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Context Tirzepatide substantially reduced hemoglobin A1c (HbA1c) and body weight in subjects with type 2 diabetes (T2D) compared with the glucagon-like peptide 1 receptor agonist dulaglutide. Improved glycemic control was associated with lower circulating triglycerides and lipoprotein markers and improved markers of beta-cell function and insulin resistance (IR), effects only partially attributable to weight loss. Objective Assess plasma metabolome changes mediated by tirzepatide. Design Phase 2b trial participants were randomly assigned to receive weekly subcutaneous tirzepatide, dulaglutide, or placebo for 26 weeks. Post hoc exploratory metabolomics and lipidomics analyses were performed. Setting Post hoc analysis. Participants 259 subjects with T2D. Intervention(s) Tirzepatide (1, 5, 10, 15 mg), dulaglutide (1.5 mg), or placebo. Main Outcome Measure(s) Changes in metabolite levels in response to tirzepatide were assessed against baseline levels, dulaglutide, and placebo using multiplicity correction. Results At 26 weeks, a higher dose tirzepatide modulated a cluster of metabolites and lipids associated with IR, obesity, and future T2D risk. Branched-chain amino acids, direct catabolic products glutamate, 3-hydroxyisobutyrate, branched-chain ketoacids, and indirect byproducts such as 2-hydroxybutyrate decreased compared to baseline and placebo. Changes were significantly larger with tirzepatide compared with dulaglutide and directly proportional to reductions of HbA1c, homeostatic model assessment 2-IR indices, and proinsulin levels. Proportional to metabolite changes, triglycerides and diglycerides were lowered significantly compared to baseline, dulaglutide, and placebo, with a bias toward shorter and highly saturated species. Conclusions Tirzepatide reduces body weight and improves glycemic control and uniquely modulates metabolites associated with T2D risk and metabolic dysregulation in a direction consistent with improved metabolic health.

Background/Introduction In a Phase 2 trial, tirzepatide (TZP) dose-dependently reduced HbA1c, body weight and serum triglycerides in moderately obese type 2 diabetes (T2D) patients. Purpose To understand changes in fasting serum lipids with TZP, lipidomics profiling of multiple lipid classes was conducted. Methods Patients (n=314) were randomized to receive weekly subcutaneous TZP, dulaglutide, or placebo for 26 weeks. Shotgun lipidomic analysis was performed in positive electrospray using a Sciex Triple TOF 5600 mass spectrometer operating in MS/MSALL mode and sphingomyelin (SPM) data were acquired in positive electrospray TOF mode. Data were assessed using MMRM. Results At 26 weeks, total cholesterol esters (CE), phosphatidylcholines (PC) and phosphatidylinositols (PI) increased with placebo; dulaglutide treatment did not affect any lipid class (Table). With TZP 10 and 15 mg, total triacylglycerides (TAG), diacylglycerides (DAG), phosphatidylethanolamines (PE), PC and PI dose-dependently decreased at 4, 12 and 26 weeks, whereas total CE and phosphatidylserines (PS) levels did not change at any timepoint. At 26 weeks, individual, but not total, SPM and ceramide (Cer) changes were observed with TZP 15 mg. Most saturated, long chain SPM (14:0, 20:0, 21:0, 22:0, 23:0, 24:0) and Cer (22:0, 23:0, 24:0) were reduced by 8–16% and 14–20%, respectively. Conversely, unsaturated SPM (24:1,24:2) increased by 6.5% and 11.4%, and unsaturated glycosylated Cer 16:0 lactosyl and 24:1 hexosyl increased by 22.4% and 19.3%, respectively. TZP 10 and 15 mg decreased total SPM by 4–6% at 4 weeks, and total Cer between 8% and 13% at 4 and 12 weeks. Conclusions Tirzepatide dose-dependently reduced levels of total TAG, DAG, PE, PC, and PI at all timepoints, whereas levels of saturated long chain SPM and Cer were reduced and those of some unsaturated SPM and glycosylated Cer increased at 26 weeks. Net improvements in lipidomics profiling with tirzepatide warrant further evaluation of potential benefits on cardiovascular events and NASH. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Eli Lilly and Company

