Comprehensive Nonclinical Safety Assessment of Nirmatrelvir Supporting Timely Development of the SARS-COV-2 Antiviral Therapeutic, Paxlovid™.

COVID-19 is a potentially fatal infection caused by the SARS-CoV-2 virus. The SARS-CoV-2 3CL protease (Mpro) is a viral enzyme essential for replication and is the target for nirmatrelvir. Paxlovid (nirmatrelvir co-administered with the pharmacokinetic enhancer ritonavir) showed efficacy in COVID-19 patients at high risk of progressing to hospitalization and/or death. Nonclinical safety studies with nirmatrelvir are essential in informing benefit-risk of Paxlovid and were conducted to support clinical development. In vivo safety pharmacology assessments included a nervous system/pulmonary study in rats and a cardiovascular study in telemetered monkeys. Potential toxicities were assessed in repeat dose studies of up to 1 month in rats and monkeys. Nirmatrelvir administration (1,000 mg/kg, p.o.) to male rats produced transient increases in locomotor activity and respiratory rate but did not affect behavioral endpoints in the functional observational battery. Cardiovascular effects in monkeys were limited to transient increases in blood pressure and decreases in heart rate, observed only at the highest dose tested (75 mg/kg per dose b.i.d; p.o.). Nirmatrelvir did not prolong QTc-interval or induce arrhythmias. There were no adverse findings in repeat dose toxicity studies up to 1 month in rats (up to 1,000 mg/kg daily, p.o.) or monkeys (up to 600 mg/kg daily, p.o.). Nonadverse, reversible clinical pathology findings without clinical or microscopic correlates included prolonged coagulation times at ≥60 mg/kg in rats and increases in transaminases at 600 mg/kg in monkeys. The safety pharmacology and nonclinical toxicity profiles of nirmatrelvir support clinical development and use of Paxlovid for treatment of COVID-19.

Efficacy of telemedicine on glycaemic control in patients with type 2 diabetes: A meta-analysis.

BACKGROUND: Telemedicine is defined as the delivery of health services via remote communication and technology. It is a convenient and cost-effective method of intervention, which has shown to be successful in improving glyceamic control for type 2 diabetes patients. The utility of a successful diabetes intervention is vital to reduce disease complications, hospital admissions and associated economic costs. AIM: To evaluate the effects of telemedicine interventions on hemoglobin A1c (HbA1c), systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), post-prandial glucose (PPG), fasting plasma glucose (FPG), weight, cholesterol, mental and physical quality of life (QoL) in patients with type 2 diabetes. The secondary aim of this study is to determine the effect of the following subgroups on HbA1c post-telemedicine intervention; telemedicine characteristics, patient characteristics and self-care outcomes. METHODS: PubMed Central, Cochrane Library, Embase and Scopus databases were searched from inception until 18th of June 2020. The quality of the 43 included studies were assessed using the PEDro scale, and the random effects model was used to estimate outcomes and I 2 for heterogeneity testing. The mean difference and standard deviation data were extracted for analysis. RESULTS: We found a significant reduction in HbA1c [-0.486%; 95% confidence interval (CI) -0.561 to -0.410, P < 0.001], DBP (-0.875 mmHg; 95%CI -1.429 to -0.321, P < 0.01), PPG (-1.458 mmol/L; 95%CI -2.648 to -0.268, P < 0.01), FPG (-0.577 mmol/L; 95%CI -0.710 to -0.443, P < 0.001), weight (-0.243 kg; 95%CI -0.442 to -0.045, P < 0.05), BMI (-0.304; 95%CI -0.563 to -0.045, P < 0.05), mental QoL (2.210; 95%CI 0.053 to 4.367, P < 0.05) and physical QoL (-1.312; 95%CI 0.545 to 2.080, P < 0.001) for patients following telemedicine interventions in comparison to control groups. The results of the meta-analysis did not show any significant reductions in SBP and cholesterol in the telemedicine interventions compared to the control groups. The telemedicine characteristic subgroup analysis revealed that clinical treatment models of intervention, as well as those involving telemonitoring, and those provided via modes of videoconference or interactive telephone had the greatest effect on HbA1c reduction. In addition, interventions delivered at a less than weekly frequency, as well as those given for a duration of 6 mo, and those lead by allied health resulted in better HbA1c outcomes. Furthermore, interventions with a focus on biomedical parameters, as well as those with an engagement level > 70% and those with a drop-out rate of 10%-19.9% showed greatest HbA1c reduction. The patient characteristics investigation reported that Hispanic patients with T2DM had a greater HbA1c reduction post telemedicine intervention. For self-care outcomes, telemedicine interventions that resulted in higher post-intervention glucose monitoring and self-efficacy were shown to have better HbA1c reduction. CONCLUSION: The findings indicate that telemedicine is effective for improving HbA1c and thus, glycemic control in patients with type 2 diabetes. In addition, telemedicine interventions were also found to significantly improved other health outcomes as well as QoL scores. The results of the subgroup analysis emphasized that interventions in the form of telemonitoring, via a clinical treatment model and with a focus on biomedical parameters, delivered at a less than weekly frequency and 6 mo duration would have the largest effect on HbA1c reduction. This is in addition to being led by allied health, through modes such as video conference and interactive telephone, with an intervention engagement level > 70% and a drop-out rate between 10%-19.9%. Due to the high heterogeneity of included studies and limitations, further studies with a larger sample size is needed to confirm our findings.

