TYM 1.

1
Overview of the drug development Pathway.
1.The Research and development process.
When I talk about the R&D process-- and that's research and development, longhand-- I like to use a quote from Albert Einstein. "If we knew what we were doing, it would not be called research, would it?" And I'd like to start this way because very few things that start in research ever end up as a drug product. And that's one of the points that we're going to cover today when we look at the actual development pathway. I learned this lesson when I was in graduate school. And I think all of us can speak to the need to go through many failures before we have a success. And you're going to see that that is clearly the case when it comes to drug development. So if you take a look at the chart that is in front of you that represents the drug development process, you can see that you start at an early stage that we call drug discovery. And you work through pre-clinical. And the next big chunk is when you do your clinical studies. And then once you get through the clinical studies and you've passed through all of these hurdles, you'll go into your marketing and post-marketing phase. But one thing that you need to understand is that at the very early stages in discovery, you may start out with anywhere from 5,000, 10,000, or 20,000 compounds. And you go through a screening process that whittles those down that by the time you go to the next stage, which we call pre-clinical-- and it's designated that because it's before you go into the clinic. When you get to that stage, you may have about 250 compounds from those tens of thousands that you looked at before. Over another series of experiments and characterization, we advance a more limited number into clinical trials. And these are just a handful that goes into clinical trials. These sometimes can be as few as two to five compounds-- again it started out from that group of tens of thousands of compounds-- will go into the clinic. What's happening throughout that process is that we are testing them to make sure they're working in the way we want them to work. In other words, if we're trying to target a certain disease such as asthma, we'll see whether it's working in a model that will help predict whether it's going to work. Then you have constraints as to the types of physical and chemical characteristics of the actual molecule, whether that can be made into something that can be turned into a medicine. And we will go through all of these types of barriers that you must cross before you can get into even a human clinical trial. Once you do pass into the phase where you're going into clinical trials, this is a very long and expensive process. So the number of drugs that go into this phase are limited not only by what could work to help a disease, but also by the expense it's going to cost to move it through that cycle. So let's talk about that cost. The average cost to develop a drug product is about $2 billion. Back the 1980s, that number was about $100 million. And you can see that over a 30- to 40-year span, that number has just risen significantly. And there are many reasons for this. You can take a look and compare pricing from 1995 to 2000, and then look even just five years later, in the 2000 to 2005 segment, and see that it increased from about $1.1 billion to $1.7 billion. If you look at the colour coding, you can see that in that time period theres a slight increase in the discovery research cost. And that's signified in the blue. The pre-clinical, which is a very small sliver of the

green, may appear small, but those costs also went up somewhat, as well as the early Phase I clinical trials. And we haven't talked about that yet, but the clinical trials are divided into phases. The early ones that have fewer patients are called Phase I. And as they go into Phase II and Phase III, you have more patients. So if you look in the one that is coded with orange and as your Phase II studies where you have more patients that are enrolled, there are significant increases in the cost. Similarly, with the Phase III studies, there's even a greater increase in the cost. And, finally, the launch the launch of these products has also increased in cost. So you can see that almost every phase has increased in cost making it not only a long process, but an even more expensive process as time goes on. So let's go back to our original diagram and go a little more in depth on each of these phases so you can get a greater understanding and appreciation for what is happening. What you'll see in the graphics is in the early discovery phase, you may screen tens of thousands of compounds before you find one that hits the target that you're looking for. It's almost like looking for a needle in a haystack. And as you go through those processes to narrow down those drug candidates, what you're looking for is the best potential for being able to achieve a very specific result. You can think of a lot of different diseases. If you're trying to treat cancer, you want to stop the growth of cancer cells. You want to eradicate them. If you want to treat something, it might be a skin condition that youre looking for a very clear end point in what you're trying to do when youre in the drug discovery process. There are some standard ways to screen potential drug products to see whether they meet these certain criterias and advance to the next phase. But don't forget the Einstein quote. Most of those that are screened do not move on to the next phase, which is what we call pre-clinical.

2.The Drug Discovery Process

Now we're going to talk about the drug discovery process, which is the part of the development pathway where you're screening for potential compounds. And this activity can take anywhere between one and three years. So this is the segment where you can narrow down from those tens of thousands of compounds that you're looking at-- and we call these leads-- and decide what you want to move forward into the preclinical phase. So why do you need to narrow it down before you go into the preclinical phase? It's all about resources, time and money. As you move through drug development, each phase becomes more labor-intensive and more expensive. So there's an incentive to narrow down the number of compounds that progress to the next phase. Also, you're discovering which ones have the most activity so they will have the most likelihood for being something that will help either mitigate or cure a certain disease. So the drug discovery process is a way of optimizing the lead candidates. And it involves several steps. First, during discovery, you will typically be working in a narrow area, such as looking at drugs that can treat a certain type of cancer, or respiratory disease, or even pain. A company may specialize in one therapeutic area. Our larger companies can look and be working actively in six to eight different therapeutic areas where they're conducting research and development activities that can address things such as cardiovascular problems, immunology, and infectious disease. There's a whole host of what we call therapeutic areas that a company can look at. In that case, there will be different discovery teams for each of the different disease areas so they can focus on identifying and characterizing the drug molecules that would be helpful to treat those diseases. And we call this phase the hypothesis validation, where these leads are fully characterized and optimized. In addition to looking at the activity that a molecule may have, you also want to look at the feasibility for making larger quantities of that molecule, even just to move into the preclinical phase. But you have to start thinking, at this very early phase, about whether you're going to be able to manufacture this particular molecule in sufficient quantities so that it can go into massive production at some point down the line if it's successful in clinical trials. And so what you're going to learn as we go through this process, many of the things that you may think happen after a drug is approved, such as deciding where it's going to be manufactured and going through that whole set of hurdles that you may have to go through-- no, it starts early. You have to think about manufacturing the drug product very early in the process. That's a tremendous consideration. All of these processes really are very tedious. And it's very important at this early stage to be very careful that what you propose to move forward has all of the characteristics of the kind of drug molecule that will be not only good from a clinical point of view but also in terms of a manufacturing perspective, but also making sure that you have something that represents a significant advance for other medical therapies that may already be out there.

