Inhaled Janus Kinase (JAK) inhibitors for the treatment of asthma

Bioorganic & Medicinal Chemistry Letters 29 (2019) 126658

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Bioorganic & Medicinal Chemistry Letters journal homepage: www.elsevier.com/locate/bmcl

Digest

Inhaled Janus Kinase (JAK) inhibitors for the treatment of asthma a,⁎

b,c

Mark Zak , Hart S. Dengler , Naomi S. Rajapaksa a b

a,c

T

Genentech Inc., Discovery Chemistry, 1 DNA Way, South San Francisco, CA 94080, USA Genentech Inc., Immunology Department, 1 DNA Way, South San Francisco, CA 94080, USA

ARTICLE INFO

ABSTRACT

Keywords: JAK Janus Kinase Kinase inhibitor Asthma Cytokine Inhalation Respiratory Lung-targeted Immunology

Multiple asthma-relevant cytokines including IL-4, IL-5, IL-13, and TSLP depend upon JAKs for signaling. JAK inhibition may, therefore, offer a novel intervention strategy for patients with disease refractory to current standards of care. Multiple systemically delivered JAK inhibitors have been approved for human use or are under clinical evaluation in autoimmune diseases such as rheumatoid arthritis. However, the on-target side effect profiles of these agents are likely not tolerable for many asthmatic patients. Limiting JAK inhibition to the lung is expected to improve therapeutic index relative to systemic inhibition. Thus, inhaled JAK inhibitors with lungrestricted exposure are of high interest as potential treatments for asthma.

Introduction to the JAK-STAT pathway The Janus Kinase (JAK) – Signal Transducer and Activator of Transcription (STAT) pathway regulates multiple fundamental biological processes including many aspects of innate and adaptive immunity, hematopoiesis, and cell proliferation.1 The key features of the signaling cascade are summarized in Fig 1.2 Circulating factors known as cytokines bind to the extracellular side of transmembrane receptors comprised of two or more subunits or chains, each associated with a JAK on the intracellular side. Upon cytokine binding, the JAKs in the receptor complex become phosphorylated and activated, leading to phosphorylation of the cytoplasmic domain of the receptor. STAT proteins dock to the phosphorylated receptor and are, themselves, subject to JAK-mediated phosphorylation. Once phosphorylated, the STATs dimerize and translocate to the nucleus where they modulate gene expression by binding to DNA.3 There are four members of the JAK family (JAK1, JAK2, JAK3, and tyrosine kinase 2 (TYK2)), each associating with specific receptor chains. These chains assemble in strictly defined combinations to form receptors for the different classes of cytokines.4 JAK3 associates with the γ-common chain, which pairs exclusively with chains associated with JAK1 to form receptors for the γ-common family of cytokines (Interleukin (IL)-2, IL-4, IL-7, IL-9, and IL-15, and IL-21). The receptor chains associated with JAK1, JAK2, and TYK2 form various heteromeric combinations with one another, for example, in the receptors for the

Type 1 interferons (JAK1, TYK2), interferon-γ (JAK1, JAK2), IL-23 (JAK2, TYK2), and IL-6 (JAK1, JAK2, TYK2). JAK2 is the only JAK to form a homodimeric pair in the receptors for cytokines such as erythropoietin (EPO), thrombopoietin (TPO), and granulocyte colony stimulating factor (G-CSF). Cytokines such as IL-5 and granulocyte macrophage colony-stimulating factor (GM-CSF) are thought to also signal primarily through JAK2.5 Inhibiting the relevant JAK(s) present in a cytokine’s receptor complex will interrupt cytokine signaling. Relevance of the JAK-STAT pathway to asthma Asthma is a chronic inflammatory disease of the airways. It results from a complex interplay between genetic factors influencing immune response and nonspecific external stimuli such as cold, allergens, and exercise.6–8 Asthma is often characterized as a heterogeneous condition, referring to the diversity of disease triggers, phenotypes, pathophysiologic drivers, and responses to therapy.6,7 Common symptoms include persistent cough, wheezing, shortness of breath, and chest tightness.9 While existing medications10 are often effective, there is a subset of patients with uncontrolled asthma who have a corresponding reduced quality of life, and increased health care use.11,12 Improved access to existing medications may benefit some of these patients, however, new asthma therapies also remain an important need. Several asthma classification systems exist, including those describing degree of clinical disease control,13,14 involvement of atopy/

Corresponding author. E-mail address: [email protected] (M. Zak). c These authors contributed equally. ⁎

https://doi.org/10.1016/j.bmcl.2019.126658 Received 7 July 2019; Received in revised form 27 August 2019; Accepted 31 August 2019 Available online 03 September 2019 0960-894X/ © 2019 Elsevier Ltd. All rights reserved.

