Abstract 3860: ERK1/2 inhibition overcomes resistance to venetoclax in AML by altering mitochondrial metabolism
Authors: Sharma Priyanka , Ostermann Lauren , Piya Sujan , Baran Natalia , Tyagi Anudishi , Hindley Christopher , Dao Kim-Hien , Sims Martin , Battula V. Lokesh , Andreeff Michael , Borthakur Gautam 
Published: June 2023

Abstract
Background: Primary or secondary resistance to venetoclax is pervasively associated with mutational/non-mutational activation of RAS/RAF/ERK pathway which confers metabolic alterations as a compensatory adaptation. Preclinical models of venetoclax resistance and primary patient samples (n=8) were used to assess the synergy of concomitant Bcl2 and ERK1/2 inhibition followed by RNAseq analysis to identify molecular mechanisms responsible for overcoming resistance to venetoclax.
Results: ERK1/2 inhibition using Compound 27 (ERKi, Heightman et al., J Med Chem. 2018), an analog of ASTX029, was highly synergistic with venetoclax at inducing apoptosis in AML. NRAS-mutant OCI-AML3 and THP1 cells, that are inherently resistant to venetoclax, were sensitized to venetoclax when combined with ERKi with ~90% apoptosis compared to 20% by venetoclax alone (Combination Index = 0.008). Synergy was also confirmed using isogenic OCI-AML2 cells with lab-generated acquired resistance to venetoclax, resulting in 75% apoptosis versus 22% by venetoclax (CI=0.6). Leukemia progenitor cells in primary AML samples were also depleted by the ven+ERKi combination (CI:0.03-0.23). In line with our in-vitro findings, treatment with ASTX029 as a single agent or in combination with venetoclax significantly inhibited leukemia burden and increased survival in an OCIAML3 xenograft model (p&lt;0.05). Single agent ERKi and combination treatment using an NRAS-mutant PDX resulted in significantly impaired clonogenic potential and decreased expression of cMyc and CD44 in CD34+CD38- population as demonstrated by CyTOF, indicating depletion of progenitors. Transcriptomic profiling of OCIAML3 cells revealed upregulation of 6 pathways in response to venetoclax including oxidative phosphorylation (OXPHOS), electron transport chain, Myc targets, E2F targets, epithelial mesenchymal transition and KRAS signaling. Interestingly, these pathways were downregulated after ERKi+venetoclax treatment along with decrease in glycolysis and fatty acid metabolism (FDR&lt;0.05). Since, venetoclax treatment significantly enriched for OXPHOS, we examined the metabolic effect of ERKi to overcome venetoclax resistance. Seahorse analysis showed increased basal and maximal respiration, and ATP production in OCIAML2 venetoclax resistant versus parental cells. Combining ERKi with venetoclax reduced OCR and ATP production in OCIAML3 and OCIAML2-venetoclax resistant cells. This was accompanied by an increase in membrane depolarization (p=0.001) as well as enhanced mitochondrial ROS (p&lt;0.001).
Conclusion: The inhibition of ERK1/2 alters mitochondrial metabolism and functional integrity to overcome resistance to venetoclax by causing apoptosis in venetoclax resistant AML cells. These data provide a strong rationale for the combination of ERK1/2 and Bcl-2 inhibitors in treatment of AML and warrant further investigation in the clinic.
Citation Format: Priyanka Sharma, Lauren Ostermann, Sujan Piya, Natalia Baran, Anudishi Tyagi, Christopher Hindley, Kim-Hien Dao, Martin Sims, V. Lokesh Battula, Michael Andreeff, Gautam Borthakur. ERK1/2 inhibition overcomes resistance to venetoclax in AML by altering mitochondrial metabolism. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3860.