3.The Proof Of Process

So when a compound moves from drug discovery, the next phase is what we call the pre-clinical phase. And pre-clinical is another term that's used as "Proof of Concept." It's really the proving ground for when you have these molecules that had some testing. They come from the more robust testing before they go into the clinic. It's really the "make it or break it" phase. And pre-clinical is a real link between what happens in a research lab and what can go into the clinic. When you move into pre-clinical, larger amounts of materials are available, traditionally so that you can test them in ways, so that you can look at their physical and chemical properties. You may need to know how easy it's going to be to formulate it into a dosage form or delivery system that you may be familiar with, whether it's an inhaled product or a transdermal patch or an intravenous injection. This is the stage at which you need to have the material so you can do testing and make sure that you're going to be able to use it in the way you need to use it. Why is this important? Well, for example, if you're trying to treat asthma, you typically would want to get as close as you can to the lung. So you'll traditionally use an inhaled product to treat some sort of lung disease. So you're going to want to make sure that whatever drug molecule you're looking at, that it can be formulated into something that can go into an inhaler, create these small particles, and go directly into your lung. And that's what we do in the pre-clinical phase. We characterize the material. We build formulations. And then we can do more robust evaluation of these to see whether they are really something that should be moved forward into the clinical phase. As a reminder, you'll have about 250 compounds coming out of drug discovery into the pre-clinical phase that very few make it into human clinical trials. About 5 out these 250 will make it in there. So this is a time when you can say it takes three to five years. There's a lot of different things you're looking at. It's very unpredictable how long it will take to not only characterize these materials, put them in formulations, but also evaluate whether they're going to say stable when they're sitting in the pharmacy. Larger quantities of the drug molecule are typically available so that you can start doing things that include the physical and chemical characterization in the materials. Now, this might just sound like a lot of science, but let me tell you why it's important. In order for a molecule to be active, it has to be able to get to wherever you want it to go in the body. In some cases, it's really important that that drug be soluble, so it can move through your GI tract. In other cases, you might want different properties so that it can be absorbed through the skin if you're going to be using a transdermal patch. If you've ever had to use an inhaled product, you know that if you use an inhaler, this has very tiny particles. So you have to know, whether for the disease that you're treating, that the material that you've been given is going to be something that you can make it into a drug product. So that's why the material characterization is a really important part of the pre-clinical process. But what also builds on that is how you develop a formulation. And we're going to be talking next week in more detail about formulation development. But what I'll talk to you about now is in the very general terms. Depending on the disease, you are going to select a very specific way to deliver a drug product. If you've ever been in a hospital or you've known somebody in the hospital, the quickest way to get a drug into somebody is through an intravenous injection, if you've seen somebody with a needle in their arm. That's the quickest way to get in because it's already dissolved. And it goes directly into the bloodstream. But it could be that you have a headache, and you want to take a tablet. And it might be that you have a condition where you want that tablet to release something over a long period of time, so you only have to take it once a day. And that's called a sustained-release delivery system. That's one term for

it. So depending on what you're treating, you may want something that gets into your system quickly, more slowly, or something that gets in at a fairly even rate. And that's what we talk about when we talk about formulation development. Then we move into the kinetics. The kinetics is how things move through your body. And this is described by how they are absorbed, how they are distributed throughout the body, how they're metabolized, and how they're excreted. And it's very important in the pre-clinical phase to understand what happens to a drug when it gets in your body. And this is what we do through pharmacokinetics because, again, it's how we predict what's going to happen when it goes into a person. We want to know if a drug, once you take it, is cleared within an hour, or does it linger for 24 hours? That will help inform us what kind of dosing is most appropriate. We also use pharmacokinetic studies to help us look at not only a time profile of how a drug is absorbed and when it might be active and become less and less active, but we also use it to determine whether or not you might need to take this with food or without food. There are many examples where you can look at data and tell that something is either better absorbed or more poorly absorbed based on whether you take it with a meal or without a meal. And so that is something that the area of pharmacokinetics is very important for each one of us because it helps us understand when we take a medicine, the proper way to take it is really defined by doing these sorts of studies. We talked a little bit, I mentioned a little bit about characterizing the materials. Not only do we look at the physical and chemical components of these materials, but we also look at, again, how easy it's going to be to make larger quantities. We may have started out with just a few grams, something you could hold on one fingertip when you're in the discovery phase. When in the preclinical phase, you may just have a handful. But certainly, when you move from pre-clinical into the clinical phase, you're going to need a significant amount of material in order to accommodate all of the patients that are in these clinical trials. So you're going to start, even at this early phase, looking at how you can increase the batch size of a manufactured product so that we're doing what's called scaling up, going from smaller quantities to larger quantities not only of the material, but of something as a tablet or a capsule or something you inhale, something you inject, a patch to put on your skin. We need to start making those in larger quantities as well.

4.Good Laboratory Practices

In the United States, the final activity that takes place in the preclinical phase is conducting what are called GLP, or Good Laboratory Practices safety studies. These are highly-regulated studies. And any laboratory that performs them must comply with Food and Drug Administration guidelines that are set forth. These are very robust studies that typically a company would talk with the Food and Drug Administration to design the studies to make sure that when they see the results, it will give them the information they need to make the decision whether or not to allow this new drug product to be tested in humans. These tests can take one to two years, and are seen as the pivotal activity since it's the link between laboratory and clinic. And in the US, only if you have conducted these studies and they had been reviewed by FDA, can you be considered to go into a human clinical trial with your new drug product.

5.What Is An IND ?
When a company has sufficient knowledge and test results to indicate that they have a novel drug that they want to have tested in clinical trials, first, you must gain approval from a regulatory agency. In the US, this is done through a process called filing an IND. And that stands for an Investigational New Drug application. As mentioned previously, you will file this application using results from the final regulated safety studies, the GLP studies. Once the FDA has an opportunity to review the Investigational New Drug application, they will either give you a go or no-go decision. If it's a go decision, then you can start your first clinical trials. And this is what we call Phase I. And there are three main phases prior to final product approval that a drug will go through. In Phase I, these are small trials, traditionally less than 100 people, typically healthy volunteers. And the purpose is to evaluate the safety of the product. If you go through Phase I with results that are positive and the FDA agrees, you can move on to a Phase II clinical trial. These trials are larger. Typically, you'll have between 100 and 300 patients. You will use patients that have the disease of interest so that you can really look not only at the safety, but now you're looking at how effective this drug is in treating a certain condition. They're looking at end points that will show them whether this new drug product is acting the way they had anticipated it would act during the discovery in preclinical phases. And it also helps them to determine what is the most appropriate dose for the patients and how often they should be receiving those doses. When you move it into a Phase III clinical trial, now these are comprised of thousands of patients. Sometimes it can even be as many as hundreds of thousands of patients. And you can imagine that not only do these trials take a longer time, but it involves a lot more money. And you're talking about millions and millions of dollars to get through these phases, because not only are you looking at active drug products, but you typically will use a placebo, or

something that doesn't have any effect, so you can gage what the new drug is doing in comparison to not having an active drug that someone is taking. You might also be looking at different doses and different dosing regimens. You also might include an already-marketed drug that is working in a similar disease area to see if what you have is an improvement upon what's already out on the market and prescribed to patients. It's an opportunity to look at side effects and be able to monitor them. And now it's no longer the researchers and investigators conducting the trials, but typically these will go to clinical physicians at a number of different sites, across the world even, where the patients are enrolled. And if it performs well, that increases the likelihood that it can be approved when it goes to the next phase.

6.Good Clinical Practices

In the clinical phase, regulatory compliance and oversight is in place throughout the entire phase. And this is called good clinical practices in the United States, or GCP. And when you finish your clinical trials and you're ready to apply to have a new drug approved, in the United States, this is in the form of a new drug application, or NDA. As you drug application goes through the process, once it is approved, then there are many activities that happen. You have to then get your marketing plan activated, because clearly they've been thinking about this for many years in planning. And now that becomes activated. You will also need to measure and ramp up of your manufacturing activities. And back in the pre-clinical and clinical faces that is when they identify where they will be manufacturing the product and scaling it up to the point where they could manufacture sufficient quantities once a product is out on the market. In addition, there are other clinical trials that will be conducted once a new drug is approved if they want to look for additional indications for that product. It's very common that a drug is approved for one use, where it could be used for several other things, but they still have to go back and do the appropriate clinical studies to support the new indications. New formulations may be optimized, such that they are easier or more effective when a patient takes them.