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approval for the treatment of asthma with an eosinophilic phenotype, or asthma dependent on oral corticosteroid use.28,29 The clinical proof of concept obtained by directly targeting these cytokines or their receptors also supports studying JAK inhibitors as potential treatments for asthma. Indeed, IL-4, IL-5, IL-9, IL-13, and TSLP signaling can be simultaneously suppressed by inhibiting the relevant JAKs (Fig. 2), offering the potential for increased efficacy and/or the ability to treat a broader range of patients compared to a single blocking antibody. The Lebrikizumab, Tralokinumab, and Dupilumab development programs also provided useful biomarker information for an inhaled JAK inhibitor. These campaigns validated the use of FeNO as an exhaled biomarker of IL-4 and/or IL-13 pathway suppression,30 a useful proxy of in vivo JAK engagement. Such an exhaled biomarker is especially important to an inhaled JAK inhibitor with lung-restricted pharmacology, as changes to typical blood biomarkers (e.g. periostin, eosinophils, or IgE) may not be relevant due to expected low systemic exposure of the inhibitor. Notably, measuring FeNO is part of the clinical development programs of GDC-0214, AZD0449, and TD-8236, the three inhaled JAK inhibitors known to have entered the clinic to date.31–34 These, and additional inhaled JAK inhibitors are discussed in further detail below. Type 2-low asthma is less well understood, hence the potential benefit of JAK inhibition to these patients is less clear than for the Type 2-high disease. Type 2-low likely encompasses an array of syndromes with different drivers of disease, and indeed, there may also be overlap and even cooperativity between Type 2-low and Type 2-high pathways in severe asthma.7,35,36 Regardless, there is a subset of severe asthmatic patients with a more neutrophilic disease where Type 2-high markers (such as eosinophils) may be reduced or absent.6,37 Neutrophilic asthma is often associated with a TH1/IFN-γ response, a TH17/IL-17 response, or a mix of the two.35–37 In addition, high concentrations of IL-6, independent of a Type 2 signature, have been measured in patients with severe asthma.38 While IL-17 is not JAK-dependent, both IFN-γ and IL-6 require JAK activity for signaling.4 However, therapeutic antibodies neutralizing IFN-γ or IL-6 signaling have not been tested clinically in asthma, thus the benefit of inhibiting these pathways via JAK inhibition is not known.39 One potential source of support for JAK intervention in Type 2-low asthma comes from the phase 2 trial of Tezepelumab. As described above, blockade of TSLP in this study produced consistent reductions in asthma exacerbations regardless of Type 2 status.24 Should this positive data be reproduced in larger phase 3 trials, it would suggest that JAK inhibition downstream of TSLP signaling (Fig. 2) could also be effective in treating Type 2-low asthma.

Fig. 1. The JAK-STAT signaling pathway.

allergic response,15,16 and disease endotype.8 An increasingly common example of the endotype approach is to classify disease based on “Type 2-high” or “Type 2-low” status.7,17,18 The Type 2-high disease is better understood and is associated with high expression of the canonical Thelper 2 (TH2) cytokines IL-4, IL-5, IL-9, and IL-13, all of which are JAK-dependent. Multiple biomarkers have also been associated with Type 2-high disease, including elevated blood and sputum eosinophils, fractional exhaled nitric oxide (FeNO), serum periostin, and serum immunoglobulin (IgE).7,17,18 Thymic stromal lymphopoietin (TSLP) is another JAK-dependent cytokine that plays an important role in Type 2high disease, serving as an alarmin upstream of TH2 cytokine production.19 Given the association of IL-4, IL-5, IL-9, IL-13, and TSLP to asthma pathologies (Fig. 2), all have been targeted with antibody-based therapeutics that bind either directly to the cytokines or their receptors.20,21 Three drugs targeting either IL-5 (Mepolizumab, Reslizumab) or the alpha chain of its receptor (Benralizumab) have been approved as treatments for asthma with an eosinophilic phenotype. An IL-9 blocking antibody showed promising effects in a pre-clinical asthma study but failed to show an effect in a clinical setting, although the extent of target engagement was not evaluated.22,23 Tezepelumab is an antagonist antibody to TSLP. Results from a phase 2 trial indicate it successfully reduced asthma exacerbations in patients both with and without Type 2-high signatures.24 Confirmatory phase 3 trials are underway. Two potential therapies targeting IL-13 (Lebrikizumab and Tralokinumab) have been advanced through phase 3 trials, with both molecules demonstrating reduction of key biomarkers linked to IL-13 including FeNO. Despite evidence of target engagement, inconsistent reductions in asthma exacerbations led the sponsoring companies (Roche and AstraZeneca, respectively) to abandon further development activities in asthma.25–27 Notably, however, an antibody blocking the activity of both IL-13 and IL-4 by targeting the alpha subunit of the IL-4 receptor (Dupilumab) not only reduced FeNO and related biomarkers, but also reduced asthma exacerbations sufficiently to gain regulatory

Oral JAK inhibitors Due to their central role in the JAK-STAT pathway and the mature understanding of kinases as drug targets, JAK inhibitors have been studied intensely as potential therapeutics. These efforts have resulted in multiple approved drugs and clinical candidates (see Table 1 for representative examples). The first two orally-delivered JAK inhibitors approved for human use in autoimmune diseases40 were tofacitinib (1),41 followed by baricitinib (2).42 Rheumatoid arthritis is the best studied autoimmune indication to date, with compounds 1 and 2 having shown convincing efficacy in patients.43,44 Recent reviews have summarized the growing body of safety data from clinical trials and long term extension trials, particularly for compounds 1 and 2.45,46 Due to the importance of JAKs to immune function and blood cell formation, theoretical and practical concerns around infections, malignancies, and changes to blood cell counts and other blood parameters dominate the safety discussion. Serious infections have been observed including herpes zoster and pneumonia. Leukemias and other malignancies have been reported. Anemia and cytopenias have been observed, as have natural killer (NK) cell reductions, and changes to plasma lipids (high density lipoproteins, low 2

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Fig. 2. JAK-STAT dependent cytokines in asthma. IL-4, IL-5, IL-9, IL-13, and TSLP signal through the JAK-STAT pathway and have been implicated in the pathogenesis of asthma.

