- TR06693098 → possibility of PLsis-related findings in male after 3-days at ≥100 mg/kg, where Cmaxis 66,914 ng/mL and AUC0-24 is 1,238,167 ng*h/mL.
- TR06980443 → No indications of PLsis-related findings in male after 3-days up to 600 mg/kg, where Cmaxis 119,000 ng/mL and AUC0-24 is 3,130,000 ng*h/mL.
- In only one rat at 600 mg/kg, decrease in spontaneous movement and/or ataxia was found and the reason is unclear. Longer duration study (14-d tox) is needed to investigate this profile. Spontaneous movement and/or ataxia would be non-specific toxicity. This finding is visible due to TR098 dosing, and a certain number of similar symptoms will be seen if the number of animals is increased. Lower dose than 600 mg/kg should be selected for 14-d tox study.
- Decrease of body temperature was observed in an animal (#4001) showing decrease in spontaneous movement at 1h after dosing, but the body temperature was recovered at 8h.
- Muscle toxicity observed in the TR443 and TR993 toxicity studies (data is not available yet) was not observed in the TR098 toxicity study.
- Phospholipidosis (PLsis)-related findings (vacuolation and foamy macrophage infiltrate) were detected in many organs of all animals of 600 mg/kg group. In the 100 mg/kg group, a few animals showed PLsis-related findings. Longer dosing periods would likely result in more animals showing symptoms of PLsis-related findings.
- It was surprised that PLsis-related findings were detected in vivo rat minitox study of TR098, because TR098 the risk of PLsis of TR098 in vitro was low (23%). TR443 did not show the PLsis-related findings in vivo 3-d rats and the results of histopathology of in vivo rat 5-d tox for TR993 are ongoing.
- to continue the investigation of TR098 as a CN candidate, and the safety profile of TR098 will be checked in 14-d tox study after CN.
| 주로 cationic amphiphilic drug (CAD) (lipophilic) 한 drug 들이 | Nonspecific binding to membrane phospholipids and uptake by acidic compartments (lysosomes) | DIPL involves the trapping of drugs within the LE/Lys compartments | accumulation of drug-phospholipid complexes within lysosomal membranes. | intracellular accumulation of myeloid bodies upon prolonged drug exposure | ↓ lysosomal function | NPC 닮아짐 | The risk of DIPL on human health is unknown. (although currently more than 250 drug candidates and marketed drugs have been reported to cause DIPL) | |
|---|---|---|---|---|---|---|---|---|
| finding | In vitro phospholipidosis fold-induction at 300uM: 098: 5.8 , 660: 15 |
Lysosomal trapping assay: Fa2N-4 (immortalized hepatocytes) liver is a lysosome rich organ. Lysosomal trapping in Fa2N-4 accumulation ratio: 098: 5.8 , 660: 15 |
Suggestive findings* in ≥100 mg/kg in rat 3-day tox: Non-adverse vacuolation and foamy macrophage infiltrates likely associated with drug-induced phospholipidosis, But no sign observed in brain! | There is currently inability to monitor DIPL routinely in clinic. The FDA formed Phospholipidosis Working Committee (PLWG), From regulatory perspective, DIPL has been considered an adverse finding whether justified or not. | ||||
| plan |
assessment in 14-day DRFs Assess in 9-week Atuka mouse study (IHC only) Pending HED |
Arthur: di-22:6-BMP as a biomarker of phospholipidosis {Liu, 2014 #2151}
TR06693098-related findings indicating generalized phospholipidosis
- Slight increases in ASL/ALT/ALP/GLDH were noted, but there were neither necrotic findings nor organ dysfunction in any organs
- No findings in the nervous system
- Can call non-adverse at this point but need to carefully check whether or not lesions would progress when dosing period is extended