7.Drug Manufacturing
After drug products are approved and they are going to be manufactured, they also have to follow a regulatory procedure for manufacturing does drug products. Not only during the pre-clinical and clinical phases are there regulations that demand compliance, but also after a drug is approved, When you manufacture a drug product, they have to be following good manufacturing practices, or GMP. In order to comply with US federal regulations for products that are going to be manufactured and distributed for human consumption. All of these regulations take time. All of these regulations are expensive. However, they are for patient safety. Every time you take a product, for example, that was manufactured in the United States, you can have complete confidence that these products were manufactured under a set Federal regulations that include consistency, monitoring of a process. Whether it's the actual making of the drug product or cleaning in between batches, these are very consumer focused processes and regulations to ensure that when you take your medicine, it's safe.

The Discovery Process an Overview From The Parma Press

We've all been touched by the miracles of modern medicine, but few people understand how medicines are made and the immense effort required to get them to market and into our hands. At any given moment, there are tens of thousands of research teams across the country working hard at analyzing diseases to find out what causes them. Once the treatment target of a disease is found, biopharmaceutical companies start investigating how to act on them to stop the diseases from getting worse or even reverse their courses. Tens of thousands of compounds are typically examined, and they come from all over-- from natural compounds that already exist to synthetic compounds made in labs or through bio-engineering. Through a long and difficult process of elimination that can take as long as six years, they get it down to a single candidate medicine. Assembling all their findings, the company will now file for permission to do clinical testing with the FDA. This will be the first time that the new drug will be given to people, and safety is the most important concern of everyone involved. If approved, the candidate drug starts to go through a three-phase clinical trial. Because of the emphasis on safety and efficacy, many drugs will not make it all the way through this process. Phase I trials are the first in humans and usually small, focusing on the medicine's safety and how the drug moves through the body. Phase II trials are larger, focusing on the medicine's efficacy and dosing. Phase III trials are much larger and focus primarily on making sure the medicine is safe and effective for a wide variety of people. After a successful clinical trial, a process that usually takes six to seven years, the biopharmaceutical company files a new drug application with the FDA. A typical application contains hundreds of thousands of pages for the FDA to review in a complex process that requires both time and scientific expertise. Once the FDA has evaluated all the available data, they will approve only those medicines they think are both safe and effective for public use. Even after approval, the FDA continues to monitor medicines on the market. Once approved, the biopharmaceutical company will manufacture and distribute the new medicine to people in order to treat and cure diseases. The result of this process seems so simple. It might be just one pill taken with water, twice a day. But how it came to be in your medicine cabinet is anything but simple. For just this one drug to come into being, it has taken up to 1,000 people 12 to 15 years and $1.3 to $1.6 billion. It's a long and expensive process filled with stops, starts, and failures. But through it, our lives are made better every day.

TYM Week 1.2 The Impact Of Drug Development on Patient Outcomes

The Changing Landscape Of drug Development

1.Facing drug Development Challenges

We've all been touched by the miracles of modern medicine, but few people understand how medicines are made and the immense effort required to get them to market and into our hands. At any given moment, there are tens of thousands of research teams across the country working hard at analyzing diseases to find out what causes them. Once the treatment target of a disease is found, biopharmaceutical companies start investigating how to act on them to stop the diseases from getting worse or even reverse their courses. Tens of thousands of compounds are typically examined, and they come from all over-- from natural compounds that already exist to synthetic compounds made in labs or through bio-engineering. Through a long and difficult process of elimination that can take as long as six years, they get it down to a single candidate medicine. Assembling all their findings, the company will now file for permission to do clinical testing with the FDA. This will be the first time that the new drug will be given to people, and safety is the most important concern of everyone involved. If approved, the candidate drug starts to go through a three-phase clinical trial. Because of the emphasis on safety and efficacy, many drugs will not make it all the way through this process. Phase I trials are the first in humans and usually small, focusing on the medicine's safety and how the drug moves through the body. Phase II trials are larger, focusing on the medicine's efficacy and dosing. Phase III trials are much larger and focus primarily on making sure the medicine is safe and effective for a wide variety of people. After a successful clinical trial, a process that usually takes six to seven years, the biopharmaceutical company files a new drug application with the FDA. A typical application contains hundreds of thousands of pages for the FDA to review in a complex process that requires both time and scientific expertise. Once the FDA has evaluated all the available data, they will approve only those medicines they think are both safe and effective for public use. Even after approval, the FDA continues to monitor medicines on the market.

Once approved, the biopharmaceutical company will manufacture and distribute the new medicine to people in order to treat and cure diseases. The result of this process seems so simple. It might be just one pill taken with water, twice a day. But how it came to be in your medicine cabinet is anything but simple. For just this one drug to come into being, it has taken up to 1,000 people 12 to 15 years and $1.3 to $1.6 billion. It's a long and expensive process filled with stops, starts, and failures. But through it, our lives are made better every day.

2.Drug Innovations
We've talked about the drug development process and the time, resources, and money involved are staggering. So is it all worth it? Well, think about the medicines that you, your family, and friends take, and I think you'll agree with me the answer is yes. It's worth all of that to have these innovations. What we're going to do in this module is to talk about some of those innovations that have come about because of the drug development process. I will be giving you some facts and figures, but you'll also be hearing about some personal stories of how drug innovations have changed people's lives for the better. So there are a variety of new treatments out there because of the sorts of research and development that's being conducted every day in the pharmaceutical industry. These innovations have worked to improve patient's health by saving and improving lives. And as we highlight some of these innovations, you're going to understand the importance of the breadth of R&D focus and the array of new treatments that have resulted from the research and development activities. It takes decades of investment to produce medicines that treat and prevent disease. You've seen all this. You're going to hear more about it over the duration of this course. But when you look at some of the examples of medicines that have resulted and have improved health outcomes, you'll see that there's a far-reaching implication for innovation. We're going to talk a little bit about cancer innovations as an example of what has happened over the past several years, and why these innovations are so important to have produced the types of treatment options that are now available. There's been substantial progress in terms of oncology innovations that help fight cancer. And the cancer death rates continue to fall. They started falling for the first time since the 1990s. In the United States, the National Cancer Institute has reported a 20% decline in cancer deaths since 1991. And this is much in part to better testing, better diagnostics, and better drug