density lipoproteins, and triglycerides). Thromboembolic events have also been described. Further study is required to precisely distinguish the degree to which these findings are drug related as opposed to being underlying co-morbidities of the patient population being treated, and to characterize the degree to which changes in lab parameters (e.g. lipid changes) translate to adverse events (e.g. negative cardiovascular outcomes). However, there is growing evidence that identifying JAK inhibitors with improved therapeutic indexes remains an important unmet need. One potential approach to improve therapeutic index is to tune the JAK family selectivity profile of the inhibitor. Indeed, as exemplified in Table 1, multiple additional compounds with a range of JAK family selectivity profiles have recently been approved for human use (3 and 4),47–50 or are progressing through clinical trials (5–8).51–54 It will be fascinating to observe over the coming years whether the risk:benefit profiles of these compounds will differentiate meaningfully from 1 or 2 in RA or other autoimmune diseases.55

discussion below) will exhibit higher effective concentrations in the lung relative to blood and peripheral tissues, leading to lung-restricted pharmacology. Thus, similar to ICS and LABA, inhaled JAK inhibitors are expected to have improved therapeutic indexes for asthma relative to orally administered agents. Considerations of inhaled, lung-restricted, drug design The lung is a highly vascular organ, possessing in its deeper generations only a thin barrier between air and blood, and also a very large surface area.58 To avoid rapid absorption across the lung and into systemic circulation, design of lung-restricted molecules must include a lung retention strategy. Such a strategy typically makes use of one or more molecular properties to slow absorption across the pulmonary membrane, for example, limiting the soluble fraction in lung (via low solubility and/or slow dissolution rate), promoting tissue affinity (with high lipophilicity and/or high basicity), or minimizing membrane permeability.59–66 Additionally, a slow off-rate from the target of interest can be beneficial in maintaining a long duration of action in the lung.61,64–68 As highlighted by inhaled compounds 9–1267–74 (Table 2), numerous lung retention strategies using different combinations of these principles can be successful. Importantly, inhaled design must contemplate not only retention of the compound within the lung, but also access of the drug to the relevant biological target.59,75,76 For example, the use of extremely low permeability to facilitate lung retention of tiotropium bromide (11)72 is viable since its target (the M3 receptor) is expressed on the cell surface. Conversely, lung retention based on very low permeability would likely not be effective for a kinase inhibitor, since it would preclude access to the intracellular target. Notably, the inhaled phosphoinositide 3-kinase δ (PI3Kδ) inhibitor 12 makes use of tissue affinity imparted by the basic piperazine (pKa = 8.173) and a relatively high cLogP (4.173) to balance lung retention with sufficient cell penetrance for target engagement. A final consideration in the design of inhaled and lung-targeted therapeutics is to keep systemic concentrations low since, even with

Rationale for inhaled, lung-restricted, JAK inhibitors in asthma Despite strong biological rationale, the authors are not aware of ongoing clinical trials of orally-delivered JAK inhibitors in asthma. Safety concerns around systemic JAK inhibition likely play a role. Indeed, unlike RA which typically manifests in older subjects of 60 years or more, asthma afflicts patients of all ages including children.56 Thus, the tolerance for toxicity in asthmatic patients is lower and a systemically delivered JAK inhibitor, regardless of isoform selectivity, is at correspondingly higher risk of failure due to safety. Inhaled delivery has been previously employed to produce acceptable safety profiles for asthma drugs. For example, inhaled corticosteroids (ICS) and inhaled long acting β2 adrenergic receptor agonists (LABA) are two of the most important existing standards of care in asthma.57 Since asthma is a disease of the lung, inhalation delivers the drug directly to the desired tissue, thereby minimizing dose. Additionally, an inhaled drug with the appropriate properties (see 3

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Table 1 Examples of orally-delivered JAK inhibitor drugs or drug candidates for autoimmune diseases.

Ex 1 2 3 4 5 6 7 8

JAK(s) Most Potently Inhibited JAK1, JAK3, JAK2 JAK1, JAK2 JAK1, JAK3 JAK1 JAK1 JAK1 JAK3 TYK2

Latest Development Stage

Lead Indication(s)

Other Indication(s)

Approved Drug Approved Drug b Approved Drug Approved Drug c Ph3 Ph3 Ph3 Ph3

a

AS, AA, DS AD, SLE

a

a

RA, PA, UC RA a RA a RA RA AD AA P a

UC, CD, PA, AD UC, CD RA, UC, CD CD, UC, SLE, PA

AA: alopecia areata, AD: atopic dermatitis, AS: ankylosing spondylitis, CD: Crohn’s disease, DS: diffuse scleroderma, P: psoriasis, PA: psoriatic arthritis, RA: rheumatoid arthritis, SLE: systemic lupus erythematosus, UC: ulcerative colitis. a Approved indications. b Japan only (to date). c Marketing authorization application (MAA) under review by the European Medicines Agency (EMA).

inhalation dosing, it is possible for a substantial amount of drug to enter systemic circulation.77 Upon inhalation only a fraction of the dose is deposited in the lung (Fig. 3a).78 The remainder is either retained in the inhaler device, or deposits in the mouth and throat and is swallowed. The swallowed component may potentially be absorbed into systemic circulation through the gastrointestinal (GI) tract (Fig. 3b). The lungdeposited portion of the dose also has two primary access points into systemic circulation. First, even a significantly lung-retained compound will eventually pass through the lung tissue and into the blood. Second, lung deposited material is subject to mucociliary clearance whereby beating ciliated cells carry material out of the lung toward the pharynx where it may be swallowed.79 Given the potential for systemic absorption either through the lung or GI, it is typically desirable for inhaled drugs to possess poor metabolic stability in liver or plasma, and corresponding rapid systemic clearance. An inhaled compound that is both significantly retained in the lung and rapidly systemically cleared will have a desirable distribution profile for lung-restricted pharmacology, characterized by sustained exposure in the lung at significantly higher concentrations than in plasma or peripheral tissues (Fig. 3c).

