Tom Reynders

In Vivo Quantification of Calcitonin Gene-Related Peptide Receptor Occupancy by Telcagepant in Rhesus Monkey and Human Brain Using the Positron Emission Tomography Tracer [11C]MK-4232

Calcitonin gene-related peptide (CGRP) is a potent neuropeptide whose agonist interaction with the CGRP receptor (CGRP-R) in the periphery promotes vasodilation, neurogenic inflammation and trigeminovascular sensory activation. This process is implicated in the cause of migraine headaches, and CGRP-R antagonists in clinical development have proven effective in treating migraine-related pain in humans. CGRP-R is expressed on blood vessel smooth muscle and sensory trigeminal neurons and fibers in the periphery as well as in the central nervous system. However, it is not clear what role the inhibition of central CGRP-R plays in migraine pain relief. To this end, the CGRP-R positron emission tomography (PET) tracer [11C]MK-4232 (2-[(8R)-8-(3,5-difluorophenyl)-6,8-[6-11C]dimethyl-10-oxo-6,9-diazaspiro[4.5]decan-9-yl]-N-[(2R)-2′-oxospiro[1,3-dihydroindene-2,3′-1H-pyrrolo[2,3-b]pyridine]-5-yl]acetamide) was discovered and developed for use in clinical PET studies. In rhesus monkeys and humans, [11C]MK-4232 displayed rapid brain uptake and a regional brain distribution consistent with the known distribution of CGRP-R. Monkey PET studies with [11C]MK-4232 after intravenous dosing with CGRP-R antagonists validated the ability of [11C]MK-4232 to detect changes in CGRP-R occupancy in proportion to drug plasma concentration. Application of [11C]MK-4232 in human PET studies revealed that telcagepant achieved only low receptor occupancy at an efficacious dose (140 mg PO). Therefore, it is unlikely that antagonism of central CGRP-R is required for migraine efficacy. However, it is not known whether high central CGRP-R antagonism may provide additional therapeutic benefit.

Evaluation of [18F]MK-0911, a positron emission tomography (PET) tracer for opioid receptor-like 1 (ORL1), in rhesus monkey and human

Antagonism of the central opioid receptor like-1 receptor (ORL1) has been implicated in cognition, and has been a focus of drug discovery efforts to ameliorate the cognitive deficits that remain during the stable treatment of schizophrenia with current antipsychotics. In order to facilitate dose selection for phase II clinical testing an ORL1-specific PET tracer was developed to determine drug plasma concentration versus occupancy relationships in order to ensure that the doses selected and the degree of target engagement were sufficient to ensure adequate proof of concept testing. MK-0911 is a selective, high affinity antagonist for the ORL1 receptor radiolabeled with high specific activity (18)F for positron emission tomography (PET) studies. Evaluation of [(18)F]MK-0911 in rhesus monkey PET studies showed a pattern of brain uptake which was consistent with the known distribution of ORL1. In vitro autoradiography with [(18)F]MK-0911 in rhesus monkey and human brain tissue slices showed a regional distribution that was consistent with in vivo imaging results in monkey. Pre-treatment of rhesus monkeys with high doses of structurally diverse ORL1 antagonists MK-0584, MK-0337, or MK-5757 achieved blockade of [(18)F]MK-0911 in all gray matter regions. Baseline PET studies with [(18)F]MK-0911 in healthy human subjects showed tracer distribution and kinetics similar to that observed in rhesus monkey. Quantification of [(18)F]MK-0911 uptake in repeat human baseline PET studies showed a test-retest variability in volume of distribution (V(T)) averaging 3% across brain regions. Humans dosed orally with MK-5757 showed reduced [(18)F]MK-0911 tracer concentration in brain proportional with MK-5757 dose and plasma level. [(18)F]MK-0911 was useful for determining MK-5757-induced receptor occupancy of ORL1 to guide MK-5757 dose-selection for clinical proof-of-concept studies. Additionally, [(18)F]MK-0911 may be a useful tool for studying the pharmacology of ORL1 in various human populations and disease states.

PET imaging in healthy subjects and migraineurs suggests CGRP receptor antagonists do not have to act centrally to achieve clinical efficacy.

Calcitonin gene-related peptide (CGRP) is a potent vasodilator and sensory neuropeptide implicated in the pathophysiology of migraine headache. CGRP receptor (CGRP-R) antagonists, including telcagepant, have shown clinical efficacy in treating migraine. CGRP-Rs are expressed in the CNS, particularly in the brainstem and cerebellum as well as in the periphery on vascular smooth muscle cells. To investigate whether central CGRP-Rs were likely to be involved in the anti-migraine effects of CGRP-R antagonists we examined central CGRP-R occupancy (CGRP RO) at an efficacious dose of telcagepant in healthy volunteers and in migraineurs during ictal and interictal periods using the novel PET tracer [11C]MK-4232. CGRP RO was evaluated in healthy subjects (n=3) at the lowest clinically efficacious dose (140 mg, PO) of telcagepant ~2h after dosing, coinciding with the time point of efficacy evaluation in clinical migraine studies. PET imaging showed only low CGRP RO (4% - 10%) which is within test-retest variability, suggesting that central activity is not a pre-requisite for anti-migraine efficacy of CGRP-R antagonists. A supratherapeutic telcagepant dose (1120 mg, PO) produced only moderate (43-58%, n=4) CGRP RO at ~Tmax (3h after administration). Subsequently, the possibility that brain penetration of telcagepant, a P-gp brain efflux pump substrate, may be increased in migraine patients or during migraine by blood brain barrier opening, was investigated by PET studies in the ictal and interictal periods in migraineurs (n=3) ~2 h after telcagepant dosing (140 mg, PO). Comparison of [11C]MK-4232 PET study results from ictal and interictal periods in migraineurs to healthy volunteers, suggests similar low RO and no significant differences between states. In conclusion, PET studies with the CGRP-R PET tracer [11C]MK-4232 after therapeutic doses of telcagepant in healthy volunteers and migraineurs suggest that central antagonism of CGRP-R is not necessary for therapeutic efficacy in migraine pain relief and that migraine pain is therefore at least in part peripheral in origin.

Discovery and Clinical Evaluation of MK‐8150, A Novel Nitric Oxide Donor With a Unique Mechanism of Nitric Oxide Release

Background Nitric oxide donors are widely used to treat cardiovascular disease, but their major limitation is the development of tolerance, a multifactorial process to which the in vivo release of nitric oxide is thought to contribute. Here we describe the preclinical and clinical results of a translational drug development effort to create a next‐generation nitric oxide donor with improved pharmacokinetic properties and a unique mechanism of nitric oxide release through CYP3A4 metabolism that was designed to circumvent the development of tolerance. Methods and Results Single‐ and multiple‐dose studies in telemetered dogs showed that MK‐8150 induced robust blood‐pressure lowering that was sustained over 14 days. The molecule was safe and well tolerated in humans, and single doses reduced systolic blood pressure by 5 to 20 mm Hg in hypertensive patients. Multiple‐dose studies in hypertensive patients showed that the blood‐pressure–lowering effect diminished after 10 days, and 28‐day studies showed that the hemodynamic effects were completely lost by day 28, even when the dose of MK‐8150 was increased during the dosing period. Conclusions The novel nitric oxide donor MK‐8150 induced significant blood‐pressure lowering in dogs and humans for up to 14 days. However, despite a unique mechanism of nitric oxide release mediated by CYP3A4 metabolism, tolerance developed over 28 days, suggesting that tolerance to nitric oxide donors is multifactorial and cannot be overcome solely through altered in vivo release of nitric oxide. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01590810 and NCT01656408.

First-in-human brain imaging of Alzheimer dementia patients and elderly controls with 18F-MK-6240, a PET tracer targeting neurofibrillary tangle pathology