products. So these improved statistics and health outcomes result from the introduction of new therapies and improved treatment regiments. Some of these treatments are in solo, just a single drug product. Others are in combination. They've done testing to find what mixture of drug products can best help, especially in treating a cancer. Because cancer is complex, and it's hard to understand exactly how to treat it in the best way without doing all of these clinical trials. And once you do that, you can understand the best approach and how a patient can benefit over time from using these new approaches. So when treatment options are lacking, FDA, when it comes to cancer products, goes a little bit different way. They may actually approve a cancer treatment based on what we call a surrogate endpoint as opposed to a full robust clinical trial prior to the long-term studies being completed. So an example of a surrogate endpoint would be, has this drug reduced the size of a tumor as opposed to looking at the longer term clinical outcome. An example of this was the FDA's approval of GLEEVEC in 2001 for the treatment of Chronic Myeloid Leukemia, or CML. And they saw that patients responded at the cellular level. And it was approved in 2001. And in 2007, when they completed the full clinical studies, they saw and were able to confirm the clinical benefit. And in fact, what they saw was an 88% survival rate versus the previous 48% survival rate prior to the introduction of GLEEVEC. But sometimes, additional testing is performed to actually expand the use of current therapies. An example of this is Docetxel, or TAXOTERE. Initially, TAXOTERE was a secondline treatment for metastatic non-small cell lung cancer. And that was in 1999. And it demonstrated that it improved the health outcome, and it was moved up to a first-line treatment for non-small cell lung cancer in 2002. Similarly, Herceptin was initially approved by FDA in 1998 for metastatic breast cancer patients whose tumors expressed the HER2 protein. In 2010, it received an additional indication for metastatic gastro or gastroesophageal junction adenocarcinomas expressing the HER2 protein as well. And again in 2006, it was approved for the postop breast cancer treatment when used in combination with other treatments. So this is an example, of you may have started with one indication and it moves along to additional indications. 340 medicines were approved by FDA in the last 10 years. And as a result of this research, some of the more recent advances in 2011, those approvals resulted in two new cancer medications for lung and melanoma cancers, for patients with tumors expressing genetic markers. This is very important because we will be talking about personalized medicine. And this, in fact, is part of the advent of personalized medical options. Also in 2011, for Hepatitis C there were two new medications that were first in class in a new class and offer a greater chance for a cure. Also in 2011, there were advances in lupus, the first new medicine since 1955. Yes, you heard me right, 1955-- was approved using a new approach to this very serious autoimmune disease. So outside of cancer, let's look at a few other of the therapeutic areas, and how innovations have impacted health care. Cardiovascular disease fell almost 30% between 1997 and 2007, in large part due to the improved treatment options that are available. Diabetes, there was an explosion of eight new classes of medicines that provide better outcomes, extend life, and the patients suffer fewer complications. And for HIV/AIDS, the death rate in the US has fallen by 83% since 1995 with the development of the highly active antiretroviral therapy, which is a combination of medicines. And again, cancer, the 5 year survival rates in the 1970s was 49%. And in 2007, the survival rate was 67%. So these new medical innovations are resulting in better quality of life, better health outcomes for patients. So in the slides that I'm showing you know, I'm going to very quickly go through some of the great moments in innovations in the last 20 years. I will highlight some of these. There is additional information that can be found online if you are interested because I will be going through these quickly. In the early 1990s, a new treatment for schizophrenia is introduced after 22 years in development. And what was exciting about it is that it was more effective and had

fewer side effects than any of the other treatments that were available prior to that time. In addition, there are two new drugs to ease chemotherapy side effects, which is huge. These chemotherapeutic agents are doing wonderful things, but they traditionally have very uncomfortable side effects, such as nausea. And two drugs were introduced in the early '90s to help with that. In addition in the early '90s, you saw treatments for Alzheimer being introduced to boost memory and mental functioning. Progressing into the mid '90s, you saw Paclitaxel, which we mentioned TAXOTERE before, which was first approved for breast cancer as it inhibited tumor growth. And in 1996, the FDA approved ivermectin to treat "river blindness," which is caused by a parasitic worm. But what you might not know is that it threatens 85 million people in Africa and Latin America. And what they were able to develop is a single annual dose. And that one single annual dose could impact up to 85 million people. So that is tremendously significant. In the late '90s, 1997, the FDA approved Rituximab, a biotech cancer treatment for Non-Hodgkin's lymphoma. And there was also breakthroughs in arthritis medications that helped millions to reduce the pain and constant anguish associated with arthritis. And in the early 2000s, probably the most significant event to happen that has continual impact on drug innovations was the mapping of the human genome. That is spurring on a number of new innovations, technologies, and strategies to both diagnose and treat diseases. And in 2004, you saw the first treatment for metastatic cancer, an angiogenesis inhibitor that was first used in colorectal cancer. And in the past few years, we've seen just a plethora of new drug products. The first vaccine to prevent cancer, and that's the Human Papilloma virus. New HIV medications, the integrase inhibitors that slow the progress of the HIV infection. And then we saw the first medicine for the treatment of the jerky, involuntary movements that are associated with Huntington's disease. There was the first immunotherapy for cancer treatments that individually tailored to prostate cancer patients. And two new medicines for multiple sclerosis, improving the quality of life and the ability to walk. And these are just a few of the innovations that have come along in the past 20 years. And there is much more being done in terms of being able to diagnose and treat and develop new products for the diseases that many of us may be suffering from and previously could not be treated. So there are a number of new drugs. There are new strategies that are having a positive impact on patients. Better quality of life, extending life, making it easier to go about your daily routine. We are seeing that these medicines are making a difference. And that's why understanding how drugs are developed and the impact that they're having, that's the first step in becoming an informed consumer. And we're hoping that by understanding these important facts that you will be able to take your medicine in a way that number one, you understand what you're taking. But number two, you appreciate what has gone into the development and the approval of these drug products to make them available to you.

Susan Brown-A Patient story- The Diagnosis

So I have a story to tell about medicines and how they changed my life and how the development of medicines made it possible for me to be here today. I was 41 years old. The year was 1993. I had three very young sons and lived in a very small town in west Texas. And I was very healthy. I didn't take medicines. I worked out every day. I ate a very low-fat diet. And I woke up one morning with a lump on my neck that didn't look right. It looked like a bubble on my neck. And went to the doctor, very nonchalantly thinking I had some kind of infection. It came back that I had a huge tumor growing in my chest. I had non-Hodgkin's lymphoma. I had the big C. I had cancer, which is very daunting for anyone. But it was really daunting for me because I thought I'd done everything right. I ate right. I worked out. I did all the things you're supposed to do. And so after a long process of going through biopsies and meeting with doctors and having X-rays and having CAT scans, I ended up in Dallas, Texas, for three months in a hospital with what I was told would be maybe my only chance of living. Because the prognosis wasn't very good. This tumor covered from my neck all the way down almost to my diaphragm. So there really wasn't a lot that they could do. And it was coming out of my thymus gland, which is behind your lungs. So that's hard to get to. So I went in the hospital. There were 50 of us using this same medicine protocol. There was several people who were very ill and very old. And there was a young man who was 17. He was a football player. And he, like I, worked out all the time. At the end of the three-month period of having this chemotherapy, he and I were the only ones alive. And it was because our bodies were strong. Our hearts were strong. And we could take the regime. So I learned very quickly to learn about my body and about my medicines and to ask questions. And my doctors were sometimes hesitant, but generally pretty open. So if you've ever known anyone who had chemotherapy, you go in the hospital. You have a port in your heart that the medicine goes in. And they bring in a medicine. And they hang it on a pole. And they put it by your bed. And then they hand you a sheet of paper to read. And it's all the legal stuff, what can happen to you if you take this medicine, how this medicine is made. And I'm not a scientist, so I don't know any of the chemical reactions. But I did know what the warnings were. And some of them were very scary and very deadly. But when you have a disease like cancer, you want someone who's smarter than you.