Activation of GIP (glucose-dependent insulinotropic peptide) receptor (GIPR) in combination with GLP-1 receptor has demonstrated reduced adiposity and bodyweight in mice. Although the incretin action of GIP in pancreatic beta cells is well characterized, its regulation of adipose tissue metabolism are incompletely understood. Using differentiated human adipocytes we demonstrated GIP suppression of insulin stimulated [14C] glucose and [14C] acetate incorporation into the cellular lipid fraction suggesting GIP/insulin co-regulation of de novo lipogenesis. To further investigate these findings, we employed an NMR and mass spec strategy. Briefly, human adipocytes were differentiated then incubated with [13C] glucose or [13C] acetate overnight in the presence GIP, insulin, GIP + insulin, or control followed by lysate preparation for mass spec and NMR analysis. Isotope label incorporation in lysate fatty acids were determined by HPLC-MS detection of base-hydrolyzed lipids. GIP significantly reduced incorporation of labeled acetate and labeled glucose in fatty acids, both in the presence and absence of insulin. Sample analysis by NMR demonstrated a GIP regulated increase in glycerol production from labeled glucose both in the presence and absence of insulin with little to no acetate incorporation into glycerol under all conditions tested. These findings demonstrate GIP signaling in adipocytes reduces de novo fatty acid synthesis while increasing glycerol formation. This suggests a model whereby GIP suppresses generation of new fatty acids from substrate but enhances appropriate storage capacity of dietary fatty acids by increasing production of glycerol required for triglyceride generation. Further studies will be required to elucidate this potential benefit of GIP to improve nutrient partitioning. Disclosure P.L. Milligan: Employee; Self; Eli Lilly and Company. K.D. Roth: Employee; Self; Eli Lilly and Company. H. Hu: None. J. Moyers: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. X. Ruan: Employee; Self; Eli Lilly and Company. W.C. Roell: Employee; Self; Eli Lilly and Company. A. Regmi: Employee; Self; Eli Lilly and Company.

Acute myeloid leukemia is associated with the abnormal proliferation of myeloid progenitor cells unable to differentiate. Somatic gain-of-function mutations in isocitrate dehydrogenase (IDH) 1 occur in 10% of newly diagnosed AML patients. IDH1 mutations cause intracellular accumulation of the oncometabolite, 2-hydroxyglutarate (2-HG), which results in a hyper-methylation phenotype and a block in differentiation. Inhibitors of IDH1 mutant enzyme reduce levels of 2-HG, which relieves the differentiation block allowing AML cells to achieve terminal maturation. Recently, Ivosidenib, an IDH1 inhibitor, has been approved for use in AML patients. However, based on clinical findings, a fraction of the IDH1 mutant AML patients treated with Ivosidenib are primary refractory or relapse while on therapy. This raises the need for development of more potent inhibitors targeting IDH1. Lilly Research Laboratories have developed a potent covalent inhibitor of mutant IDH1, LY3410738 that modifies a single cysteine (Cys269) in an allosteric binding pocket and rapidly inactivates the enzyme, selectively inhibiting 2-HG production without affecting alpha-ketoglutarate (a-KG) levels. Here, we have assessed the activity of LY3410738 in IDH1 mutated patient-derived AML models and AML cell lines engineered to express wild-type IDH1 or mutant IDH1R132H. In vitro, LY3410738 displayed greater potency for inhibition of 2-HG production and differentiation of the IDH1 mutant cells compared to AG-120. Similarly, in vivo, we observed sustained 2-HG inhibition leading to a more robust and durable efficacy for LY3410738 with respect to AG-120. We next evaluated the combination activity of LY3410738 with Cytarabine and Azacitidine or the FLT3 inhibitor Midostaurin, the latter in FLT3-mutated AML. Combining LY3410738 with the chemotherapeutics resulted in increased efficacy, exhibiting a potent anti-leukemic effect, reduction of 2-HG level, and enhanced differentiation of the leukemic blasts in the mice. In addition, since IDH1 mutant AML cells have been shown to strongly depend on the anti-apoptotic Bcl-2 for the survival, we also combined LY3410738 with FDA approved Bcl-2 inhibitor, venetoclax. In vitro, isogenic cells with IDH1R132H mutation were more sensitive to the combination than wild-type IDH1-expressing cells. Importantly, the combination of LY3410738 with Venetoclax was also efficacious in an AML xenograft model derived from a patient refractory to AG-120. In conclusion, LY3410738 exhibits enhanced efficacy in IDH1 mutant AML PDX models in combination with Cytarabine, Azacitidine, Midostaurin and Venetoclax and demonstrates improved potency and durability compared to Ivosidenib. Citation Format: Vivian Salama, Nathan Brooks, Anna Skwarska, Lisa Kays, Paul Milligan, Katherine Newell, Kenneth Roth, Sandaruwan Geeganage, Raymond Gilmour, Steven M. Chan, Jean-Emmanuel Sarry, Mary Sabatier, Courtney DiNardo, Marina Konopleva. LY3410738, a novel inhibitor of mutant IDH1 is more effective than Ivosidenib and potentiates antileukemic activity of standard chemotherapy in preclinical models of acute myeloid leukemia (AML) [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6417.

