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Acute myeloid leukemia (AML) is characterized by the uncontrolled expansion of un-differentiated hematopoietic progenitor myeloblasts. AML treatment is very challenging owing to its complex heterogeneity resulting in a dismal 5-year overall survival rate particularly in elderly patients unfit for standard induction chemotherapy. The expansion of AML requires the availability of sufficient nucleotides supporting the anabolic processes required for AML growth thus, targeting nucleotide biosynthesis can halt AML progression. Indeed, targeting dihydroorotate dehydrogenase (DHODH), a critical rate-limiting step in the de novo pyrimidine synthesis pathway not only induced cytotoxicity but has been shown to promote blast differentiation in a HOXA9/MEIS1 over-expressing model. We sought to develop a DHODH inhibitor that had superior properties to those reported for AML therapy. Compound 41 (cmpd 41) demonstrates sub-nanomolar 50% inhibitory concentration for DHODH biochemical activity and potent in vitro activity across several AML cell lines and primary AML cells independent of mutational subtype, including mutated TP53. Cmpd 41 also demonstrated superior in vivo anti-leukemic activity in multiple AML xenograft models as monotherapy and demonstrated synergy with a hypomethylating agent, decitabine in TP53 mutated AML. Given the heterogeneity of AML and frequent emergence of resistant clones, we aimed to investigate ways to enhance response to DHODH inhibitors through combination. After in vitro treatment of AML cell lines and primary patient samples with DHODH inhibitors, we observed an increase in CD38 surface expression suggesting synergy with CD38 targeting monoclonal antibody (mAb) immunotherapies. Indeed, we are the first to report synergy between DHODH inhibitors and anti-CD38 mAb in AML which emphasizes the synergy between this promising novel class of agents with immunotherapies via recruiting innate immunity. Consequently, given the relevance of CD38 mAb therapy to multiple myeloma (MM), we extended these studies to MM and remarkably found that cmpd 41 was highly efficacious as a monotherapy and in combination with CD38 mAb, resulted in complete tumor regression in a subcutaneous MM xenograft model. In summary, we introduce a best in class DHODH inhibitor with a data-driven combination strategy for both AML and MM. Our studies suggest a highly synergistic combination strategy involving immunotherapy for AML and other hematologic malignancies. Citation Format: Ola A. Elgamal, Sandip Vibhute, Sydney Fobare, Abeera Mehmood, Mariah L. Johnson, Jean Truxall, Emily Stahl, Bridget Carmichael, Shelley J. Orwick, Ramasamy Santhanam, Kasey Hill, Susheela Tridandapani, Christopher C. Coss, Alice S. Mims, Karilyn T. Larkin, Mitch A. Phelps, Sharyn D. Baker, Alex Sparreboom, Thomas E. Goodwin, Gerard Hilinski, Chad E. Bennett, Erin Hertlein, John C. Byrd. Introducing a novel DHODH inhibitor with superior in vivo activity as monotherapy or in novel combination regimen with immunotherapy for hematological malignancies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1060.

Hydrocarbon-stapled α-helical peptides are a new class of targeting molecules capable of penetrating cells and engaging intracellular targets formerly considered intractable. This technology has been applied to the development of cell-permeable ligands targeting key intracellular protein–protein interactions. However, the properties governing cell penetration of hydrocarbon-stapled peptides have not yet been rigorously investigated. Herein we report our studies to systematically probe cellular uptake of stapled peptides. We developed a high-throughput epifluorescence microscopy assay to quantitatively measure stapled peptide intracellular accumulation and demonstrated that this assay yielded highly reproducible results. Using this assay, we analyzed more than 200 peptides with various sequences, staple positions and types, and found that cell penetration ability is strongly related to staple type and formal charge, whereas other physicochemical parameters do not appear to have a significant effect. We next investigated the mechanism(s) involved in stapled peptide internalization and have demonstrated that stapled peptides penetrate cells through a clathrin- and caveolin-independent endocytosis pathway that involves, in part, sulfated cell surface proteoglycans, but that also seems to exploit a novel, uncharacterized pathway. Taken together, staple type and charge are the key physical properties in determining the cell penetration ability of stapled peptides, and anionic cell surface proteoglycans might serve as receptors to mediate stapled peptide internalization. These findings improve our understanding of stapled peptides as chemical probes and potential targeted therapeutics, and provide useful guidelines for the design of next-generation stapled peptides with enhanced cell permeability.

Conformationally stabilized α-helical peptides are capable of inhibiting disease-relevant intracellular or extracellular protein-protein interactions in vivo. We have previously reported that the employment of ring-closing metathesis to introduce a single all-hydrocarbon staple along one face of an α-helical peptide greatly increases α-helical content, binding affinity to a target protein, cell penetration through active transport, and resistance to proteolytic degradation. In an effort to improve upon this technology for stabilizing a peptide in a bioactive α-helical conformation, we report the discovery of an efficient and selective bis ring-closing metathesis reaction leading to peptides bearing multiple contiguous staples connected by a central spiro ring junction. Circular dichroism spectroscopy, NMR, and computational analyses have been used to investigate the conformation of these "stitched" peptides, which are shown to exhibit remarkable thermal stabilities. Likewise, trypsin proteolysis assays confirm the achievement of a structural rigidity unmatched by peptides bearing a single staple. Furthermore, fluorescence-activated cell sorting (FACS) and confocal microscopy assays demonstrate that stitched peptides display superior cell penetrating ability compared to their stapled counterparts, suggesting that this technology may be useful not only in the context of enhancing the drug-like properties of α-helical peptides but also in producing potent agents for the intracellular delivery of proteins and oligonucleotides.

A majority of proteins responsible for the establishment and maintenance of human disease states are unable to be targeted therapeutically by molecules belonging to either of the two established classes of drugs, namely small molecules and protein therapeutics. Recent efforts toward drugging these ‘undruggable’ proteins have led to greatly increased focus on cell-penetrating mini-proteins as a new class of agents for targeting intractable intracellular proteins. These molecules are designed to combine the advantages intrinsic to each conventional therapeutic modality while overcoming their individual limitations. One class of cell-penetrating mini-proteins, all-hydrocarbon stapled peptides, has recently demonstrated the ability to potently and specifically target previously intractable proteins such as transcription factors, vaulting this class to the forefront of a new wave of next-generation drugs.

Proteins that engage in intracellular interactions with other proteins are widely considered among the most biologically appealing yet chemically intractable targets for drug discovery. The critical interaction surfaces of these proteins typically lack the deep hydrophobic involutions that enable potent, selective targeting by small organic molecules, and their localization within the cell puts them beyond the reach of protein therapeutics. Considerable interest has therefore arisen in next-generation targeting molecules that combine the broad target recognition capabilities of protein therapeutics with the robust cell-penetrating ability of small molecules. One type that has shown promise in early-stage studies is hydrocarbon-stapled α-helical peptides, a novel class of synthetic miniproteins locked into their bioactive α-helical fold through the site-specific introduction of a chemical brace, an all-hydrocarbon staple. Stapling can greatly improve the pharmacologic performance of peptides, increasing their target affinity, proteolytic resistance, and serum half-life while conferring on them high levels of cell penetration through endocytic vesicle trafficking. Here, we discuss considerations crucial to the successful design and evaluation of potent stapled peptide interactions, our intention being to facilitate the broad application of this technology to intractable targets of both basic biologic interest and potential therapeutic value.