Medical Innovations That Impact You

100 years of medical Innovation
[MUSIC PLAYING] Over the last century, 17 US presidents have been inaugurated. During that same period, America has celebrated major medical milestones that have transformed health care for patients around the world. For most Americans in the early part of the 20th century, life was short. When Woodrow Wilson took office in 1913, US life expectancy was just above 50 years. By the time Warren Harding was sworn in, millions of diabetics in the US had no treatment options. Children with type I diabetes simply died. But later that year scientists discovered insulin, which controlled the disease and ultimately saved countless lives. In the 1930s and '40s, Franklin Roosevelt was inaugurated four different times. During this period, the president's body and much of the nation, was ravaged by polio. But just about a decade after his final inauguration, a vaccine was discovered that would eradicate polio in the United States. When John F. Kennedy was sworn in the 1961, death from heart disease was reaching epidemic proportions. But by the time Ronald Reagan took office, numerous medicines to prevent heart attacks were in development. By the end of the decade, heart attack related deaths were cut almost in half. Around the same time heart attacks were on the decline, America was shaken by a deadly new virus called HIV. But when Bill Clinton was inaugurated in 1997, a new antiretroviral treatment had been discovered by scientists. Death from HIV has dropped an incredible 79 percent and millions of HIV/AIDS patients are now able to live full lives. In 2001 when George W. Bush was sworn into office, scientists announced the mapping of the human genome, which has helped researchers develop personalized medicines that are transforming how we treat serious diseases like cancer. In January 2013, President Obama is sworn in for a second time. Thanks in part to medical advancements, US life expectancy has increased by almost three decades since 1913. Today the average American lives to be 78-years-old. What will the next century of medical breakthroughs look like? [MUSIC PLAYING]

A Patients Story-Arlyn Kloesel

1.Meet Arlyn Kloesel
My name is Arlyn Kloesel. I am a 1962 graduate of the University of Texas College of Pharmacy. I practiced 18 years in a community pharmacy until 1980, at which time I joined the University of Texas College of Pharmacy as director of professional affairs. I'm currently a distinguished senior lecturer at the college, and I teach the introduction the pharmacy class or introduction to patient care class at the college and have taught it since I've been there.

2.A Personal Story from Arlyn

I do have a personal story that I think ties into my responsibilities at the college. And that is that in 1988, I underwent quadruple bypass surgery. Now, the story behind that is I did not suffer a heart attack prior to undergoing surgery. I was in very good shape, I thought. I was running about five miles a day, four, five times a week. I went to my normal annual checkup each year, and it came out fine except for the last four, five years prior to '88. My cholesterol was somewhat high, but wasn't alarmingly high, so I didn't have to take any medication. And in fact, at that time, there were no statins available for high cholesterol. I went to my annual physical. I found out that I had an abnormal EKG. Was the first EKG I'd ever taken. So two days after that, the doctor asked that I do a stress test. I did a stress test. It came back abnormal. So two days after that, I had quadruple bypass surgery. Now, the interesting part about that is number one, I didn't have a heart attack. Number two is I had been exercising pretty vigorously almost my whole life. And number three, I wasn't sure that actually the surgery was necessary, if you can believe that. And now, in fact, my cardiologist says that perhaps had statins been available to me, I would avoided my quadruple bypass surgery. And I say that because I think it's very important that students understand that statins only came into being in the 1980s, the late 1980s. And because of we complain a lot about the high cost of medications-- this would have paid off for me, and I could have avoided a quadruple bypass surgery had the statins been available. I've had no problems whatsoever since that time. My cholesterol is under control, because I began on a statin and then continued on it, and changed statins. But I'll talk about collaboration with other health care professionals later on to tell you what I believe the direction pharmacy is going.

Week 2.1-Drug Discovery

1.Week 2 introduction
[MUSIC PLAYING] This week features Doctor Alan Moats, who will help you understand the first two phases of the drug development process-- drug discovery and pre-clinical phases. These are the phases in which new drug molecules are discover, sometimes not just from the original use, but they can be repurposed from their originally use. And then they're tested and formulated into drug products, which may, hopefully, qualify to enter into human clinical trials at some point. There's indepth information about inhalation drug products, as described by Doctor Bill Williams and Doctor Hugh Smyth. And you'll see hear the answer to the question, what is pharmacology toxicology, as told by Doctor Carl Erickson. You'll hear from two academic researchers Doctor Brent Iverson will talk about how he discovered the antidote to anthrax. And also, you'll hear from Doctor Jonathan Sessler, who talks about his drug-discovery efforts in terms of fighting cancer. Here's to knowing your medicine and taking your medicine for better health. [MUSIC PLAYING]

2.Drug Discovery Overview

Hello and welcome to the drug discovery module. This module will provide you with an overview of the steps involved in finding a new compound for use in a therapeutic product or a diagnostic product. First, I'd like to clarify what I mean when I refer to a compound. A compound can be made using chemistry or biology and when given to a patient can treat or eliminate a disease. As you might imagine, these compounds are not easy to find and, in fact, are becoming harder and harder for scientists to discover. In the last century, we effectively discovered most compounds occurring in nature and synthesized all small and easily synthesize chemicals. In this module, I'll explain to you how today's drug researchers go about discovering new drugs and why it's not quite as easy as it used to be. In the early days of drug discovery, we didn't know where to look. Many known drugs were simply home remedies passed down from earlier generations. And nearly all of them were initially discovered by accident. One of the most influential drugs ever discovered was actually discovered by accident. One day in 1928, a scientist named Alexander Fleming was observing the bacteria he was growing in a Petri dish in his lab. He came across one dish that appeared to be contaminated with some sort of fungus. Before discarding the ruined sample, he noticed something strange. The area around the fungus growth was completely void of the staphylococcus bacteria he was growing. Not realizing the full potential of his discovery, he isolated this mold juice and planned to use it to prevent certain types of bacteria from growing in other experiments. It wasn't until insole Howard Florey, another scientist at Oxford, began researching the use of this mold juice to treat wounded soldiers in World War II that the full potential of penicillin was realized. Recognizing the drug's lifesaving potential, Florey traveled to the United States to enlist the help of the US Department of Agriculture and pharmaceutical companies. With their help, improved methods for

synthesis and purification of penicillin were developed. And the age of antibiotics had begun. While much less common today, these discoveries by serendipity still occur. However, it's unlikely that any will have the same global impact as penicillin. For drug discovery today, a more methodical approach, involving university researchers, government agencies, industry, and philanthropic organizations, is necessary. Today, the discovery stage initiates the drug development process. In order to get a single drug all the way through development and to the patients that need it, drug developers start with approximately 10,000 potential drug candidates. The development process is important because it systematically filters out all other 9,999 of these potential compounds and selects the very best new drug. Of course, these numbers aren't exact. But you can begin to get an idea of the process of nearing down the best candidate. The drug chosen at the conclusion of this process will have the best balance of effectiveness and safety and should be the best candidate from all the 10,000 compounds that were considered at the beginning of the discovery stage. Over the next few minutes, we'll discuss the stages of drug discovery and provide examples that will hopefully illustrate how those stages can result in an approved drug. The drug discovery process can easily be broken down into three stages-- one, identify a drug target; two, screen for compounds that bind to that drug target; and three, optimize these compounds to produce a lead candidate. These steps describe the most commonly accepted approach to drug discovery. Although there are methods that differ slightly from this standard approach. These alternate methods will be mentioned. But our primary focus will be on target identification, compound screening, and lead optimization.

3.Identifying Disease Target

If you tried to guess, you might say that the development of a new drug starts by considering a large number of compounds that are screened for their activity against a disease. That is actually the second step of the process. The first step is the identification and selection of a biological target for that compound. So what do I mean when I say biological target? Well, these are typically proteins within the body where a drug compound can bind and have some effect on that protein's function within the body. Proteins are the workers and doers of cells, and carry out almost every activity within a human cell. It makes sense, then, that these workers of the cell are the target for most drugs, and that these drugs would bind to the protein target to change its activity. The altered functionality of that protein can effectively do something to help eliminate or reduce disease in a human cell. In addition to proteins, genes can also be targets. Genes are the managers of the cell, and are responsible for providing instruction for how a protein is created and what tasks they carry out within a cell. These targets aren't always human proteins or genes. Sometimes they are proteins in genes of an invading organism that has infected the body to cause disease. Of all known drug targets, approximately 15% to 20% ARE actually targets of a non-human pathogen. In total, scientists have discovered hundreds of targets. And basic researchers are very focused on finding new ones. Often, these basic researchers are at universities, and task their research labs with understanding every pathway and mechanism behind a disease with the hopes of finding a new drug target. Large federal grants are typically the major funders of these university researchers, so it's critical that government leaders continue to fund agencies like the National Institute of Health and the Food and Drug Administration so that we can continue to learn more about the diseases that affect all of us. The problem with many diseases is that there are often hundreds of genes and proteins involved in their progression. So it is important that the discovery scientist selects a target that is key to the manifestation of the disease. Determining the level to which a single gene or protein function or dysfunction plays a role in a disease that often involves hundreds of genes and proteins is not a simple task. The uncertainty in large amounts of data that describe these diseases often require statistical analysis to identify the most influential gene or protein, and thereby the most suitable target. So what are some examples of how a target can affect a disease? Well, sometimes the target is simple, and once a drug compound binds to it, the disease is essentially eliminated. Amoxicillin is an example of a drug that has a simple target and effect. This drug binds to a protein in the invading bacterial cell wall, resulting in the rupture of the cell wall and the death of the bacterial cell. There is, however, one complication that can occur, and that occurs when the target changes. This is the case in bacterial infections that have evolved a resistance to antibiotics. Methicillin-resistant staphylococcus aureus is an infection that has made the news in recent years, and has developed a resistance due to changes in the target protein. The antibiotic loses its therapeutic action when the compound binds less effectively to the target, or when the target's role in bacterial survival changes. By killing off all of the bacterial cells that are sensitive to a drug, we are essentially driving these bacteria to evolve. Developers are in a constant battle to stay ahead of evolving infection strains. Another example of a disease where one can easily target and affect the disease state is in heartburn, which is also known as gastroesophageal reflux disease. This disease can often be reversed by limiting the acidity of the stomach. One way this is accomplished is through drugs that bind to the protein that is responsible for pumping acid into the stomach. These drugs are called

protein pump inhibitors, and include Nexium, Prevacid, and Prilosec. Unfortunately, some diseases are not so closely tied to one target. Adult onset diseases like Alzheimer's, often caused by a combination of genetic, environmental, and lifestyle factors, are very complicated, and poorly understood. While many good potential targets for Alzheimer's have been discovered, the complexity of this disease may call for a multi-targeted approach. This could be accomplished by administering multiple drugs that bind to single targets, one drug that binds to multiple targets, or some combination of the two. We'll discuss a little later some of the pros and cons around a multitargeted approach to therapy.

4.Screening Drug Candidate

Let's say we've identified an acceptable target. This target has been studied extensively and is thought to play a key role in the progression of disease. The process is now handed off to the second stage to screen this compound for hits that bind to the target. This approach is responsible for the discovery of the majority of today's marketed drugs. And is called a target based screening approach. Often at this stage, a scientist may have an idea of the class of compound that might or might not bind well with the target. Using this information, the number of compounds for initial screening can be reduced allowing for a more informed approach. Additional reduction of the number of compounds to be screened in the lab can be accomplished using computer software and virtual compounding libraries. When lab screening does commence, it is often accomplished in multi well plates containing the targets of interest. And uses automated equipment to allow for higher throughput. This automation allows for very large libraries of potential compounds to be evaluated in a relatively short amount of time. The target based approach to screening has proven very useful. However, some scientists believe that it's limiting criteria might prevent novel or unexpected discoveries. Target based screening assumes that we know definitively how that target affects disease. And that the better a chemical binds to that target, the better the outcome we could expect. This is not always the case. Diseases can be very complex. And at times understanding every mechanism of disease progression and every role drug targets play in that disease is nearly impossible. With this in mind, drug developers have begun to use what is called a phenotypic approach to drug discovery and screening, as an alternative to the target based approach. In a phenotypic screen, a scientist has a living model of disease to test for hits. However, the target and the mechanism of action remains unknown to the scientist. The only thing the scientist investigates is if the compound has been able to somehow reduce or eliminate the signs of that disease. Often, these living models are cells, tissue cultures, are mice that have been developed to model a human disease. The benefit of this approach is that potential for first in class compounds is much higher than in the hypothesis driven target approach. Also since the target is unknown, further chemical modifications to a hit compound can be very difficult in the phenotypic approach. Because it is unknown how this change might affect binding to the target. Now, we should also mention here that there is a more modern class of compounds that does not use either of these two screening pathways. Compounds referred to as biologics are produced from a living system rather than in a chemistry lab. These compounds also behave differently therapeutically. Rather than binding to a very specific target, some biologics just copy an existing system in the body. An example of this is insulin, which is a naturally occurring substance secreted by the pancreas. But can be administered to diabetics to help regulate blood glucose. For use as a therapeutic in diabetic patients, insulin was originally isolated from the pancreas of cows and pigs. However, it can now be produced with genetic engineering by inserting the human insulin gene into bacterial DNA. As these bacterial colonies divide and grow, they read the inserted human gene, and produce insulin. Newer biologics actually do have a more targeted approach. However, they still mimic the body's own targeting mechanisms to take action against disease. Antibodies and proteins can be tailor made to bind with disease causing cells or interfere with chemical signaling that progresses disease.

5.Drug Discovery Example : Ivacaftor

One recent drug approval to treat cystic fibrosis serves as an interesting example of the modern drug discovery process and may point to a new potential strategy to find first in class drugs. The drug, Ivacaftor, which has the marketed name Kalydeco, is a compound used to treat a sub-population of cystic fibrosis patients with a specific gene mutation. This mutation results in the loss of function in the CFTR protein, which is critical for allowing ions to transport across a cell membrane. This and other similar mutations leave CF unable to absorb nutrients in the intestine and produce a thick mucus secretion in the lungs that are a breeding ground for infection. Although it does not cure the genetic mutation, Ivacaftor is the first approved drug for direct treatment of the underlying protein dysfunction of CF. The story of the discovery of Ivacaftor starts more than 20 years ago when Francis Collins, who later headed the Human Genome Project, discovered the gene mutation responsible for cystic fibrosis. The search for a treatment specific to this mutation was led by a pharmaceutical company, Vertex, given funding assistance from a non for profit, the Cystic Fibrosis Foundation, and fast-tracked by regulators at the FDA. With the mutation identified by Doctor Collins, researchers were able to reproduce a cell-based model to screen more than 200,000 compounds for their ability to restore protein functionality the researchers selected the basic structure five or castor since it appeared to be the best to restore the proteins normal function in the cell lines the exact mechanism of action or target for Ivacaftor is still unknown, since a biological system, the mutated cell line was used to screen these compounds. So in essence, although Doctor Collins's basic genetics research helped lead to this discovery, this drug was screended using a phenotypic approach. Many hope this new model involving a fundamental knowledge of genetics combined with a scalable phenotypic screen can lead drug developers to more first in class therapies.

6.Optimization Of Drug Candidate

After a large library of compounds has been screened, the handful of hits that emerge need to be whittled down and optimized for key criteria. To further reduce the number of drug candidates, researchers will characterize how a compound binds to its target. This optimization process is really only applicable to a target-based approach. Optimization of a phenotypic screening candidate can prove very difficult due to the limited understanding of the compound mechanism of action. So, what are some of the important factors that correlate to target binding? A few of the most important factors are the degree of affinity a drug has for a target, how many other targets a drug binds with, and how long a drug stays bound to a target. These criteria will help to determine the effective dose and the severity of any unwanted side effects that might occur for that drug candidate. Additionally, it's important to eliminate candidates that are likely to be toxic at levels needed for therapy, ones that may be chemically unstable in solid state or solution, and those that are overly costly to synthesize. After all this optimization is complete, lead candidates can also be sent back to chemists to produce analogs. Analogs are structurally similar compounds that may produce some improvement in one or more of the criteria that were just mentioned. There are other key tasks that scientists working in lead candidate optimization are focused on. One important task is the determining of the correlation between chemical structure and activity. This is commonly referred to as the Structure Activity Relationship. By combining different structures in a compound with this activity, scientists can make more informed decisions on where to modify a lead candidate and how to go about making analogs. A compound's drugability is another area where compounds can be evaluated. This term is used to describe a drug's ability to reach its target, bind to it, and produce some sort of measurable effect. There's a general guideline called the rule of five that scientists can refer to when considering a compound's drugability. This rule states that compound is drugable as an oral medication if it has no more than 5 hydrogen donor bonds, no more than 10

hydrogen bond acceptors, a molecular weight less than 500, and a log p less than 5. An explanation of these rules and the principles behind them will be further discussed in the pre-clinical module.

Drug Discovery & Cancer 1.Fighting Cancer

Good afternoon. My name is Jonathan Sessler, and I'm a chemistry professor here at the University of Texas at Austin. I'm going to try and tell you a story. It's a personal story, but it's also a drug development story. It goes way back to when I was much younger and better looking. I won't say I was good looking, but better looking. And the story has two or three themes that intertwine to lead to a tale of what it takes to try, fail, and try again at drug development for cancer. The peroration of this talk will lead to efforts to develop platinum using texaphyrin as a specific carrier to overcome resistance. But before we get to that, I want to wind all the way back and start at one of the two beginnings leading to this story. So this goes to maybe a long time ago, because I've had the privilege of being here on the faculty for many, many years. But in 1984, when I was 28 years old, I came here. I had done my education, undergraduate at Berkeley, graduate work at Stanford, also in the Bay Area. Then I worked for postdocs-- so this is after one's PhD-- with a soon-to-be but not yet Nobel Prize winner named Jean-Marie Lehn in France. Then I did a further half a year or so of additional study in Kyoto, Japan, and that was a delightful cultural center. I must have been one of the few people who showed up in Austin Texas in late August and thought it was cool, compared to the heat and humidity of Kyoto, Japan. While doing my PhD with the famous Jim Collman, supervising professor at Stanford, and then also studying in France and Japan, I had worked on a class of compounds called porphyrin. And that's shown on this slide as the first chemical picture. And a porphyrin, if you're not a scientist or even if you're a scientist and not an organic chemist, you may not know this name. Unless you're unfortunate to have one of the rare diseases associated with poor metabolism called porphyria, you may have never heard of this. But you have seen it. That red color comes from porphyrin. It's the ring that holds the iron to make heme that goes into hemoglobin, which carries oxygen around in your body. And porphyrin has many other functions for electron transfer, for catalysis, and no fewer than four Nobel Prizes have been awarded to porphyrins. So I thought it would be fun to continue studies of these molecules. But I quickly realized that in Texas things are different from in other places. And on this part of the slide, you can see two major influences. One, on the right-hand side of the slide, you can see the famous Lone Star of Texas. But notice up close the star of Texas has five points to it. If you go back to porphyrin and you look at it carefully, you see N's. That stands for the element nitrogen. And if we count, we see four. But in Texas, it better be five. So this is a disconnect. The other thing you see on the slide are longhorns. I came to Texas, and I thought, wow, animals here in Texas are bigger than they are back where I grew up in California. We had little squirrels, but we didn't have longhorns. It occurred to me that in Texas things should be bigger. And it turns out that's an animating philosophy in Texas. Things should be bigger. And we're proud here at the University of Texas that they're often better as well. So if you map this set of influences into porphyrin chemistry, you come, as I do, to the next concept, which is the idea that you should make not a porphyrin but a texaphyrin, which would be a Texas-sized porphyrin. And so we set out to do that. As a young faculty member, the rank is called assistant professor. And that is not a permanent position. You have five or six years to prove yourself to the world, and it really is world-class chemistry that you must do if you're going to become part of

a permanent staff at the University of Texas. That's appropriate, but it's challenging. And my thought was a very simple one. If I made a molecule and named it after the state, it would be very difficult to deny me tenure. I'm pleased to report that that experiment was successful. That led to this new molecule, maybe 20% bigger than the porphyrins you'd find north of the Red River. So we had succeeded in the basic chemistry. And we quickly found out, as you can see from this technical slide, which shows something called a cyclic voltammogram, which tells you how electrons go in and out of molecules, in contrast to what's true for typical Yankee-size porphyrins that the Texas porphyrin, or texaphyrin, captured electrons a lot easier. Once it captures electrons, it will hand the electrons off to oxygen. Oxygen, as we know, will take electrons. That's the basic process of burning. But normally, it is very slow. It's what chemists call kinetically inhibited, unless you activate the oxygen. Typically, we do that with a match, when we are lucky enough to enjoy this lovely weather and stoke up the coals and have a nice barbecue. But you can also do it with light. And here we're doing it with chemistry. We take oxygen, take an electron from the reduce or electron-captured version of texaphyrin. And that makes a radical species called superoxide. That goes on and does many things, disproportionates to make hydrogen peroxide, but all these daughter products and the original radical reactive species, superoxide, these are cancer-killing agents. They'll kill other cells as well, but cancer is more susceptible. So the idea is with a molecule that's easy to catch an electron, it should be able to do that from any of the metabolites or some of the metabolites in your bloodstream, produce these reactive forms of oxygen, and kill cancer. If you take that heme out of the hemoglobin that's in your blood and purify it and re-inject it, it will localize to cancers. This has been known since World War II in German chemists. Back in those days when you made something new, it was traditional to test it on yourself. And from people of Meyer-Betz, World War I era on, [INAUDIBLE] World War II, this was done. We knew then that a porphyrin would go to cancer. We knew that the texaphyrin would give this active form of oxygen. Maybe if we were lucky the texaphyrin would model the normal porphyrin, go to cancer, and now produce this killing agent. So that was the idea. Then we decided that we could take texaphyrin and try and cure cancer.

