Preclinical Development of Hosu-53, a Novel Potent Dihydroorotate Dehydrogenase Inhibitor with Impressive Single Agent Efficacy and Combination Approaches in Hematological Malignancy (2022)

Common FDA approved strategies for hematological malignancies include chemotherapy, targeted therapies, immune therapies, hypomethylating agents, and cell-based therapeutics. However, recurrence often occurs resulting in poor prognosis particularly in acute myeloid leukemia (AML) with first relapse and multiple myeloma (MM) following several relapses based upon more therapies being available. The emergence of dihydroorotate dehydrogenase as an appealing mechanistic target in AML has propelled the development of several clinical candidate DHODH inhibitors (DHODHi) such as brequinar. Here we describe HOSU-53, a novel DHODHi with favorable oral bioavailability (>50% in mouse, rat, and dog) and a pharmacodynamic (PD) biomarker for target engagement, enabling clinical in vivo monitoring of potency and on-target anti-tumor activity. Here we describe the development of a series of DHODHi through a collaboration between Hendrix College and The Ohio State University (OSU). Our initial screen of 18 novel compounds synthesized at Hendrix College identified HOSU-3 as a potent DHODHi with efficacy equivalent to brequinar, however in vivo efficacy in a MOLM-13 AML xenograft model revealed further optimization would be required to compete with leading clinical candidates. Further structure activity relationship studies and lead optimization performed in collaboration with the Drug Development Institute at OSU led to screening over 200 additional analogs and the development of three additional compounds (HOSU-28, -49 and -53). HOSU-53 has subnanomolar biochemical activity against human DHODH in a cell-free enzyme assay, with a cellular IC50 ranging from 2 - 45 nM across a panel of AML cell lines, and 12-42 nM in MM cell lines. While HOSU-53 is highly plasma protein bound, it exhibits a moderate serum shift in assays using human plasma proteins with an IC50 of 457 nM, well below the in vivo Cmax and AUC achieved in rodent and canine pharmacokinetic (PK) studies (Cmax = 79.4-210 μM and AUC = 997-7961 μM-h). Additional absorption, distribution, metabolic and excretion (ADME) and safety studies revealed that HOSU-53 displays very favorable drug-like properties sufficient for development as a pre-clinical candidate. A MOLM-13 xenograft study verified that HOSU-53 was a potential new best in class DHODHi, with efficacy superior to the Bayer clinical candidate. We performed a follow-up study to determine the efficacy of dosing daily at 4, 10, and 20 mg/kg versus 30 mg/kg twice a week. Correlative PK/PD studies were also conducted to measure plasma HOSU-53 and DHO levels at day 1 and 14. We observed a dose linear relationship between HOSU-53 plasma concentration and DHO accumulation. Collectively, our efficacy and PK/PD studies indicate that 10 mg/kg is a highly efficacious and tolerable daily regimen, while higher doses can be safely administered intermittently, and DHO accumulation serves as an important plasma biomarker to identify in vivo therapeutic responses and toxicity. Confirmatory studies in rat subcutaneous MOLM-13 and MV4-11 xenograft models further demonstrated the efficacy of HOSU-53. Our group has previously described synergy between HOSU-53 and decitabine in AML, as well as monoclonal antibodies directed to CD38 in AML and MM. Furthermore, a novel combination between HOSU-53 and CD47 antibody is described in a separate abstract at this current meeting. We expanded our combination studies by testing HOSU-53 with another standard of care, the FLT3 inhibitor gilteritinib, using the MOLM-13 FLT3-ITD mutant xenograft model. NCG mice were enrolled ten days post engraftment to receive daily 4 mg/kg HOSU-53, 30 mg/kg gilteritinib or the combination. Single agent HOSU-53 and gilteritinib prolonged survival (median survival of 37 and 47 days, respectively) while the combination significantly improved survival with 9/10 mice in the combination group remaining on study at day 80. Collectively, we provide a thorough preclinical assessment for HOSU-53 for treatment in hematological malignancy both as a monotherapy and combined with other effective approved therapies including decitabine, monoclonal antibodies and gilteritinib. We have initiated IND enabling studies including GLP toxicity studies planned for late 2022 and have initiated human dose projection models based on our multi-species PK/PD analysis. We anticipate filing an IND application in 2023 for a phase 1 clinical trial in AML and MM.