Nx-5948, a Selective Degrader of BTK with Activity in Preclinical Models of Hematologic and Brain Malignancies
Authors: Robbins Daniel W , Noviski Mark , Rountree Ryan , Tan May , Brathaban Nivetha , Ingallinera Timothy , Karr Dane E , Kelly Aileen , Konst Zef , Ma Jun , Tenn-McClellan Austin , McKinnell Jenny , Perez Luz , Guiducci Cristiana , Hansen Gwenn , Sands Arthur 
Published: November 2021

Abstract
Bruton's tyrosine kinase (BTK) plays a key role in cell survival in B cell malignancies, and covalent inhibitors of BTK, such as ibrutinib and acalabrutinib, have proven efficacious in chronic lymphocytic leukemia (CLL), mantle cell lymphoma (MCL), marginal zone lymphoma (MZL), and Waldenstrom's macroglobulinemia (WM). BTK inhibitors have also demonstrated clinical activity in small trials of patients with relapsed/refractory primary central nervous system lymphoma. The long-term efficacy of BTK inhibitors is limited by the emergence of resistance mutations, most commonly at C481 of BTK. These mutations preclude formation of a covalent bond with BTK and lead to diminished efficacy and disease progression. Several noncovalent BTK inhibitors, which do not require covalent binding to C481, are currently being investigated in clinical trials as potential therapies for patients with relapsed and refractory disease. However, other mutations have been shown to decrease the in vitro activity of these non-covalent BTK inhibitors, suggesting that mutations may ultimately limit the effectiveness of these compounds as well.
Small molecule-induced protein degradation offers a unique approach to target BTK for the treatment of B-cell malignancies. Chimeric Targeting Molecules (CTMs) catalyze ubiquitylation and proteasomal degradation of target proteins and are comprised of a target binding element ("hook"), a linker, and ubiquitin ligase binding element ("harness"). NX-5948 is a CTM that contains a BTK hook linked to a cereblon (CRBN) harness. While some CRBN-binding drugs, such as lenalidomide and pomalidomide, promote the degradation of neo-substrate proteins, such as the transcription factors Aiolos and Ikaros, NX-5948 has been engineered to avoid Aiolos and Ikaros degradation and therefore does not possess IMiD activity.
Preclinical studies have shown that NX-5948 catalyzes the degradation of 50% of cellular BTK (DC 50) at &lt; 1 nM concentrations in lymphoma cell lines and peripheral blood mononuclear cells (PBMCs). NX-5948 impairs viability in the BTK-dependent ABC-DLBCL cell line, TMD8 (EC 50: &lt; 10 nM after 72 hours). Importantly, NX-5948 induces degradation of the mutated BTK-C481S in cells and inhibits proliferation of BTK-C481S mutant TMD8 cells more effectively than ibrutinib (NX-5948 EC 50 values of &lt; 10 nM versus &gt; 1 μM for ibrutinib). NX-5948 also catalyzes selective degradation of BTK. In an unbiased proteomics experiment, NX-5948 treatment of TMD8 cells demonstrates robust BTK degradation without significant downregulation of other off-target proteins.
Oral administration of NX-5948 in mice leads to dose-proportional exposure in plasma and BTK degradation to &lt;10% of baseline levels in circulating and splenic B cells. In a TMD8 xenograft model in mice containing the BTK-C481S mutation, daily oral administration of NX-5948 resulted in superior tumor growth inhibition (TGI) as compared to ibrutinib. Following a single oral dose of NX-5948 in cynomolgus monkeys, BTK degradation to &lt;10% of baseline levels is observed in the circulating B cells.
In addition, NX-5948 penetrates the central nervous system (CNS) and demonstrates activity in a model of brain malignancies. Following oral dosing of NX-5948 to mice, NX-5948 was detectable in the cerebrospinal fluid at a comparable level to the unbound concentration of NX-5948 in mouse plasma. In an intracranial TMD8 xenograft model, treatment with NX-5948 resulted in degradation of BTK in intracranial TMD8 cells, decreased intracranial tumor burden and improved survival relative to treatment with vehicle.
The potent BTK degradation activity of NX-5948 and the ability of this molecule to penetrate the CNS supports its development for the treatment of B-cell malignancies, including CNS lymphoma.

Disclosures
Robbins: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Noviski: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Rountree: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Tan: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Brathaban: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Ingallinera: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Karr: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Kelly: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Konst: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Ma: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Tenn-McClellan: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. McKinnell: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Perez: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Guiducci: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Hansen: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Sands: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees.