Lost in the fanfare surrounding the BTK inhibitor Ibrutinib and the PI3Kdelta inhibitor Idelalisib at this year’s American Society of Clinical Oncology meeting (ASCO 2013) was some rather stunning data from AbbVie on their Bcl-2 selective inhibitor ABT-199.

ABT-199 binds to Bcl-2 in such a manner as to prevent this protein from interacting with pro-apoptotic proteins such as BAX and BID, thereby allowing them to attach to the mitochondrial membrane, induce cytochrome-c release and trigger apoptotic cell death. Tumors disable the Bcl-2 pathway in a number of clever ways. Many tumor types delete p53, a protein that normally up-regulates expression of BAX and BID and down-regulates expression of Bcl-2 and related proteins (BclxL, Mcl-1, Bcl-w, etc). Tumors with this deletion phenotype are termed 17p(del) referring to the site of chromosomal alteration. Such tumors are generally very aggressive, resistant to chemotherapy and radiation, and associated with poor prognosis.

B cell lymphomas constitute a diverse collection of lymphomas and some leukemias (the distinctions have become blurred). B cell lymphomas have historically been classified as Hodgkin lymphomas or the very diverse Non Hodgkin lymphomas (NHL). The term NHL is confusing as this covers chronic lymphocytic lymphoma (CLL), mantle cell lymphoma (MCL), diffuse large B cell lymphomas of 2 subtypes (DLBCL-ABC and DLBCL-GCB), indolent Non Hodgkin lymphoma (iNHL) and a host of other tumor types. A baffling mix of biology and acronyms, but simply put, all of these tumor types are derived from various stages of B cell development, and most require signaling through the B cell receptor (BCR) to survive. The BCR triggers proliferative and survival (anti-apoptotic) signals, and therefore Bcl-2 becomes a relevant target in NHL.

Not surprisingly, genetic evaluation of B cell lymphomas has revealed mutations in Bcl-2 or downstream of Bcl-2 that foster lymphoma cell survival. Examples include constitutive activation of Bcl-2 in follicular lymphoma (FL) and CLL, amplification of Bcl-2 in MCL, down-regulation of NOXA (another pro-apoptotic protein) and BIM (a protein that regulates Bcl-2 activity) in iNHL and CLL, and down-regulation of expression of the caspases, part of the apoptotic machinery triggered by mitochondrial cytochrome-c release, in CLL.

ABT-199 was developed as a follow-on to the earlier Abbott compound navitoclax (ABT-263). Navitoclax inhibited multiple Bcl-2 family members, including BclxL, and was associated with severe thrombocytopenia (platelet loss) in clinical trials. Bcl-xL is an obligate pro-survival protein for platelets and thrombocytopenia became a dose limiting toxicity in navitoclax clinical trials. ABT-199 has a much lower affinity for BclxL than for Bcl-2, and spares other proteins in this family, as shown in this data reproduced from a recent AbbVie paper (Souers et al. 2013. Nat Med 19: 202-210):

                                 TR-FRET Ki (nM)

                      Bcl-2    Bcl-xL    Mcl-1    Bcl-w

navitoclax       0.044    0.055      > 224     > 7

ABT-199      < 0.01     48          > 444     245

What is important to note here is the relative difference in potency of ABT-199 against Bcl-2 (less than 10 picomolar, an unbelievable potency number) vs 48nM against BclxL. Taken at face value this is a 4800 fold difference in target potency. As noted below however, the number may be deceiving given the drug exposure achieved in patients.

AbbVie presented several studies at ASCO, including their Phase 1b trial in CLL. What is striking about the data is the response rates, as these compare favorably with similar data shown recently for BTK inhibitors and PI3K inhibitors, from Gilead (Idelalisib), Infinity (IPI-145), Celgene (CC-292) and J&J (ibrutinib). A snapshot of results from the CLL trials is shown below.