(HDM) challenges with the addition of either bacterial or fungal adjuvants including cyclic-diguanylate, or Aspergillus and Alternaria, respectively.39,81 Incorporation of methacholine challenge can also induce an airway hyperreactivity response (AHR).82–86 Finally, key biomarkers in the JAK-STAT pathway, such as phosphorylated STATs (pSTATs), can be induced in the lung by either Ova challenge or by direct in vivo stimulation with cytokines (e.g. IL-13-pSTAT6 or IL-6pSTAT3).87 Inhaled JAK inhibitors A number of companies have disclosed data on inhaled JAK inhibitors. Fig. 4 shows either the structures of these compounds, or, when structure has not been disclosed, a representative example from the relevant company’s JAK publications and/or patent literature. Additionally, biochemical and cell-based potencies collated from the indicated sources are summarized in Table 3. While the data in Table 3 gives a sense of JAK-family potency and selectivity, direct comparison between molecules is challenging since the data was generated in different labs often using different experimental protocols. Indeed, variations in parameters such as ATP concentration in biochemical assays, and cell-type, serum concentration, and stimulation conditions in cellbased assays can all affect JAK potency and selectivity. Thus, a systematic effort to profile key inhaled JAK inhibitors in the same assays from the same lab, similar to what was done previously for oral JAK inhibitors,4 would be a valuable contribution to the literature.

Preclinical efficacy models Typical preclinical efficacy models for asthma include ovalbumin (Ova) sensitization/challenge models that produce a primarily TH2/ eosinophilic response in the lung.80 Models with a greater degree of neutrophilic response have also been developed using house dust mite 4

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Table 2 Examples of inhaled, lung-targeted, drugs or drug candidates.

Ex

Biological Target

Latest Development Stage

Lung Retention Strategy

9

Glucocorticoid Receptor β2-Adrenergic Receptor

Approved Drug

Limited soluble fraction, Tissue affinity (lipophilic) Limited soluble fraction, Tissue affinity (lipophilic and basic), a Slow off-rate Low permeability, Slow off-rate Tissue affinity (lipophilic and basic)

10

11

Muscarinic Receptor (M3) PI3Kδ

12 a

Approved Drug

Approved Drug Ph2

Apparent slow off-rate, likely due to selective partitioning into cell membranes and/or cooperative binding to a putative “exo-site”.

Pfizer: PF-06263276 (14)

revealed that it bound in a type 1.5 mode, with the phenolic moiety occupying an induced pocket produced by significant movement of the protein’s methionine gatekeeper residue. While there was no significant movement of the DFG motif, the phenol also formed favorable hydrogen bonds with the backbone NH of the DFG Phe (F995) and the αGlu (E898) of the C-helix. Further optimization to ensure low-yetmeasurable aqueous solubility and poor metabolic stability resulted in pan-JAK inhibitor 14. 14 maintained a long cellular duration of action with a T1/2 of 9 h in the PBMC washout assay. Further characterization of 14 revealed high plasma clearance in rat

The discovery and characterization of PF-06263276 (14) was described by Pfizer scientists.88 Following a hypothesis that a type 2 inhibitor might have a slow off-rate, a virtual screen of Pfizer’s internal crystal structures for compounds that might access the kinase back pocket yielded indazole 13. This compound displayed both an extended enzymatic off-rate for JAK3 (0.006 min−1, T1/2 = 114 min) and prolonged cellular duration of action (T1/2 in IL-2-pSTAT5 PBMC assay after washing = 6.5 h). A crystal structure of 13 in complex with JAK2

Fig. 3. a. Fate of a drug after inhalation. b. Potential routes of inhaled drug entry into systemic circulation. c. A representative drug distribution profile for an inhaled, lung targeted drug. 5

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Fig. 4. Structures of JAK inhibitors. aCompounds specifically disclosed as inhaled JAK inhibitors. bRepresentative structures from relevant publications and/or patent literature of companies with inhaled JAK programs.

and dog after intravenous (i.v.) dosing and low oral bioavailability in rat as desired. Consistent with the goal of lung-targeted JAK inhibition, intratracheal (i.t.) administration of 14 (10 µg) in mouse fully inhibited IL-6-induced pSTAT3 formation in the lung without inhibiting GM-CSF induced pSTAT5 production in the blood. Extended in vivo JAK1 target occupancy was also demonstrated in the mouse lung after i.t. dosing, with significant occupancy retained after 4 h. Although lung and plasma concentrations were not shown, compound 14 exhibited lungrestricted pharmacology indicative of lung retention after i.t. dosing. Lung retention is likely driven by multiple factors including limited soluble fraction in lung, and tissue affinity imparted by high lipophilicity (cLogP = 4.4, LogD = 3.9). Although a slow enzymatic off-rate was targeted with this class of compounds, the authors highlighted that the cellular half-lives of the JAK proteins have previously been shown to be only 2–3 h.98 Thus, a slow dissociation rate from JAK proteins, themselves, may not be the primary driver of either in vitro cellular duration of action (T1/2 in PBMC washout assay = 9 h), or extended in vivo retention of 14 within the lung. Compound 14 also showed promising results upon topical application in a mouse psoriasis model. It was advanced to phase 1 clinical trials as an investigational topical psoriasis treatment,99,100 however, it did not have significant effects on the endpoints reported.100 The clinical progression status of compound 14 as an inhaled therapy for asthma or other respiratory diseases is not known.

representative compound 15 appears in multiple patent publications, including ones for JAK inhibitors in respiratory disease,101 crystalline forms,102 and methods of treatment.89 In a pharmacokinetics study, compound 15 delivered to mice via i.t. aspiration was found to have a 55-fold greater AUC in lung than in plasma.89 When dosed i.t. in an in vivo pharmacodynamics model, compound 15 inhibited IL-13-triggered pSTAT6 formation in mouse lung by approximately 60%, while exhibiting between 50 and 100-fold greater concentrations in the lung than in plasma.89,101 Finally, compound 15 also exhibited in vivo efficacy in several models, including a model of Alternaria alternata-induced lung inflammation, where an oropharyngeally-aspirated dose of 15 reduced lung eosinophilia by 88% relative to control.89,101 Compound 15 has multiple potentially ionizable centers, the strongest of which are calculated to be the basic piperidine (pKa = 10.5) and imidazopiperidine (pKa = 7.7), and the acidic phenol (pKa = 8.4).104 If the calculated values are accurate, compound 15 is likely zwitterionic with a further moderately basic center (pKa = 7.7). Lung retention after inhaled dosing may, thus, be facilitated by tissue affinity imparted by the moderately basic center and the relatively lipophilic nature of the molecule (cLogP: 4.5, cLogD: 2.0).104 Finally, while in vitro cellular duration of action has not been reported, the structural similarity to 14 makes it possible compound 15 may also exhibit that phenotypic effect. Detailed clinical results of TD-823633b, confirmation of its structure,105 and the story of its discovery and preclinical characterization are all awaited.