Activation of Skeletal Muscle AMPK Promotes Glucose Disposal and Glucose Lowering in Non-human Primates and Mice.

The AMP-activated protein kinase (AMPK) is a potential therapeutic target for metabolic diseases based on its reported actions in the liver and skeletal muscle. We evaluated two distinct direct activators of AMPK: a non-selective activator of all AMPK complexes, PF-739, and an activator selective for AMPK ß1-containing complexes, PF-249. In cells and animals, both compounds were effective at activating AMPK in hepatocytes, but only PF-739 was capable of activating AMPK in skeletal muscle. In diabetic mice, PF-739, but not PF-249, caused a rapid lowering of plasma glucose levels that was diminished in the absence of skeletal muscle, but not liver, AMPK heterotrimers and was the result of an increase in systemic glucose disposal with no impact on hepatic glucose production. Studies of PF-739 in cynomolgus monkeys confirmed translation of the glucose lowering and established activation of AMPK in skeletal muscle as a potential therapeutic approach to treat diabetic patients.

Statistical power analysis of cardiovascular safety pharmacology studies in conscious rats.

UNLABELLED: Cardiovascular (CV) toxicity and related attrition are a major challenge for novel therapeutic entities and identifying CV liability early is critical for effective derisking. CV safety pharmacology studies in rats are a valuable tool for early investigation of CV risk. Thorough understanding of data analysis techniques and statistical power of these studies is currently lacking and is imperative for enabling sound decision-making. METHODS: Data from 24 crossover and 12 parallel design CV telemetry rat studies were used for statistical power calculations. Average values of telemetry parameters (heart rate, blood pressure, body temperature, and activity) were logged every 60s (from 1h predose to 24h post-dose) and reduced to 15min mean values. These data were subsequently binned into super intervals for statistical analysis. A repeated measure analysis of variance was used for statistical analysis of crossover studies and a repeated measure analysis of covariance was used for parallel studies. Statistical power analysis was performed to generate power curves and establish relationships between detectable CV (blood pressure and heart rate) changes and statistical power. Additionally, data from a crossover CV study with phentolamine at 4, 20 and 100mg/kg are reported as a representative example of data analysis methods. RESULTS: Phentolamine produced a CV profile characteristic of alpha adrenergic receptor antagonism, evidenced by a dose-dependent decrease in blood pressure and reflex tachycardia. Detectable blood pressure changes at 80% statistical power for crossover studies (n=8) were 4-5mmHg. For parallel studies (n=8), detectable changes at 80% power were 6-7mmHg. Detectable heart rate changes for both study designs were 20-22bpm. DISCUSSION: Based on our results, the conscious rat CV model is a sensitive tool to detect and mitigate CV risk in early safety studies. Furthermore, these results will enable informed selection of appropriate models and study design for early stage CV studies.

Design, synthesis, and evaluation of imidazo[4,5-c]pyridin-4-one derivatives with dual activity at angiotensin II type 1 receptor and peroxisome proliferator-activated receptor-γ.

Identification of a series of imidazo[4,5-c]pyridin-4-one derivatives that act as dual angiotensin II type 1 (AT1) receptor antagonists and peroxisome proliferator-activated receptor-γ (PPARγ) partial agonists is described. Starting from a known AT1 antagonist template, conformational restriction was introduced by incorporation of an indane ring that when combined with appropriate substitution at the imidazo[4,5-c]pyridin-4-one provided novel series 5 possessing the desired dual activity. The mode of interaction of this series with PPARγ was corroborated through the X-ray crystal structure of 12b bound to the human PPARγ ligand binding domain. Modulation of activity at both receptors through substitution at the pyridone nitrogen led to the identification of potent dual AT1 antagonists/PPARγ partial agonists. Among them, 21b was identified possessing potent dual pharmacology (AT1 IC(50) = 7 nM; PPARγ EC(50) = 295 nM, 27% max) and good ADME properties.

Identification of Tetrahydropyrido[4,3-d]pyrimidine Amides as a New Class of Orally Bioavailable TGR5 Agonists.

