Preclinical Studies of the IAP Antagonist Debio 1143 in Combination with Cytarabine or Doxorubicin in a Mouse Model of AML
Authors: Campbell Ambrose , Chendamarai Ezhilarasi , Holt Matthew , Prior Julie , Eissenberg Linda , Rettig Michael P. , Vuagniaux Gregoire , Zanna Claudio , DiPersio John F. 
Published: October 2019

Abstract
Background: Relapse and drug resistance remains the major cause of therapy failure in Acute Myeloid Leukemia (AML). Inhibitors of apoptosis proteins (IAPs) are a family of proteins that suppress proapoptotic signaling and represent attractive targets to overcome chemotherapy resistance. Debio 1143 (a.k.a. AT-406) is an orally-active IAP antagonist able to promote apoptosis alone and/or in combination with chemotherapy. We recently reported the results of a Phase 1 study of Debio 1143 in combination with daunorubicin and cytarabine (araC) in poor-risk AML patients (DiPersio et al. J Clin Oncol 32:5s, 2014, a7029). Although Debio 1143 showed good tolerability and could be safely combined with chemotherapy, 62% (8/13) of patients with complete remissions relapsed within the study period. Here, we used a preclinical AML model to begin examining the effects of BM stroma on the efficacy of Debio 1143 combined with araC or doxorubicin (dox).
Methods: We generated murine acute promyelocytic leukemia (APL) cell lines that are resistant to araC and dox both in vitro and in vivo by chronically exposing APL cells to increasing concentrations of drug in vitro. This APL model was previously generated by knocking in the human PML-RARa cDNA into the cathepsin G locus (Westervelt et al. Blood, 2003). We used WST-1 cell proliferation assays and bioluminescence imaging (BLI) to evaluate the efficacy of Debio 1143 to induce apoptosis alone and in combination with araC or dox in vitro in chemotherapy sensitive and resistant APL cells in the presence and absence of M2-10B4 stromal cells. Dox or araC was provided for (a) a 6h period initiated 24h before Debio 1143 (i.e., with an intervening 18h washout of the chemotherapy), (b) simultaneously with Debio 1143, or (c) 6h after Debio 1143. To assess Debio 1143 in vivo, we injected APL cells into syngeneic mice. In our first experiment, mice (n=5/cohort) were treated with PBS, araC (500 mg/kg, s.c.), dox (50 mg/kg, s.c.), Debio 1143 (100 mg/kg, p.o.) or their combination on days 5, 6, 12, and 13 after APL injection. In our second experiment, mice (n=8/cohort) were treated with PBS, araC (200 mg/kg, s.c.), dox (10 mg/kg, s.c.), Debio 1143 (100 mg/kg, p.o.) or their combination on days 3 to 7 and 10 to 16 after APL injection. In both experiments, Debio 1143 was given 2 hours prior to chemotherapy.
Results: Figure 1shows that coculture of APL cells with stromal cells protects them from araC-induced killing (Figure 1A) and that our araC-resistant cells are indeed resistant to araC (Figure 1B). Treatment with Debio 1143 alone has no effect on parental or araC-resistant APL survival in the presence or absence of stroma cells. However, Debio 1143 in combination with araC killed the parental APL cells and overcame the stroma cell-mediated chemotherapy protection (Figure 1A). Although combination therapy partially inhibited araC-resistant APL cell proliferation in the absence of stroma, it had no effect when the cells were cultured in the presence of stroma (Figure 1B). We obtained similar results with dox and dox-resistant cells (data not shown). This in vitro data with the parental APL cell line was confirmed in vivo. Combination therapy with chemotherapy (araC or dox) and Debio 1143 for 4 days (EXP#1) or 10 days (EXP#2) significantly prolonged the overall survival of mice by 4 to 7 days compared to single agent therapy (Debio 1143, araC, or dox) in this aggressive tumor model (Table 1). Preliminary in vitro data suggests that pretreatment of parental or araC-resistant APL cells with chemotherapy (araC or dox) enhances their killing by Debio 1143 compared to simultaneous treatment.
Conclusions: Debio 1143 combined with chemotherapy inhibits parental and chemotherapy-resistant APL growth in vitro and in vivo. Future mechanistic studies are required to determine how Debio 1143 can overcome stroma-mediated resistance.
Figure 1 Figure 1.
Figure 2 Figure 2.

Disclosures
Rettig: Debiopharm International SA: Research Funding. Vuagniaux:Debiopharm International SA: Employment. Zanna:Debiopharm International SA: Employment. DiPersio:Debiopharm International SA: Research Funding.