“Generally, phospholipidosis occurs without any concurrent target organ toxicity or dysfunction and the general consensus is that phospholipidosis is an adaptive response, however, some regulators consider phospholipidosis as an adverse event since certain xenobiotics cause concurrent target organ toxicity and dysfunction.” https://journals.sagepub.com/doi/full/10.1177/0192623316672352
| Animals | Sprague-Dawley Rats (Males, 10 weeks of age) | ||||
|---|---|---|---|---|---|
| Test article | Control* | TR06693098 | |||
| Dose (mg/kg/day) | 0 | 30 | 100 | 600 | |
| Dose volume (mL/kg/day) | 5 | 5 | 5 | 5 | |
| No. of animals | 3 | 3 | 3 | 3 | |
| Mortality | 0 | 0 | 0 | 0 | |
| Clinical signs | - | - | - | Decrease in spontaneous movement and/or ataxia# (#4001: 1 and 4h postdose on Day 3, and Day 4) | |
| Body weights | - | - | - | - | |
| Food consumption | - | - | - | - | |
| Body temperature | - | - | - | ↓ (1h) | |
| Hematology | - | - | - | - | |
| Coagulation | - | - | - | - | |
| Blood chemistry | - | ↓ Triglyceride ↑ AST, ALT, ALP, GLDH, Glucose, ↓ Calcium | |||
| Macroscopic examination | - | - | - | - | |
| Microscopic examination | - | - |
Vacuolation: Adrenal cortex, Foamy macrophage infiltration: Axillary/Inguinal/Submandibular lymph node, Lung Stomach: Eosinophil infiltration, Thyroid: Follicular hypertrophy |
Vacuolation: Renal proximal tubule, Hepatocyte/bile duct/Kupffer cell in the liver, Pancreatic acinar cell, Splenic lymphocyte, Foamy macrophage infiltration: Mesenteric lymph node, Spleen, Testis, Thymus Stomach: Single cell necrosis of glandular epithelium, Mucosal hyperplasia, Edema in limiting ridge | |
Toxicokinetics parameters for TR0663098 (mean, n=3)
| Parameter | 30 | 100 | 600 | ||
|---|---|---|---|---|---|
| tmax (hr) | Day 1 | 1.67 | 2.00 | ||
| Day 3 | 1.33 | 3.67 | |||
| Cmax (ng/mL) | Day 1 | 20,088 | 55,577 | ||
| Day 3 | 23,204 | 66,914 | |||
| AUCτ (h*ng/mL) | Day 1 | 261,866 | 874,406 | ||
| Day 3 | 356,669 | 1,238,167 | |||
Day 3 (high-dose extension column): tmax 18.67 / 3.00 hr, Cmax 80,269 / 111,397 ng/mL, AUCτ 1,671,556 / 2,327,628 h*ng/mL.
Tissue concentrations of TR06693098 (mean, n=3)
| Tissue | 30 mg/kg | 100 mg/kg | 600 mg/kg |
|---|---|---|---|
| CSF (ng/mL) | 123 | 905 | |
| Liver (ng/g) | 26,654 | 313,365 | |
| Brain (ng/g) | 2,419 | 21,260 |
Extended (600 mg/kg post-extension column): CSF 6,227 ng/mL, Liver 4,652,897 ng/g.
[Clinical testing for DIPL]
- Very good resosurce: Chatman (important) 2009: tiered strategy
- Functional consequence: DIPL itself is not a direct toxic end point: 있어도 organ toxicity 없으면 갠찮고, organ toxicity 있어도 not 해: clinical monitoring plan, blood cell (wbc, smear, TEM), or
- Consideration:
- Critical organ? Neuron, heart, eye (all terminally differentiated)
- Reversibility,
- Biopsy & TEM
- currently relies on the histopathological examination of tissue biopsies, bronchoalveolar lavage (BAL), peripheral blood cells (i.e. lymphocytes, neutrophils). Although TEM is considered the “gold standard” approach for determining DIPL, it is invasive, relatively non-quantitative, expensive and time-consuming. It may be difficult or not feasible to biopsy the tissues of interest (e.g. heart, brain, neurons).
- peripheral blood cells & TEM
- In clinical studies, peripheral blood cells may be more readily accessible for light microscopic and ultra-structural studies. However, the accuracy of blood cell testing would be based on the assumption that changes in peripheral cells reflect the extent of DIPL in other tissues.
- The presence of PL in peripheral leukocytes is generally accepted as compound specific and is often predictive of PL in solid tissues. (… continued)
- Regulatory
- Black box warning example of Amiodarone: .. these changes also are present in approximately 50% of all patients on Cordarone therapy. These cells should be used as markers of theraphy, but not as evidence of toxicity.
Drugs (brand)ᵃ known to cause DIPL in animals
| Drugs (brand)ᵃ known to cause DIPL in animals | Drug label/summaryᵇ | Clinical case reports | References | |
|---|---|---|---|---|
| DIPL in humans | Reported with concurrent toxicities | |||
| Antidepressant | ||||
| Citalopram (Celexa, Loxapram) | √ | |||
| Clomipramine (Anafranil) | √ | |||
| Duloxetine (Cymbalta) | √ | |||
| Fluoxetine (Prozac) | √ | √ | Pulmonary toxicity | Gonzalez (...) |
| Paroxetine (Paxil, Paroxetin) | √ | |||
| Antipsychotic | ||||
| Chlorpromazine (Thorazine) | √ | Keratopathy, cataract | Webber (...) | |
| Antimalarial | ||||
| Amodiaquine (Camoquin, Flavoquine) | √ | Ocular changes | Hirst et al. | |
| Chloroquine (Aralen) | √ | Kidney toxicity, cardiotoxicity, keratopathy, retinopathy, myopathy | Jones et al. and Ro... | |
| Hydroxychloroquine (Plaquenil) | √ | Myopathy, kidney toxicity | Bolaños..., Khubchand... | |
| Tafenoquine | √ | Keratopathy | Nasveld... | |
| Antiviral | ||||
| Tilorone (Amixin IC) | √ | Keratopathy | Weiss (...) | |
| Antibiotic | ||||
| Amikacin | √ | Kidney toxicity | DeBroe (...) | |
| Azithromycin (Zithromax) | √ | |||
| Clarithromycin (BIAXIN) | ||||
| Gentamicin (Garamycin) | √ | Kidney toxicity | DeBroe (...) | |
| Telithromycin (Ketek) | √ | |||
| Tobramycin (TOBI) | √ | Kidney toxicity | DeBroe (...) | |
| Trimethoprim | √ | Hepatotoxicity | Muñoz (...) | |
| Antifungal | ||||
| Posaconazole (Noxafil, Posanol) | √ | |||
| Antimicrobial | ||||
| Pentamidine | √ | Lung toxicity | Filippo (...) | |
| Antiarrhythmic | ||||
| Amiodarone (Cordarone) | √ | √ | Pulmonary toxicity, keratopathy, hepatotoxicity, neuropathy, kidney toxicity | Adams (...) |
| Dronedarone (Multaq) | √ | |||
| Antianginal | ||||
| Perhexiline (Pexid) | √ | Hepatotoxicity, neuropathy | Bertrand (...) | |
| 4,4'-diethylaminoethoxyhexesterol (Coralgil) | √ | Hepatotoxicity, pulmonary toxicity, splenomegaly | Yamamoto (...) | |
| Statin | ||||
| Rosuvastatin | √ | Pulmonary toxicity | Lantuejoul (...) | |
| Atorvastatin | √ | Pulmonary toxicity | Huang (...) | |
(… drug list continues onto next photo)
Uncertain Spans
| location | transcription | uncertainty |
|---|---|---|
| TR06980443 row | Cmaxis 119,000 ng/mL and AUC0-24 is 3,130,000 ng*h/mL. | The number 119,000 could read 119000 or 119000.0 depending on small comma resolution. |
| Reference column | Gonzalez (...), Webber (...), etc. | All cited author surnames are partially cropped at the right edge; only the first surname segment is read with confidence. |
| Tissue concentrations row | extension column 4,652,897 ng/g | Last cell may include an additional unit suffix that is cropped. |
| Microscopic examination 600 mg/kg row | Stomach: Single cell necrosis of glandular epithelium, Mucosal hyperplasia, Edema in limiting ridge | The phrase Edema in limiting ridge could end with an additional word that is cropped. |
| Clinical testing bullet | Critical organ? Neuron, heart, eye (all terminally differentiated) | The trailing parenthetical is consistent across tile reads; one or two words may be cropped after differentiated. |