Pharma Strategy Blog

Commentary on Pharma & Biotech Oncology / Hematology New Product Development

There are a lot of clinical trials out there right with tyrosine kinase inhibitors; unfortunately many will fail because they were rushed into phase II or III trials without thinking through all the options.  There are, however, some smart companies out there who do think.

What was noticeable at AACR this year, was the surfeit of posters and presentations regarding logical combinations designed to eliminate escape routes and hence resistance.  For example, cross-talk is a common problem between ligands, eg IGF-1R and EGFR, so combining the two may reduce the problem but that isn't the whole story.

Feedback loops also exist, so targeting PI3-kinase alone is less likely to be effective than targeting both PI3-kinase and mTOR.  Neal Rosen from MSKCC showed some interesting data to this effect and argued cogently that oncogenes tend to lead to constitutive negative feedback.  He also noted that the BRAF mutation predicts for sensitivity to MEKi, for example.  Michael Korn also discussed the feedback activation loop between the RAS-ERK and PI3K pathways and how the inhibition of autophagy (where cells self digest themselves) can enhance apoptosis and the anti-tumour effect with smart combinations.

Targeting both MEK and AKT may therefore also have more effect than either alone, as you can see in the chart below: 

Picture 10Source: Array Biopharma

In a recent trial reported at the the ASCO GI meeting in January, Merck described an elegant design where IGF-1R, EGFR and AKT inhibitors were all combined to target advanced pancreatic cancer, with promising early results.  I thought this was a prescient approach at the time, since it clearly sought to eliminate both cross-talk and feedback, so it was interesting to see numerous researchers advocating similar approaches in different tumour types based on the overexpression profiles at AACR last week. The design is based on rational biochemistry, which regular PSB readers will know I'm a big fan of, rather than randomly adding a kinase inhibitor to whatever is the standard chemotherapy of the day in a haphazard blunderbuss approach.

There are a number of MEKi and AKTi inhibitors out there (I counted nearly a dozen last time I checked), as well as a plethora of PI3-kinase and mTOR inhibitors, either alone or in combination.  Merck and AstraZeneca announced an interesting deal earlier this year to jointly pursue research with their AKT (MK-2206) and MEK (AZD6244) inhibitors.  This collaboration makes a lot of sense biochemically.  Novartis (a client) have one of a broadest kinase pipelines in the industry and just added to it prior to AACR in a deal with Array BioPharma to license their MEK inhibitors, of which ARRY-162 is the lead candidate. 

The compounds that ultimately win the race may not necessarily be the ones furthest ahead in clinical trials right now, but the ones with the smartest clinical trial designs to eliminate some of the issues associated with kinase inhibition – cross-talk, feedback, feed-forward loops and additional mutations. 

MEKi and AKTi are two of my favourite kinase approaches right now because they offer the flexibility to add to existing TKI's such as erlotinib, sorafenib or everolimus, for example, potentially improving the outcomes further in a variety of different cancers, never mind the future combination possibilities.  It's going to be a very interesting and hot area to watch in the near future, that's for sure.

If you have any thoughts or questions on this fascinating topic, please do add them in the comments below.


4 Responses to “#AACR10: The Kinase Dilemma”

  1. sgcox

    If effective therapy requires simultaneous inhibition of two kinases, would it mean the easier resistance emergence ?
    Mutation in just one out of two targets will stop the treatment regime working, right?

  2. craig

    Hi Sally,
    Have you heard anything about MK-8669 (mTOR) and MK-646 (IGF-1R) combo trials?

  3. MaverickNY

    Hi Craig,
    There is one phase I trial I know of that is ongoing with ridoforolimus and dalotuzumab in combination in advanced solid tumours.
    According to my notes, the trial was basically a dose finding study with the following:
    Catch-All study in metastatic colorectal or advanced non-small cell lung cancer who had failed at least one therapy.
    Starting dose of oral ridaforolimus is 10 mg/day, QD, for five days. Dose rising up to 40 mg/day, QD for five days. Dose range for intravenous dalotuzumab is 7.5 mg/kg/week, 10 mg/kg/week or 7.5 mg/kg/every 14 days.
    Dalotuzumab given as an IV infusion over 1 or 2 hrs.
    The trial isn’t slated to end until next year, so it’ll be a while before we hear any data.

  4. MaverickNY

    Not necessarily. The concept is far too early to tell whether it really works or not, but my guess is that resistance will more likely occur when only blocking one pathway rather than several.

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