18F-MK-6240 (18F-labeled 6-(fluoro)-3-(1H-pyrrolo[2,3-c]pyridin-1-yl)isoquinolin-5-amine) is a highly selective, subnanomolar-affinity PET tracer for imaging neurofibrillary tangles (NFTs). Plasma kinetics, brain uptake, and preliminary quantitative analysis of 18F-MK-6240 in healthy elderly (HE) subjects, subjects with clinically probable Alzheimer disease (AD), and subjects with amnestic mild cognitive impairment were characterized in a study that is, to our knowledge, the first to be performed on humans. Methods: Dynamic PET scans of up to 150 min were performed on 4 cognitively normal HE subjects, 4 AD subjects, and 2 amnestic mild cognitive impairment subjects after a bolus injection of 152–169 MBq of 18F-MK-6240 to evaluate tracer kinetics and distribution in brain. Regional SUV ratio (SUVR) and distribution volume ratio were determined using the cerebellar cortex as a reference region. Total distribution volume was assessed by compartmental modeling using radiometabolite-corrected input function in a subgroup of 6 subjects. Results: 18F-MK-6240 had rapid brain uptake with a peak SUV of 3–5, followed by a uniformly quick washout from all brain regions in HE subjects; slower clearance was observed in regions commonly associated with NFT deposition in AD subjects. In AD subjects, SUVR between 60 and 90 min after injection was high (approximately 2–4) in regions associated with NFT deposition, whereas in HE subjects, SUVR was approximately 1 across all brain regions, suggesting high tracer selectivity for binding NFTs in vivo. 18F-MK-6240 total distribution volume was approximately 2- to 3-fold higher in neocortical and medial temporal brain regions of AD subjects than in HE subjects and stabilized by 60 min in both groups. Distribution volume ratio estimated by the Logan reference tissue model or compartmental modeling correlated well (R2 > 0.9) to SUVR from 60 to 90 min for AD subjects. Conclusion: 18F-MK-6240 exhibited favorable kinetics and high binding levels to brain regions with a plausible pattern for NFT deposition in AD subjects. In comparison, negligible tracer binding was observed in HE subjects. This pilot study suggests that simplified ratio methods such as SUVR can be used to quantify NFT binding. These results support further clinical development of 18F-MK-6240 for potential application in longitudinal studies.

DISCOVERY AND FIRST-IN-HUMAN EVALUATION OF THE TAU-IMAGING PET RADIOTRACER [18F]MK-6240

Parametric [C]PBB3, and [C]PiB PET images were generated by calculation of target-to-cerebellar cortex standardized uptake value ratio (SUVR) at 30-50 min, and 50-70 min after radiotracer injection, respectively. [C]PiB retention was assessed by visual inspection of SUVR images. A two sample t-test was also performed on [C]PBB3 PET SUVR images between each patient and 13 HCs using SPM12. Neuropathological and autoradiographic examinations were performed in postmortem brain sections of other patients with three MAPT mutations. Results: All subjects were negative for amyloid PET. Five subjects with MAPT gene mutations exhibited increased [C]PBB3 binding in the brain compared with HCs. In the N279K mutation carriers, increased [C]PBB3 bindings were detected at an asymptomatic stage, and were spatially extended involving white matter with the progression of clinical manifestations. In contrast, patients with R406W and G272V mutations showed increased [C]PBB3 binding mostly restricted to gray matter in the brain. Autoradiographic signals and fluorescence labeling of brain sections revealed that PBB3 binds to various tau inclusions in the brain with these three mutations. Conclusions: [C]PBB3 PET can detect diverse tau inclusions, and may be useful for monitoring disease progression and therapeutic effect of anti-tau therapy in patients with MATP mutations, and other tauopathies.

Preliminary evaluation of the amyloid PET Radioligand [18F]MK-3328 in Alzheimer's Disease patients

P2-035 PRELIMINARY EVALUATION OF THE AMYLOID PET RADIOLIGAND [18F]MK-3328 IN ALZHEIMER’S DISEASE PATIENTS Sandra Sanabria-Bohorquez, Eric Hostetler, Koen Van Laere, Michel Koole, Guy Bormans, Kim Serdons, Jan de Hoon, Rik Vandenberghe, Jan Versijpt, Inge De Lepeleire, Tom Reynders, Gilles Tamagnan, Kenneth Marek, John Seibyl, Danna Jennings, Olivier Barret, Andrei Koren, Laura Rosen, Richard Hargreaves, Jeffrey Evelhoch, Cyrille Sur, Mark Forman, Merck, West Point, Pennsylvania, United States; University Hospital Leuven, Leuven, Belgium; UZ Leuven, Leuven, Belgium; KU Leuven, Leuven, Belgium; University Hospitals Leuven, Leuven, Belgium; UZ Brussels, Brussels, Belgium; Merck, Brussels, Belgium; MNI, New Haven, Connecticut, United States; Merck, Upper Gwynedd, Pennsylvania, United States; Merck, West point, Pennsylvania, United States.