The table is adapted from results presented at ASH 2012, ASCO 2013 and this year’s European Hematology Association meeting (EHA 2013), as generously posted on Twitter by @andybiotech. ABT-199 differentiates from the competing drugs in several critical ways. First the OR rate reached 84% and was not statistically different between CLL patients having or not having the p53 deletion, ie.17p(del). Second, the CR rate was 18%, meaning that this many patients absolutely cleared disease from the bloodstream, lymphatic fluid, and lymph nodes. In addition AbbVie stated at ASCO that in the CR group, 11% had complete recovery of the bone marrow and 7% had partial bone marrow recovery – these are responses that are not seen with BTK or PI3Kg/d or PI3Kd inhibitors.

So why did the fanfare around NHL treatment coming out of Chicago in May during ASCO 2013 not include ABT-199? The answer was toxicity, and this toxicity came in 2 distinct forms. One has been addressed recently, the other is somewhat complex.

Tumor Lysis Syndrome (TLS) is a drastic physiological response to the sudden and acute destruction of massive numbers of tumor cells, more or less simultaneously. The disgorging of massive quantities of intracellular material triggers acute physiologic response as the heart, kidney, spleen and other organs cope with a titanic overload of potassium, calcium, phosphate, and uric acid. Organs fail and circulation collapses the patient drops quickly toward death. ABT-199 caused this syndrome in the first 3 patients that were dosed, each having been given 200mg of drug. One died. Faced with this spectacular disaster AbbVie immediately halted all ABT-199 clinical trials. That was back in January or February of this year. So the update at the end of May was tempered by this ongoing toxicity issue, and what AbbVie had to say at that point didn’t help. Starting with a lower dose of 50 mg they had restarted all trials, and gotten the drug into 34 CLL patients. Three experienced TLS, 1 died, 1 lost renal function (acute renal failure, generally meaning a lifetime of dialysis or a transplant). In addition, other toxicities were present, as seen in the next table showing severe toxicities (grade 3+) in CLL clinical trials. URI: upper respiratory infection. NA: data not available

The table is adapted from results presented at ASH 2012, ASCO 2013 and EHA 2013, as generously posted on Twitter by @andybiotech.

Where really jumps out here is at the level of thrombocytopenia and neutropenia seen in patients receiving ABT-199. Its worth noting that patients taking any of these new drugs are already at risk for decreased cellularity due to chemotherapy, and so adding to this burden complicates their subsequent care. Neutropenia is a bona fide pathway toxicity as demonstrated by defective expression of Bcl-2 in Kostmann syndrome (severe congenital neutropenia) and so there is nothing to do about this but lower drug exposure, potentially at the expense of efficacy. An interesting question in this regard is whether the thrombocytopenia and anemia seen are due to residual inhibition of BclxL. If you look at the PK data presented from the CLL trial, its pretty clear the effective concentrations of drug are far in excess of what is needed to inhibit BclxL. Taking data presented by Seymour et al. at ASCO 2013, abstract #7018, its clear that the maximum concentration achieved after multiple doses (Cmax_(ss)) is up to 2mg/ml, which is going to give low mM exposure. So, at Cmax and for some time thereafter, drug concentration exceeds that required to inhibit BclxL by as much as 50-fold. Whether the duration of inhibition is sufficient to induce thrombocytopenia and anemia in patients is not known.

Why does all this matter? Selective Bcl-2 inhibition is a unique strategy and ABT-199 illustrates compelling activity. In the era of rapidly advancing combination therapy for NHL, this could be an important component of the evolving treatment paradigm. With a lower dose they will try to avoid TLS and perhaps blunt thrombocytopenia and neutropenia. In the near term this drug may play a prominent role in patients who are at high risk (17p(del) or who are refractory to other targeted therapies. More interestingly, Bcl-2 inhibition in combination therapy may be a breakthrough treatment paradigm, and in this regard, AbbVie is swinging for the fences with trials combining ABT-199 with R-CHOP (Rituxan + chemotherapy) in pursuit of achieving outright cures. Combine this with genetic profiling of Bcl-2 and related proteins across many tumor types, and you have a very interesting story.