Theravance: TD-8236 (structure not disclosed, 15 is a representative example89,101,102)

Rigel/AstraZeneca: R256/AZD0449 (structure not disclosed, 16 is a representative example106)

Theravance recently announced that its inhaled, lung-restricted pan-JAK inhibitor TD-8236 entered phase 1 clinical evaluation as a potential treatment for asthma and other serious respiratory conditions.34,103 While the structure of TD-8236 has not been disclosed,

AstraZeneca has recently advanced the inhaled JAK inhibitor R256, in-licensed from Rigel107 and renamed AZD0449,108 to phase 1 clinical trials for the treatment of asthma.32,109 Rigel’s discovery strategy aimed 6

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Table 3 a Biochemical and cell-based potency of inhaled JAK inhibitors. Compoundb PF-06263276 1488

1589

AZD0449/R25690

“Example 35”: 1791

LAS194046: 1892–94

VR58895

IJC-196

iJAK-381: 2187,97

NR NR NR NR NR

5 mM <3 1220 > 30,000 NR

Km 5.46 0.4 2.1 21.8

NR 4.2 0.7 2.1 6.0

NR 0.12 0.82 20 0.21

Km 0.26d 0.62d 21d 3.2d

Biochemical Assaysc

ATP Concentration JAK1 JAK2 JAK3 TYK2

1 mM 2.2 23 60 30

Km 0.063d 0.016d 0.20d 0.16d

Cell-Based Assaysc,e (JAKs Recruited) [Cell type]

IL-2 → IFNγ (JAK1/3) IL-2 → pSTAT5 (JAK1/3) IL-2 → Proliferation (JAK1/3) IL-4 → pSTAT6 (JAK1/3)

70 [PBMC]

50 [T-cells] 20 [T-cells]

e

1800 [HWB]

44 [T-cells]

7.9 [T-cells]

IL-4 → Eotaxin production (JAK1/3) IL-4 → CD23 (JAK1/3) IL-6 → pSTAT3 (JAK1/2/TYK2) IFNα → pSTAT3 (JAK1/ TYK2) IFNα → pSTAT1 (JAK1/ TYK2) IFNγ → pSTAT1 (JAK1/2) IFNγ → ICAM-1 (JAK1/2) IL-13 → CCL26 (JAK1/2)

209 [NR] 29 [NR] 16 [Lymphocytes] 26 [Monocytes] 15 [rat lymphocytes]

20 [NHLF] e

2100 [HWB] 620e [HWB]

40 [T-cells]

32 [monocytes]

37 [NHLF]

62 [NR]

0.4 [T-cells]

19 [B-cells]

6520 [U937]

11 [NHLF]

IL-13 → pSTAT6 (JAK1/2)

6.3 [BEAS-2B]

EPO → pSTAT5 (JAK2/2) EPO → Survival (JAK2/2) GM-CSF → pSTAT5 (JAK2/ 2) IL-5 → Survival (JAK2/2) IL-12 → pSTAT4 (JAK2/ TYK2)

5200e [HWB]

72 [T-cells]

24 [PBMC]

IL-13 → Periostin (JAK1/2) IL-13 → Eotaxin production (JAK1/2)

6.3 [BEAS-2B]

37 [NHLF]

6.0 [Lung Fibroblasts]

34 [U937]

1350 [erythroblasts]

24 [NHBE] 48 [NHBE]

8.1 [TF-1] 13 [BEAS-2B] 82 [TF-1]

37 [Monocytes]

220 [PBMC]

31 [Eosinophils]

a Abbreviations used. Km: Michaelis constant. NR: not reported. PBMC: peripheral blood mononuclear cell. HWB: Human whole blood. BEAS-2B: Human bronchial epithelial cell line. NHLF: Normal human lung fibroblasts. U937: Human macrophage cell line. NHBE: Normal human bronchial epithelial cells. TF-1: Human erythroleukemia cells. b See indicated references for data sources. Listed in the table is the species to which data is linked; in some cases molecule name only (R256, VR588, IJC-1), in some cases molecule structure only (15), in some cases both molecule name and structure (PF-06263276: 14, “Example 35”: 17, LAS194046: 18, iJAK-381: 21). c IC50 values reported unless otherwise indicated. Units: nM. d Ki values reported. Units: nM. e Plasma protein binding measured to be 99.9%. Free IC50 is calculated to be 1000× more potent.

models when dosed orally, 90 indicating it has sufficient oral bioavailability at higher doses to drive significant pharmacologic effects. While the structure of R256 has not been released, there is evidence to suggest it is a pyrimidine diamine such as 16. Compound 16 and related molecules appear in a Rigel patent application,106 and 16 was the subject of a large campaign by AstraZeneca and others to identify crystalline forms with an ideal dissolution rate for inhaled delivery.111 Pyrimidine 16 has only weakly ionizable centers (basic pKa = 5.9, acidic pKa = 8.9). Thus, basicity likely does not play a major role in its

to selectively inhibit IL-13/IL-4 signaling while sparing JAK2-dependent pathways to potentially improve safety.90 One of the compounds identified during that effort was R256, which selectively inhibited JAK1 and JAK3 in cellular assays.90 When dosed i.t., R256 reduced AHR and infiltration of neutrophils and macrophages in a mouse Ova model of chronic asthma. Additionally, in mouse pharmacokinetics studies, i.t. delivery of R256 led to a marked separation between lung and plasma concentrations, indicating it was retained in the lung after pulmonary delivery.110 Notably, however, R256 was also efficacious in mouse Ova 7