Nonalcoholic fatty liver disease (NAFLD) affects a significant number of patients with T2DM and places them at an increased risk of steatohepatitis (NASH) and cirrhosis. However, it is widely underdiagnosed due to lack of a simple, non-invasive test for its diagnosis. The aim of this study was to establish a plasma biomarker profile to identify NAFLD and NASH in patients with T2DM. We recruited 220 patients with T2DM (59±8 years; BMI: 33.6±4.8 kg/m2; A1c: 7.1±1.2%) and screened them for NAFLD by liver magnetic resonance spectroscopy (No NAFLD: n=76; NAFLD: n=144). If positive, a liver biopsy was performed (Isolated steatosis: n=73; NASH: n=71). All patients underwent untargeted plasma metabolomics and lipidomics. To account for multiple comparisons, a Bonferroni’s adjusted p-value Conclusion: Metabolomics/lipidomics may hold promise to non-invasively diagnose NAFLD in patients with T2DM, although its ability to identify those with NASH remains to be established. Disclosure F. Bril: None. S. Kalavalapalli: None. K.L. Duffin: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Pfizer Inc. M.L. Hartman: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. Y. Chen: None. Q. Yang: None. J.V. Haas: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. P.L. Milligan: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. K.D. Roth: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. K. Cusi: Consultant; Self; Janssen Global Services, LLC., Eli Lilly and Company. Research Support; Self; Cirius Therapeutics. Other Relationship; Self; Nordic Bioscience. Research Support; Self; Novartis Pharmaceuticals Corporation, Novo Nordisk Inc.. Other Relationship; Self; Quest Diagnostics. Research Support; Self; Zydus Pharmaceuticals (USA) Inc.. Other Relationship; Self; OWL metabolomics, Echosens. Research Support; Self; Janssen Global Services, LLC.. Consultant; Self; Tobira Therapeutics, Pfizer Inc..

Somatic gain-of-function mutations in IDH1 have been identified in multiple tumor types including AML, glioma, cholangiocarcinoma and chondrosarcoma. The neo-enzymatic activity of mutant IDH1 results in accumulation of the oncometabolite 2-hydroxyglutarate (2-HG), leading to a hyper-methylation phenotype, a block in cell differentiation, and tumor growth. Using a structure-based drug design approach, we have developed a highly potent covalent inhibitor of mutant IDH1. LY3410738 modifies a single cysteine (Cys269) in the allosteric binding pocket and rapidly inactivates the enzyme with a KI/Kinact = 84,257 M-1sec-1. The compound selectively inhibits the 2-HG in IDH1 mutant tumor cells without depleting the levels of a-ketoglutarate. Using patient-derived primary AML cells, we demonstrated that LY3410738 was more potent than AG120 in reversing the block in differentiation associated with IDH1 mutant activity. In vivo, LY3410738 displayed prolonged pharmacodynamic activity, depleting 2-HG levels in tumors at low circulating exposures and for an extended time after clearance of compound. Importantly, LY3410738 has the ability to cross the blood-brain barrier and can achieve concentrations in the brain that exceed those needed to engage the target. Consistent with this, LY3410738 effectively inhibits 2HG in orthotopic glioma models. Using patient-derived IDH1 mutant orthotopic AML models, we demonstrated that LY3410738 effectively inhibited 2-HG, induced differentiation, and cleared AML from mice. Collectively, LY3410738 represents the first covalent brain-penetrant mutant IDH1 inhibitor with potential for Best-in-Class activity. Citation Format: Nathan Brooks, Robin DeWalt, Serge Boulet, ZhaoHai Lu, Lisa Kays, Rachel cavitt, Sandra Gomez, John Strelow, Paul Milligan, Kenneth Roth, Renato Bauer, Stephen Antonysamy, Patric Hahn, Zoran Rankovic, Denis McCann, Gary Mo, Ramon Tiu, Timothy Burkholder, Sandaruwan Geeganage, Raymond Gilmour. Identification and characterization of LY3410738, a novel covalent inhibitor of cancer-associated mutant Isocitrate Dehydrogenase 1 (IDH1) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-274.

