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The New Paradigm for Proarrhythmia Assessment Without the TQT Study

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Presentation on theme: "The New Paradigm for Proarrhythmia Assessment Without the TQT Study"— Presentation transcript:

1 The New Paradigm for Proarrhythmia Assessment Without the TQT Study
Philip Sager, MD, FACC, FAHA, FHRS Pharmaceutical/Device Consultant Consulting Professor of Medicine Stanford University School of Medicine Chair, Scientific Programs Committee, Cardiac Safety Research Consortium

2 Collaborators Drs. Stockbridge, Gintant, Pettit FDA EMA PMDA
Health Canada CSRC HESI  SPS In Silico Modelers Pharmaceutical and Device Companies CRO’s Numerous Academic Groups

3 QT Prolonged/Drug-Induced Torsade
QT prolongation/TdP – single most common cause of withdrawal or restriction on marketed drugs This has resulted in the need for regulatory guidance TdP rarely observed during clinical development Focus on surrogates- HERG and QTc testing QTc- sensitive but not very specific

4 S7B: Nonclinical Testing Strategy
Chemical/Pharma-cological Class Integrated Risk Assessment Follow-up studies None Weak Strong Evidence of Risk Other nonclinical and clinical information In vivo QT assay In vitro IKr assay* *The hERG (gene for Kv11.1 alpha subunit of IKr)) related current is used

5 Gather basic clinical data (e.g. tolerability, PK)
Clinical QT Update Guidance document – ICH E14 Applicable to all new drugs with systemic bioavailability Gather basic clinical data (e.g. tolerability, PK) Relatively early in development design and conduct “Thorough QT Study” at substantial multiples of anticipated maximum therapeutic exposure +ve (>5ms) -ve* Conduct normal ECG monitoring in development Stop development or Fully describe QT effect in target patient population; Extensive QT evaluation in Phase 2/3 * Positive represents an approximately 1.5% increase in the QTc

6 Consequences: Compound with QT effect
ICH E14- increase in QTc~5m is “positive Consequences of developing a compound with QT effect Significant development burden Increased perceived risk = increased burden to demonstrate benefit Increased costs Delays in filing and/or approval Label warnings and competitive implications Licensing/partnering issues Often leads to termination of development

7 Torsadogenic Drugs Success!
ICH E14/S&B have resulted in no drugs with unrecognized risk being approved Success! Negative impact on drug development Premature discontinuation due to hERG or QT “signal” (Inaccurate) perception of risk, development burden, costs, labeling Some potentially good compounds never get evaluated in humans Drug development in specific areas- CNS Many drugs with QT labeling are unlikely proarrhythmic

8 Ventricular Repolarization

9 QT Prolongation: Dissociation from TdP
Sodium Pentobarbital - Prolongs QT but no TdP Inhibits Ikr, Iks, and late INa Amiodarone - TdP very rare Inhibits Ikr, Iks, late INa, and Ica Verapamil Inhibits IKr but also Ca influx Ranolazine - Inhibits late INa, Ikr, and INaCa

10 QT Prolongation: Dissociation from TdP
Sodium Pentobarbital - Prolongs QT but no TdP - Inhibits Ikr, Iks, and late INa - No EAD’s, reduces dispersion Amiodarone - TdP very rare - Inhibits Ikr, Iks, late INa, and ICa Verapamil - Inhibits IKr but also Ca influx No QT prolongation or TdP Ranolazine - Inhibits late INa, Ikr, and INaCa - No EAD’s, reduces dispersion; - Suppresses E4031 induced TdP Thus QTc Prolongation need not cause TdP

11 Issues QT prolongation = Proarrhythmia HERG block = Proarrhythmia
Negative impact on drug development New paradigm- based on our deep mechanistic understanding of TdP

12 New Paradigm Might a new cardiac safety paradigm focused on non-clinical measurement of proarrhythmia proclivity: Focus on the real issue: Proarrhythmia Reduce the premature termination of drugs with favourable benefit:risk profiles Make drug development more efficient Move the bulk of proarrhythmic assessment to the discovery phase Use the assays to potentially guide candidate selection Obviate the TQT study Enhance the accuracy with which existing and/or new drugs are labelled relative to actual proarrhythmic risks

13 Nature Review: Drug Discovery. Aug 2013
July CSRC/HESI/FDA Meeting “Rechanneling the Current Cardiac Risk Paradigm:  Arrhythmia Risk Assessment During Drug Development Without the Thorough QT Study” Goal- favorably impact drug development while assuring drug safety Proarrhythmic risk can be deter- mined by pre-clinical assessments Proclivity to develop EAD’s Ionic Currents in silico modeling Cell-Based Approach Focus on high throughput approaches ECG Phase 1 Assessment Nature Review: Drug Discovery. Aug 2013

14 Proarrhythmic risk can be determined by pre-clinical assessments
Proclivity to develop EAD’s Ionic Currents in silico modeling Cell-Based Approach Focus on high throughput approaches ECG Phase 1 Assessment (American Heart J 2014 (In Press (available on-line)

15 Background: Proarrhythmic Vulnerability and Early Afterdepolarizations (EAD’s)
We understand the mechanism! Proarrhythmic vulnerability linked to impairment of repolarization and repolarization instability manifest culminating in early afterdepolarizations (EAD’s) EAD’s are triggers for Torsades de Pointes arrhythmia Ease of EAD induction reflects proarrhythmic vulnerability Provide means of ranking proarrhythmic potential

16 Development of TdP Torsade de pointes  Net repolarizing current
Action potential duration and QT interval Early afterdepolarizations (EADs)  Dispersion of ventricular repolarization (ΔAPD) Trigger Substrate Torsade de pointes Antzelevitch C et al. J Cardiovasc Pharmacol Therapeut ;9(suppl 1):S65-83. APD = action potential duration

17 Assays and Approaches Considered for Comprehensive Assay (In Order of Complexity, Integration)

18 CiPA: Two Component Proposal
Ionic Currents / In Silico Myocyte-Based Based Approach Approach Effects on Human Ventricular Myocytes (In Vitro Studies) Effects on Multiple Cardiac Currents (Voltage Clamp Studies) + Reconstruction of Cellular Electrophysiology (In Silico Studies) Complementary approaches Not designed to reproduce arrhythmia Define a gradation of risk instead of a binary approach

19 Core In Vitro Strategy. Voltage Clamp Studies
Ionic Currents Voltage clamp studies Effects on cardiac currents Human channels in in n heterologous expression systems Establish best practices, standardization across assays, laboratories Inhibition of current, ? Use dependency Higher throughput automated patch platforms - Efficiently determine basic characteristics of drug effects on currents for in silico reconstruction

20 Likely Candidate Currents
iKr (hERG) – delayed ventricular repolarization INafast (Nav1.5) – excitability, conduction INalate (Nav1.5) – repolarization, mitigate hERG block ICaL (Cav1.2) – A-V conduction, mitigate hERG block IKs (KvLQT1-minK) – delayed ventricular repolarization IK1 (Kir2.1) – excitability, conduction, repolarization

21 Core in silico Strategy: Reconstruction of the Cardiac Action Potential
Silico Reconstruction of Action Potentials Global effects on repolarization based on multiple ion channel effects Approach based on link between delayed repolarization supporting early afterdepolarizations (EAD’s) and TdP

22 Core In vitro Strategy: Human Cardiomyocytes
Electrophysiologic studies: - Human stem-cell derived ventricular cardiomyocytes; well characterized, physiologic recording conditions - Action potential studies, focus on repolarization (duration, early afterdepolarizations, cellular integration) Reproducibility essential, robust validation Confirm drug effects from voltage clamp/in silico reconstructions

23 Stem-Cell Derived Myocytes: Possible Experimental Approach
Field Potential Measures (Microelectrode Array Techniques) E-4031: Concentration-dependent Block of iKr Delays Repolarization, Provokes EAD’s Nifedipine: Concentration-dependent Block of IcaL Speeds Repolarization

24 Stem-Cell Derived Myocytes: Possible Experimental Approach
Perforated patch method ? Determine excitability during Phase 3 Ma J Am J Physiol Heart Circ Physiol 301: H2006–H2017, 2011

25 Human IPS-Derived Stem Cells
New technology that is evolving Desire to have as homogenous a population of adult cardiomyocytes as possible Evolving maturation and changes in EP properties over time “Standardization” across laboratories and stem cell sourcing Determination of appropriate drug-induced metrics indicating proarrhythmia proclivity

26 Summary and Paths Forward: CiPA Proposal
Approach based on a) mechanistic understanding, integrating effects on multiple ion currents with in silico reconstruction b) confirmation in human ventricular myocyte-based assay - Not typical preclinical assay based on binary discrimination in complex, integrated (poorly understood) biological system - Need input from safety pharmacologists, electrophysiologists, computational modelers, cell biologists, regulators First Steps: Seek Input, Establish Workstreams (ongoing)

27 Comprehensive In Vitro ProArrhythmia Assay (CiPA)
What It Will Do: Standardize in vitro assays (used to characterize drug effects) and in silico modeling of drug effects Define role of human cardiomyocytes to inform on proarrhythmic potential of drugs Provide proarrhythmic ranking based on calibration efforts with agreed-upon standards Not a binary approach What It Will Not Do: Maintain status-quo for an imperfect surrogate marker of proarrhythmia I’d delete (beyond hERG) The last bullet seems incorrect. I’d change it to something like this – Focus on proarrhythmia rather than QT interval prolongation

28 CIPA PROCESS Work streams Topical area leads
In Silico, Ion Channel, Myocyte, Regulatory, Steering Team Topical area leads Coordination and cross-stream interaction

29 Work Streams In Silico – model design, execution, feedback and vetting Tom Colatsky Ion Channel – channel selection, protocol development, novel data generation to test model; Syril Petit Stem Cell Myocyte – protocols, platforms and validation; Regulatory – model design and validation compound selection, arrhythmia metrics, ECG assessment Steering Team – Coordination and integration Norman Stockbridge, FDA: Jennifer Pierson (HESI): Jennifer Pierson

30 CIPA Steering Team Name Organization Representing
Work Stream Represented Norman Stockbridge FDA US Regulators All Tom Colatsky In Silico Work Stream Gary Gintant AbbVie Pharm/Non-clinical community Hugo Vargas Amgen Pharma/SPS Ion Channel Work Stream Derek Leishman Lilly Jean-Pierre Valentin AZ Pharma/Non-clinical community Ion Channel Work Stream, Regulatory Work Stream Philip Sager CSRC Clinical Community Regulatory Work Stream, Ion Channel Work Stream Jiwen Zhang GE Healthcare Pharma/Stem Cell Community Myocyte Work Stream Krishna Prasad EMA Non-US Regulators Regulatory Work Stream Colette Strnadova Health Canada Natalia Trayanova Johns Hopkins Modeling Community Syril Pettit HESI HESI Cardiac Safety Committee Jennifer Pierson To Be Determined PMDA Japanese Regulators

31 CIPA Steering Team Name Organization Representing
Work Stream Represented Norman Stockbridge FDA US Regulators All Tom Colatsky In Silico Work Stream Gary Gintant AbbVie Pharm/Non-clinical community Hugo Vargas Amgen Pharma/SPS Ion Channel Work Stream Derek Leishman Lilly Jean-Pierre Valentin AZ Pharma/Non-clinical community Ion Channel Work Stream, Regulatory Work Stream Philip Sager CSRC Clinical Community Regulatory Work Stream, Ion Channel Work Stream Jiwen Zhang GE Healthcare Pharma/Stem Cell Community Myocyte Work Stream Krishna Prasad EMA Non-US Regulators Regulatory Work Stream Colette Strnadova Health Canada Natalia Trayanova Johns Hopkins Modeling Community Syril Pettit HESI HESI Cardiac Safety Committee Jennifer Pierson To Be Determined PMDA Japanese Regulators

32 Summary Exciting potential evolution in CV Arrhythmia assessment
Potential to change current approaches with positive impact on drug development Can concepts be extended to other areas? Many opportunities for those interested in contributing to become involved

33 Galapagosization

34 Thank you Philip Sager, MD, FACC, FAHA Psager@Stanford. edu Ph 1-650

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