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stimulation.95 Intranasal (i.n.) administration of VR588 to mice provided dose-dependent and sustained lung exposure for 24 h. Importantly, the exposure in plasma was approximately 1000-fold lower than in lung, suggesting VR588 would have minimal JAK inhibition in the periphery.117 The high melting points of crystalline forms of 19 indicate that lung retention may be driven by a limited soluble fraction in lung. In a murine HDM asthma model, VR588 dosed i.n. showed efficacy on a number of endpoints including a reduction of inflammatory cells in BAL, reduction of AHR, and reduced pulmonary expression of cytokines such as IL-4, IL-5, and IL-17.117 Sustained pSTAT3 reduction was also demonstrated over 24 h. In 2016, Vectura conducted bronchoscopies on patients with severe asthma to collect epithelial cells for ex-vivo testing with VR588.118 The current progression status of VR588 beyond this study is not known.

lung retention. The compound has low solubility (crystalline solubility = 0.03 µM) and is relatively lipophilic (LogD = 4.2). As inferred by the crystal form campaign, the observed lung retention after pulmonary delivery is likely attributable to the effect of these properties on limiting soluble fraction in the lung and promoting tissue affinity. Clinical results of R256 / AZD0449, confirmation of its structure, and a detailed description of its discovery are all awaited. AstraZeneca: “Example 35” (17) An additional inhaled JAK inhibitor from AstraZeneca (17) was reported as “example 35” in a recent patent application.91 Inhibitor 17 is highly selective for JAK1 with greater than 400-fold selectivity over JAK2 and greater than 10,000-fold selectivity over JAK3 in enzymatic assays.91 A publication describing related chemical matter clarifies that the high isoform selectivity is achieved through a 2-point interaction of the sulfone moiety of the ligand with an arginine residue in JAK1, which is not possible with the corresponding residues in JAK2 (glutamine) or JAK3 (serine).112 In a rat Ova model, 17 (0.6 µg/kg) administered by dry powder inhalation reduced eosinophils in bronchoalveolar lavage (BAL) fluid by 68%. However, no improvement was observed at higher dose (61% inhibition at 4.76 µg/kg).91 Although lung and plasma pharmacokinetic profiles are not available, if the compound is indeed retained in the lung after inhaled dosing, tissue affinity imparted by basicity would likely play a role (calculated pKa = 7.9).104 Interestingly, 17 also exhibited efficacy in a mouse model of alopecia areata upon oral administration (stepwise increased dosing at 0.5, 2.5, and 12.5 mg/kg QD for two weeks at each dose), indicating it has some degree of oral bioavailability. Notably, the doses of 17 used in the oral alopecia areata study were significantly higher than those used in the inhaled Ova study. Thus, while the oral bioavailability of 17 could theoretically lead to undesirable systemic pathway suppression in the inhaled setting, the very low efficacious doses could result in circulating levels of inhibitor being too low to be pharmacologically relevant outside the lung. The progression status of 17 is currently not known.

Merck: iJAK-001 and IJC-1 (structure(s) not disclosed, 20 is a representative example) Merck has been active in the area of inhaled JAK inhibitors and has presented preclinical data on compound IJC-1.96 IJC-1 is most potent against JAK1 and TYK2 in biochemical assays and is also potent in cellular assays stimulated with cytokines dependent JAK kinases (Table 3). In addition to demonstrating cellular inhibition of inflammatory signaling, IJC-1 inhibited inflammatory functions in human tissues. In human lung slices stimulated with IL-13, IJC-1 inhibited the release of thymus and activation regulated chemokine (TARC) and monocyte chemoattractant protein (MCP-4), both proinflammatory cytokines. Additionally, it suppressed goblet cell increases and restored cilia beating in IL-13 stimulated human airway epithelial cells. IJC-1 showed efficacy in models of airway exacerbation in multiple animal models. In a mouse HDM asthma model, IJC-1 (1 mg/kg, i.t.) suppressed lung inflammation to an extent comparable to positive control dexamethasone (1 mg/kg, i.t.). In an additional model with HDM and influenza exacerbation, IJC-1 demonstrated synergy with dexamethasone (both dosed 1 mg/kg, i.t.), suppressing influx of eosinophils to the lung. Finally, when administered as a micronized dry powder in sensitized sheep, IJC-1 suppressed airway resistance for several hours upon challenge with inhaled Ascaris suum. Merck also recently published preclinical pharmacokinetic characterization of an inhaled pan-JAK inhibitor, iJAK-001.119 Neither biochemical nor cellular potency were reported for iJAK-001, but the compound demonstrated efficacy in multiple models, including in A. suum-sensitized sheep when dosed as a micronized dry powder. Additionally, a suspension of iJAK-001 dosed i.t. in rat showed sustained lung exposure over 24 h, with an unbound lung to plasma ratio greater than 1000. iJAK-001 was described as a neutral compound with high permeability and low solubility, suggesting that lung retention is driven by a limited soluble fraction in lung. While structures have not been disclosed for IJC-1 or iJAK-001, it is possible that these names refer to the same compound. Pyrazolopyridone 20 is a structure from the patent literature120 with a molecular weight consistent with what was reported for iJAK-001,119 and biochemical potencies consistent with IJC1.96 The iJAK-001/IJC-1 progression status is not known.

Almirall: LAS194046 (18) Almirall recently disclosed inhaled JAK inhibitor, LAS194046 (18).93,94 Fluoropyrimidine 18 is a potent pan-JAK inhibitor with some discrimination over TYK2 and similar cell-based potencies in assays dependent on JAK1/3 or JAK2 (table 3). In rats, 18 demonstrated favorable pharmacokinetic properties for an inhaled therapy. When dosed i.t., 18 (0.3 mg/kg) exhibited prolonged retention within the lung with free lung levels in excess of the unbound rat IC80 for ∼16 h and much higher concentrations in lung than in plasma.113 Delivery of a nebulized solution of 18 (1 mg/kg) provided efficacy in a rat Ova model, inhibiting influx of inflammatory cells (e.g. eosinophils and neutrophils) and cytokines (e.g. IL-6) in BAL, reducing histological lung lesions, and showing a prolonged inhibition of pSTAT3 formation.113 The lung retention of 18 is thought to be driven by tissue affinity imparted by the molecule’s dibasic nature (calculated basic pKa’s = 8.6, 6.7).104 Tissue affinity may further be facilitated by lipophilicity (cLogP = 3.8. cLogD7.4 = 2.2).104 The current progression status of LAS194046 has not been disclosed.

Genentech: iJAK-381 (21) and GDC-0214 Genentech has recently published a series of highly potent JAK1/2 inhibitors,121 as well as iJAK-381 (21), a related molecule optimized for inhaled delivery.87 In biochemical assays 21 was most potent against JAK1 with modest selectivity over JAK2 and with more discrimination over JAK3 and TYK2. In a cell based-assay, 21 was ∼10 times more potent in blocking signaling of IL-13 via JAK1/JAK2 than in blocking signaling of EPO via JAK2/JAK2. 21 inhibited IL-13 signaling in multiple cell types, and also blocked signaling of IL-4 and IL-6. Lung retention of compound 21 after inhalation was tuned by making it weakly basic (cpKa = 6.4) to impart some degree of tissue affinity, moderately

Vectura: VR588 (structure not disclosed, 19 is a representative example114,115) While the structure of VR588 has not been disclosed, a JAK inhibitor originally discovered by Palau Pharma (19)116 has appeared in two Vectura patent applications describing crystalline or co-crystalline forms that may be suitable for inhaled delivery.114,115 VR588 demonstrates pan-JAK inhibition, with single-digit biochemical IC50’s, translating to potent inhibition in cellular assays based on IL-2 or IL-6 8

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soluble (kinetic solubility, pH7.4 = 34 µM) to limit soluble fraction in lung, and moderately permeable (Madin-Darby canine kidney (MDCK) Papp A:B = 2.7 cm/s 10−6) to attenuate flux through the pulmonary membrane. The compound was also designed to have poor metabolic stability in liver microsomes to promote rapid systemic clearance. After either i.n. or dry powder inhalation in mice, 21 exhibited a favorable pharmacokinetics profile with sustained concentrations in the lung and much lower concentrations in plasma. After dry powder inhalation, 21 inhibited multiple relevant pharmacodynamic markers and efficacy endpoints in different models and species. For example, 21 reduced pSTAT6 production after either IL-13 stimulation or Ova challenge in the mouse. 21 also inhibited influx of inflammatory cells into the lungs of mice in both a highly eosinophilic Ova-induced efficacy model, and an allergen-driven model with a neutrophilic component. Systemic markers of JAK inhibition were not affected, including NK cells or cellularity in the spleen, indicating the pharmacology was lung-restricted. Finally, 21 was found to both reduce methacholine-induced AHR in Ova sensitized and treated mice, and to inhibit Ova-induced lung inflammation in guinea pigs as measured by histology. Genentech has also advanced the inhaled JAK inhibitor GDC-0214 into a phase 1 clinical study in healthy volunteers and mild asthmatic patients.31 Clinical results of GDC-0214, its chemical structure, and details of its preclinical discovery and characterization will be reported in due course.

surrounding efficacy, safety, and the influence of selectivity are eagerly awaited. This information will be instrumental in clarifying the potential for lung-restricted JAK inhibition to improve the lives of patients suffering from asthma poorly controlled by current treatment options. Acknowledgements The authors thank Nico Ghilardi and Callie Bryan for proofreading the manuscript, as well as the reviewers and the editor, Peter Bernstein, for their helpful comments on the initial submission. The authors are employees of Genentech Inc, which provides financial support for their work. References 1. Shuai K, Liu B. Regulation of JAK-STAT signalling in the immune system. Nat Rev Immunol. 2003;3:900. https://doi.org/10.1038/nri1226. 2. Murray PJ. The JAK-STAT signaling pathway: input and output integration. J Immunol. 2007;178:2623. 3. O'Shea JJ, Schwartz DM, Villarino AV, Gadina M, McInnes IB, Laurence A. The JAKSTAT pathway: impact on human disease and therapeutic intervention. Annu Rev Med. 2015;66:311. https://doi.org/10.1146/annurev-med-051113-024537. 4. Clark JD, Flanagan ME, Telliez JB. Discovery and development of Janus kinase (JAK) inhibitors for inflammatory diseases. J Med Chem. 2014;57:5023. https://doi. org/10.1021/jm401490p. 5. Perugini M, Brown AL, Salerno DG, et al. Alternative modes of GM-CSF receptor activation revealed using activated mutants of the common beta-subunit. Blood. 2010;115:3346. https://doi.org/10.1182/blood-2009-08-235846. 6. Borish L, Culp JA. Asthma: a syndrome composed of heterogeneous diseases. Ann Allergy Asthma Immunol. 2008;101:1. https://doi.org/10.1016/s1081-1206(10) 60826-5. 7. Robinson D, Humbert M, Buhl R, et al. Revisiting Type 2-high and Type 2-low airway inflammation in asthma: current knowledge and therapeutic implications. Clin Exp Allergy. 2017;47:161. https://doi.org/10.1111/cea.12880. 8. Lotvall J, Akdis CA, Bacharier LB, et al. Asthma endotypes: a new approach to classification of disease entities within the asthma syndrome. J Allergy Clin Immunol. 2011;127:355. https://doi.org/10.1016/j.jaci.2010.11.037. 9. Zoratti EM, Krouse RZ, Babineau DC, et al. Asthma phenotypes in inner-city children. J Allergy Clin Immunol. 2016;138:1016. https://doi.org/10.1016/j.jaci.2016. 06.061. 10. Sobieraj DM, Baker WL. Medications for Asthma. JAMA. 2018;319:1520. https:// doi.org/10.1001/jama.2018.3808. 11. https://www.cdc.gov/asthma/asthma_stats/uncontrolled_asthma.htm. Accessed 4/ 23/2019. 12. Corren J. New targeted therapies for uncontrolled asthma. J Allergy Clin Immunol Pract. 2019;7:1394. https://doi.org/10.1016/j.jaip.2019.03.022. 13. Koshak EA. Classification of asthma according to revised 2006 GINA: evolution from severity to control. Ann Thorac Med. 2007;2:45. https://doi.org/10.4103/18171737.32228. 14. Reddel HK, Bateman ED, Becker A, et al. A summary of the new GINA strategy: a roadmap to asthma control. Eur Respir J. 2015;46:622. https://doi.org/10.1183/ 13993003.00853-2015. 15. Mathur SK, Viswanathan RK. Relevance of allergy in adult asthma. Curr Allergy Asthma Rep. 2014;14:437. https://doi.org/10.1007/s11882-014-0437-5. 16. de Groot JC, ten Brinke A, Bel EHD. Management of the patient with eosinophilic asthma: a new era begins. ERJ Open Res. 2015;1:00024. https://doi.org/10.1183/ 23120541.00024-2015. 17. Woodruff PG, Modrek B, Choy DF, et al. T-helper type 2-driven inflammation defines major subphenotypes of asthma. Am J Respir Crit Care Med. 2009;180:388. https://doi.org/10.1164/rccm.200903-0392OC. 18. Wan XC, Woodruff PG. Biomarkers in Severe Asthma. Immunol Allergy Clin North Am. 2016;36:547. https://doi.org/10.1016/j.iac.2016.03.004. 19. Kitajima M, Lee HC, Nakayama T, Ziegler SF. TSLP enhances the function of helper type 2 cells. Eur J Immunol. 2011;41:1862. https://doi.org/10.1002/eji.201041195. 20. Lawrence MG, Steinke JW, Borish L. Cytokine-targeting biologics for allergic diseases. Ann Allergy Asthma Immunol. 2018;120:376. https://doi.org/10.1016/j.anai. 2018.01.009. 21. Gandhi NA, Bennett BL, Graham NM, Pirozzi G, Stahl N, Yancopoulos GD. Targeting key proximal drivers of type 2 inflammation in disease. Nat Rev Drug Discov. 2016;15:35. https://doi.org/10.1038/nrd4624. 22. Oh CK, Leigh R, McLaurin KK, Kim K, Hultquist M, Molfino NA. A randomized, controlled trial to evaluate the effect of an anti-interleukin-9 monoclonal antibody in adults with uncontrolled asthma. Respir Res. 2013;14:93. https://doi.org/10. 1186/1465-9921-14-93. 23. Oh CK, Raible D, Geba GP, Molfino NA. Biology of the interleukin-9 pathway and its therapeutic potential for the treatment of asthma. Inflamm Allergy Drug Targets. 2011;10:180. 24. Corren J, Parnes JR, Wang L, et al. Tezepelumab in Adults with Uncontrolled Asthma. N Engl J Med. 2017;377:936. https://doi.org/10.1056/NEJMoa1704064. 25. Panettieri Jr RA, Sjobring U, Peterffy A, et al. Tralokinumab for severe, uncontrolled asthma (STRATOS 1 and STRATOS 2): two randomised, double-blind, placebo-

Conclusion Inhaled JAK inhibitors offer an intriguing new class of investigational treatments for asthma, however, several important questions remain to be clarified. The first is whether the lung-restricted nature of inhaled JAK inhibitors will meaningfully shift the efficacy vs. toxicity profile relative to systemic drugs. From the efficacy perspective, asthma is a disease that manifests in the lung, however, there is relevant biology that occurs in distal tissues. It is currently unknown whether inhibiting only the lung-specific activities of relevant cytokines will translate to improvement in asthma symptoms. For example, one asthma-relevant role of IL-5 is to spur development of eosinophils in the bone marrow. A lung-restricted JAK inhibitor will not inhibit IL-5 signaling in the bone marrow, hence will not inhibit all asthma-relevant aspects of IL-5 biology. There is a similar consideration for toxicity. The lung-restricted pharmacology of inhaled inhibitors should ameliorate any JAK-dependent toxicity driven by biology outside of the lung, such as herpes zoster infection, or changes to lipids and blood parameters. However, the benefit of inhaled delivery to any potential toxicity within the lung is less clear. It is possible that issues such as pulmonary infections (as observed for oral JAK inhibitors),45 or pulmonary alveolar proteinosis due to GM-CSF inhibition122–125 could manifest. Conversely, the largely uninterrupted immune and hematopoietic function in the peripheral tissues and blood may also confer a protective effect to the lung. An additional question is the ideal JAK family selectivity profile. The most validated cytokines in asthma (Fig. 2) all signal through JAK1 and/or JAK2, hence targeting those isoforms is likely to be important. Inhibition of JAK3 and TYK2 may provide additional benefit in blocking some of the cytokines in Fig. 2, or other cytokines with a less well-appreciated link to asthma. Thus, it is highly likely that potent pan-JAK inhibition will provide maximal efficacy in the widest patient population, however, also with the greatest risk of toxicity due to broad pathway suppression. A final question centers upon the breadth of asthma types that may be improved by inhaled JAK inhibitors. Benefit in Type 2-high asthma is best validated given the JAK dependence of Type 2 cytokines and the success in targeting these signaling pathways with antibody therapeutics. Type 2-low asthma may also potentially benefit from JAK inhibition due to interrupting signaling of TSLP or other less well-validated cytokines. The first generation of inhaled JAK compounds have now entered the clinic, and answers to questions 9

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