LY2584702 is an inhibitor of p70 S6 kinase-1 previously developed for the treatment of cancer. In two phase 1 trials in oncology patients, significant reductions of total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglyceride were observed. In the current study, we sought to understand the potential mechanism of action of this compound in regulating lipid metabolism. In Long Evans diet-induced obese (DIO) rats, oral administration of LY2584702 for 3-4 weeks led to robust reduction of LDL-C up to 60%. An unexpected finding of liver triglyceride (TG) increase implicated a metabolite of LY2584702, 4-aminopyrazolo[3,4-day]pyrimidine (4-APP), in modulation of lipid metabolism in these rats. We showed that low-dose 4-APP, when administered orally for 3-4 weeks to Long Evans DIO rats, produced lipoprotein profile changes that were strikingly similar to LY2584702. Kinetic studies suggested that both LY2584702 and 4-APP had no effect on chylomicron-TG secretion and only exerted a modest effect on hepatic very low-density lipoprotein (VLDL)-TG secretion. In human hepatoma HepG2 cells, 4-APP, but not LY2584702, increased LDL uptake. We hypothesize that generation of the 4-APP metabolite may contribute to the efficacy of LY2584702 in lowering LDL-C in rats and potentially in humans as well. This mechanism of LDL-C lowering may include inhibition of VLDL production and increase in LDL clearance.

The manganese(III)-bis[poly(pyrazolyl)borate] complexes, Mn(pzb)2SbF6, where pzb- = tetrakis(pyrazolyl)borate (pzTp) (1), hydrotris(pyrazolyl)borate (Tp) (2), or hydrotris(3,5-dimethylpyrazolyl)borate (Tp*) (3), have been synthesized by oxidation of the corresponding Mn(pzb)2 compounds with NOSbF6. The Mn(III) complexes are low-spin in solution and the solid state (μeff = 2.9−3.8 μB). X-ray crystallography confirms their uncommon low-spin character. The close conformity of mean Mn−N distances of 1.974(4), 1.984(5), and 1.996(4) A in 1, 2, and 3, respectively, indicates absence of the characteristic Jahn−Teller distortion of a high-spin d4 center. N−Mn−N bite angles of slightly less than 90o within the facially coordinated pzb- ligands produce a small trigonal distortion and effective D3d symmetry in 1 and 2. These angles increase to 90.0(4)o in 3, yielding an almost perfectly octahedral disposition of N donors in Mn(Tp*)2+. Examination of structural data from 23 metal−bis(pzb) complexes reveals systematic...

The manganese(III)-bis[poly(pyrazolyl)borate] complexes, Mn(pzb)2SbF6, where pzb- = tetrakis(pyrazolyl)borate (pzTp) (1), hydrotris(pyrazolyl)borate (Tp) (2), or hydrotris(3,5-dimethylpyrazolyl)borate (Tp*) (3), have been synthesized by oxidation of the corresponding Mn(pzb)2 compounds with NOSbF6. The Mn(III) complexes are low-spin in solution and the solid state (microeff = 2.9-3.8 microB). X-ray crystallography confirms their uncommon low-spin character. The close conformity of mean Mn-N distances of 1.974(4), 1.984(5), and 1.996(4) A in 1, 2, and 3, respectively, indicates absence of the characteristic Jahn-Teller distortion of a high-spin d4 center. N-Mn-N bite angles of slightly less than 90 degrees within the facially coordinated pzb- ligands produce a small trigonal distortion and effective D3d symmetry in 1 and 2. These angles increase to 90.0(4)degrees in 3, yielding an almost perfectly octahedral disposition of N donors in Mn(Tp*)2+. Examination of structural data from 23 metal-bis(pzb) complexes reveals systematic changes within the metal-(pyrazolyl)borate framework as the ligand is changed from pzTp to Tp to Tp*. These deformations consist of significant increases in M-N-N, N-B-N, and N-N-B angles and a minimal increase in Mn-N distance as a consequence of the steric demands of the 3-methyl groups. Less effective overlap of pyrazole lone pairs with metal atom orbitals resulting from the M-N-N angular displacement is suggested to contribute to the lower ligand field strength of Tp* complexes. Mn(pzb)2+ complexes undergo electrochemical reduction and oxidation in CH3CN. The electrochemical rate constant (ks,h) for reduction of t2g4 Mn(pzb)2+ to t2g3eg2 Mn(pzb)2 (a coupled electron-transfer and spin-crossover reaction) is 1-2 orders of magnitude smaller than that for oxidation of t2g4 Mn(pzb)2+ to t2g3 Mn(pzb)22+. ks,h values decrease as Tp*pzTpTp for the Mn(pzb)2+/0 electrode reactions, which contrasts with the behavior of the comparable Fe(pzb)2+/0 and Co(pzb)2+/0 couples.