattin; Morgan, Jennifer; Muntoni, Francesco (17 Oct 2012). "Exon Skipping Quantification by qRT-PCR in Duchenne Muscular Dystrophy Patients Treated with the Antisense Oligomer Eteplirsen". Hum Gene Ther Methods. 23 (5): 336–45. doi:10.1089/hgtb.2012.117. PMID 23075107.
  3. ↑ Moulton, HM; Moulton, JD (17 Feb 2010). "Morpholinos and Their Peptide Conjugates: Therapeutic Promise and Challenge for Duchenne Muscular Dystrophy". Biochim Biophys Acta 1798 (12): 2296–303. doi:10.1016/j.bbamem.2010.02.012. PMID 20170628.
  4. ↑ Gary Roper/Manager Clinical Research Governance Organisation, Imperial College London. "Safety and Efficacy Study of Antisense Oligonucleotides in Duchenne Muscular Dystrophy". ClinicalTrials.gov. US Government, NIH. Retrieved 30 October 2012.
  5. ↑ Kinali, M; Arechavala-Gomeza, V; Feng, L; Cirak, S; Hunt, D; Adkin, C; Guglieri, M; Ashton, E; Abbs, S; Nihoyannopoulos, P; Garralda, ME; Rutherford, M; McCulley, C; Popplewell, L; Graham, IR; Dickson, G; Wood, MJ; Wells, DJ; Wilton, SD; Kole, R; Straub, V; Bushby, K; Sewry, C; Morgan, JE; Muntoni, F (25 Aug 2009). "Local restoration of dystrophin expression with the morpholino oligomer AVI-4658 in Duchenne muscular dystrophy: A single-blind, placebo-controlled, dose-escalation, proof-of-concept study". Lancet Neurol. 8 (10): 918–28. doi:10.1016/S1474-4422(09)70211-X. PMC 2755039. PMID 19713152.
  6. ↑ Professor Francesco Muntoni, University College of London Institute of Child Health. "Dose-Ranging Study of AVI-4658 to Induce Dystrophin Expression in Selected Duchenne Muscular Dystrophy (DMD) Patients". ClinicalTrials.gov. US Government, NIH. Retrieved 30 October 2012.
  7. ↑ Cirak, S; Arechavala-Gomeza, V; Guglieri, M; Feng, L; Torelli, S; Anthony, K; Abbs, S; Garralda, ME; Bourke, J; Wells, DJ; Dickson, G; Wood, MJ; Wilton, SD; Straub, V; Kole, R; Shrewsbury, SB; Sewry, C; Morgan, JE; Bushby, K; Muntoni, F (23 Jul 2011). "Exon skipping and dystrophin restoration in patients with Duchenne muscular dystrophy after systemic phosphorodiamidate morpholino oligomer treatment: an open-label, phase 2, dose-escalation study". Lancet. 378 (9791): 595–605. doi:10.1016/S0140-6736(11)60756-3. PMC 3156980. PMID 21784508.
  8. ↑ Sarepta Therapeutics. "Efficacy Study of AVI-4658 to Induce Dystrophin Expression in Selected Duchenne Muscular Dystrophy Patients". ClinicalTrials.gov. US Government, NIH. Retrieved 30 October 2012.
  9. ↑ Sarepta Therapeutics. "Efficacy, Safety, and Tolerability Rollover Study of Eteplirsen in Subjects With Duchenne Muscular Dystrophy". ClinicalTrials.gov. US Government, NIH. Retrieved 30 October 2012.
  10. ↑ Mendell, Jerry; Rodino-Klapac, Louise R; Sahenk, Zarife; Roush, Kandice; Bird, Loren; Lowes, Linda P; Alfano, Lindsay; Gomez, Ann Maria; Lewis, Sarah; Kota, Janaiah; Malik, Vinod; Shontz, Kim; Walker, Christopher M; Flanigan, Kevin M; Kean, John R; Allen, Hugh D; Shilling, Chris; Melia, Kathleen R; Sazani, Peter; Saoud, Jay B; Kaye, Edward M; Kaye, Edward M. (2013). "Eteplirsen for the treatment of duchenne muscular dystrophy". Ann. Neurol. 74 (5): n/a. doi:10.1002/ana.23982.
  11. ↑ Sarepta Therapeutics. "Confirmatory Study of Eteplirsen in DMD Patients (PROMOVI)". ClinicalTrials.gov. US Government, NIH. Retrieved 3 October 2014.
  12. ↑ FDA rejects BioMarin's muscle wasting drug; Sarepta drug in focus. Jan 2016
  13. ↑ "FDA Accepts Sarepta's NDA for Eteplirsen". Rare Disease Report.
  14. ↑ http://www.nytimes.com/2016/04/26/business/muscular-dystrophy-drug-fda-sarepta-eteplirsen.html
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