Preclinical and early clinical profile of a highly selective and potent oral inhibitor of aldosterone synthase (CYP11B2)

K Bogman, D Schwab, ML Delporte, G Palermo… - …, 2017 - Am Heart Assoc
K Bogman, D Schwab, ML Delporte, G Palermo, K Amrein, S Mohr, MC De Vera Mudry…
Hypertension, 2017Am Heart Assoc
Primary hyperaldosteronism is a common cause of resistant hypertension. Aldosterone is
produced in the adrenal by aldosterone synthase (AS, encoded by the gene CYP11B2). AS
shares 93% homology to 11β-hydroxylase (encoded by the gene CYP11B1), responsible for
cortisol production. This homology has hitherto impeded the development of a drug, which
selectively suppresses aldosterone but not cortisol production, as a new treatment for
primary hyperaldosteronism. We now report the development of RO6836191 as a potent (Ki …
Primary hyperaldosteronism is a common cause of resistant hypertension. Aldosterone is produced in the adrenal by aldosterone synthase (AS, encoded by the gene CYP11B2). AS shares 93% homology to 11β-hydroxylase (encoded by the gene CYP11B1), responsible for cortisol production. This homology has hitherto impeded the development of a drug, which selectively suppresses aldosterone but not cortisol production, as a new treatment for primary hyperaldosteronism. We now report the development of RO6836191 as a potent (Ki 13 nmol/L) competitive inhibitor of AS, with in vitro selectivity >100-fold over 11β-hydroxylase. In cynomolgus monkeys challenged with synthetic adrenocorticotropic hormone, single doses of RO6836191 inhibited aldosterone synthesis without affecting the adrenocorticotropic hormone–induced rise in cortisol. In repeat-dose toxicity studies in monkeys, RO6836191 reproduced the adrenal changes of the AS/− mouse: expansion of the zona glomerulosa; increased expression of AS (or disrupted green fluorescent protein gene in the AS−/− mouse); hypertrophy, proliferation, and apoptosis of zona glomerulosa cells. These changes in the monkey were partially reversible and partially preventable by electrolyte supplementation and treatment with an angiotensin-converting enzyme inhibitor. In healthy subjects, single doses of RO6836191, across a 360-fold dose range, reduced plasma and urine aldosterone levels with maximum suppression at a dose of 10 mg, but unchanged cortisol, on adrenocorticotropic hormone challenge, up to 360 mg, and increase in the precursors 11-deoxycorticosterone and 11-deoxycortisol only at or >90 mg. In conclusion, RO6836191 demonstrates that it is possible to suppress aldosterone production completely in humans without affecting cortisol production.
Clinical Trial Registration
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01995383.
Am Heart Assoc