Takeda G-protein-coupled receptor 5 (TGR5) represents an exciting biological target for the potential treatment of diabetes and metabolic syndrome. A new class of high-throughput screening (HTS)-derived tetrahydropyrido[4,3-d]pyrimidine amide TGR5 agonists is disclosed. We describe our effort to identify an orally available agonist suitable for assessment of systemic TGR5 agonism. This effort resulted in identification of 16, which had acceptable potency and pharmacokinetic properties to allow for in vivo assessment in dog. A key aspect of this work was the calibration of human and dog in vitro assay systems that could be linked with data from a human ex vivo peripheral blood monocyte assay that expresses receptor at endogenous levels. Potency from the human in vitro assay was also found to correlate with data from an ex vivo human whole blood assay. This calibration exercise provided confidence that 16 could be used to drive plasma exposures sufficient to test the effects of systemic activation of TGR5.

Review of companies and drug classes in the 2007-2011 antihypertensive patent literature.

Hypertension, defined as elevated systolic blood pressure and/or diastolic blood pressure generally greater than 140/90 mmHg, is a significant risk factor for cardiovascular outcomes such as arterial aneurysm, myocardial infarction and stroke, and for nonvascular conditions such as Alzheimer's disease. The prevalence of the disease is rapidly increasing both in the USA and in the rest of the world. Hypertension can be managed to a degree through behavioral changes (e.g., reduction in salt intake and loss of excess body weight). When lifestyle changes fail, pharmacological therapy provides benefits, with combination drug therapy often required for many patients to reach their blood pressure-reduction goals. Approximately one-third of hypertensive patients who seek treatment fail to reach their goals, either because they are resistant to drug therapy or stop treatment due to side-effect issues. A medical need exists for new antihypertensive agents with improved risk-benefit profiles. However, within the past decade, the economics of bringing a new antihypertensive agent to market have become challenging due to the plethora of generic drugs available, the advent of polypharmacology, and the difficulty of identifying agents that are better than the standard of care. Only a few new mechanistic classes of antihypertensive agents have been recently approved, suggesting a lack of innovation within the industry. In this review, we describe the results of a survey of drug companies and drug classes in the 2007-2009 antihypertensive patent literature and comment on the current state of innovation in antihypertensive drug discovery.

Discovery of a series of imidazo[4,5-b]pyridines with dual activity at angiotensin II type 1 receptor and peroxisome proliferator-activated receptor-γ.

Mining of an in-house collection of angiotensin II type 1 receptor antagonists to identify compounds with activity at the peroxisome proliferator-activated receptor-γ (PPARγ) revealed a new series of imidazo[4,5-b]pyridines 2 possessing activity at these two receptors. Early availability of the crystal structure of the lead compound 2a bound to the ligand binding domain of human PPARγ confirmed the mode of interaction of this scaffold to the nuclear receptor and assisted in the optimization of PPARγ activity. Among the new compounds, (S)-3-(5-(2-(1H-tetrazol-5-yl)phenyl)-2,3-dihydro-1H-inden-1-yl)-2-ethyl-5-isobutyl-7-methyl-3H-imidazo[4,5-b]pyridine (2l) was identified as a potent angiotensin II type I receptor blocker (IC(50) = 1.6 nM) with partial PPARγ agonism (EC(50) = 212 nM, 31% max) and oral bioavailability in rat. The dual pharmacology of 2l was demonstrated in animal models of hypertension (SHR) and insulin resistance (ZDF rat). In the SHR, 2l was highly efficacious in lowering blood pressure, while robust lowering of glucose and triglycerides was observed in the male ZDF rat.

SRT1720, SRT2183, SRT1460, and resveratrol are not direct activators of SIRT1.

Sirtuins catalyze NAD(+)-dependent protein deacetylation and are critical regulators of transcription, apoptosis, metabolism, and aging. There are seven human sirtuins (SIRT1-7), and SIRT1 has been implicated as a key mediator of the pathways downstream of calorie restriction that have been shown to delay the onset and reduce the incidence of age-related diseases such as type 2 diabetes. Increasing SIRT1 activity, either by transgenic overexpression of the Sirt1 gene in mice or by pharmacological activation by small molecule activators resveratrol and SRT1720, has shown beneficial effects in rodent models of type 2 diabetes, indicating that SIRT1 may represent an attractive therapeutic target. Herein, we have assessed purported SIRT1 activators by employing biochemical assays utilizing native substrates, including a p53-derived peptide substrate lacking a fluorophore as well as the purified native full-length protein substrates p53 and acetyl-CoA synthetase1. SRT1720, its structurally related compounds SRT2183 and SRT1460, and resveratrol do not lead to apparent activation of SIRT1 with native peptide or full-length protein substrates, whereas they do activate SIRT1 with peptide substrate containing a covalently attached fluorophore. Employing NMR, surface plasmon resonance, and isothermal calorimetry techniques, we provide evidence that these compounds directly interact with fluorophore-containing peptide substrates. Furthermore, we demonstrate that SRT1720 neither lowers plasma glucose nor improves mitochondrial capacity in mice fed a high fat diet. SRT1720, SRT2183, SRT1460, and resveratrol exhibit multiple off-target activities against receptors, enzymes, transporters, and ion channels. Taken together, we conclude that SRT1720, SRT2183, SRT1460, and resveratrol are not direct activators of SIRT1.