2.A Personal Story : DR. SESSLER

Here you see the old logo for Pharmacyclics, a company I co-founded, with a gentlemen whose picture from the time, Richard Miller, is shown in this slide. I told them that we had this new molecule, and his reaction is, oh, let's start a company, and let's cure cancer, which was a bit of a leap. But this is a testament to Dr. Miller and his vision. But it goes back way before that. When I was an undergraduate, my senior year, I was diagnosed with Hodgkin's lymphoma. And I spent my senior year enjoying radiation therapy. And if can turn around, maybe I can share with you some of the radiation therapy hairstyle. Maybe I need to give that a little bit more time for the camera. So that's a very special hairstyle. And I think if you were a punk rocker, maybe you would pay a lot of money for that privilege. But I got it for free by having radiation therapy. I then went from Berkeley undergraduate chemistry studies to Stanford chemistry studies. And one of the reasons I did that is, at the time, the great Henry S. Kaplan and his school had developed the leading treatments for this Hodgkin's disease, a lymphoma. And lymphomas are typically divided into Hodgkin's disease, which has a better prognosis than non-Hodgkin's lymphoma. And at the time-- late '70s, early 1980s-- the prognosis for Hodgkin's lymphoma was about 50% survival and about 50% the other outcome. And radiation therapy was state of the art. Rosenberg and other people were beginning to develop chemical agents, so-called chemotherapy. And Ron Levy was then head of that department, and there was a young doctor named Richard Miller. I met Richard Miller when I was in my third year in graduate school when, unfortunately, this disease came back. I then enjoyed a much tougher year on chemotherapy under his tutelage. And he kept saying, what do you do? Why are you here? When can you come for an appointment? And I'd say, well, I'm only five minutes away. I'm just across the street. What are you--? Well, I'm a chemistry graduate student. And can you use chemistry to cure cancer, he would ask? I said, well, I'm researching blood pigments. And he said, how can those be used to cure cancer? So his great strength was he believed in everybody, unbelievably wise, but also has a vision for how far things could go. And I was lucky to be one of his first patients and hence benefit from even more personal attention than I think subsequent patients may have enjoyed.

3.Texaphrins & Cancer

The recognition that we could produce these reactive oxygen species, the finding that texaphyrin, like porphyrin, would localize to cancer. And you can see three panels down below where we're using the gadolinium version of texaphyrin. For those of you who are not chemists, gadolinium is way down in the middle of the bottom part of the periodic table. And it's highly paramagnetic. So what's that mean? It has unpaired electrons. And it acts as a baby bar magnet. And it's used to enhance the contrast of magnetic resonance imaging, MRI. And that's billion dollar-plus industry making contrast agents. But the ones that are on the market are localizing mostly the water-soluble. So they're so-called blood pooling agents. And we found early on, and this is some of our early clinical work from a poor girl with the pediatric brainstem glioma, that the texaphyrin would localize very well. And you see that as enhancement, white spots. And if you're a radiologist, maybe are smart enough and good enough that you don't need the benefit of this contrast; but if you're like me, a chemist, with no great training in reading MRI films, seeing the white spots allows you to see where the cancer is. And unfortunately, for this poor patient, it's quite dispersed. And that translates to not particularly good prognosis. So with the gadolinium texaphyrin as the lead compound, we then needed to make the organic version water-soluble. And we tried a couple of iterations. Not as many as the typical drug development timeline would suggest, in part because we were being funded by venture capitalists and had a very tight set of deadlines we needed to meet in terms of our so-called Gantt charts. And in part, because we were lucky enough by iteration number 2 or 3 to have something that showed acceptable properties. So typically, thousands of compounds are made and screened. We went with candidate number 3-- the choice of gadolinium among all the metals that we can put in the middle of these porphyrin-like rings was because of the MRI enhancement. Iron is what normally is used in nature, but gadolinium is bigger, and our molecule is bigger, so it all makes sense. So that led to the co-founding of Pharmacylics. And Dr. Miller quit his job. He was vice president, if I recall correctly, at IDEC, which is now part of Biogen Idec. And what he had developed there with Dr. Ron Levy, the anti-idiotype antibody therapies are among now the hallmarks of cancer therapy. So Dr. Miller has had a number of tremendous successes, and he's also helped with this project. So pretty quickly, we decided to focus on non-small cell lung cancer. This decision was based as much on clinical need as it was on fundamental science. And in retrospect, it's not clear that this was the best choice, but it's the one we made. And that's where the bulk of the resources were focused. With cancer treatment for tough diseases, like non-small cell lung cancer that metastasizes to the brain, these are tough, serious problems. And everybody says or asked, why isn't there a cure for cancer? And the answer, on an equally glib note or level, is that it is a hard problem. It's not that we're lazy. Please come by my lab at 1 or 2 o'clock in the morning, you'll find people working. We're driven, we're dedicated, we're doing our best; but Mother Nature doesn't give up her secrets easily. And cancer is a particularly tough nut because the difference between disease and healthy is a very small margin. So we decided to work on this tough problem. And in doing so, we set a goal that we thought was realistic, which was to reduce the time, the so-called neurological progression. So if you'll pardon me waving my hands a bit-- when tumor in your brain starts growing, it grows and grows and grows. And then all of a sudden, it will hit a nerve. And that nerve might regulate your ability to flex your toes in your left leg. Or it might regulate heart function. Or it might regulate your ability to go to the bathroom, maintain your balance. And when these events, the nerve from the growing cancer gets squooshed and you lose function, a critical function, that's called the

neurological progression. And so we did not set out to try and cure this disease, but improve the quality of life so that you could work, eat, play with your grandchildren, for instance, while at least maintaining some semblance of a normal life rather than being in a complete vegetative state. This science for this basis for this choice was at an early screening phase 3 trial. We saw enhancements in the time in our neurological progression. So these are so-called Kaplan-Meier curves. The higher up you are, the better off you are. So the lower curve is standard of care at the time the trial was started, which is whole brain radiation therapy. On the top, it's whole brain radiation therapy with the drug, which is given a trade name of Xcytrin. So maybe a third of a billion dollars went into this program; so mostly, money raised from Wall Street after the company went public. And what we found were what we thought were reasonably good results. So this went into about 550 patients in 64 sites worldwide. And we found about 50% improvement. But unfortunately, the statistical power was not up to the pre-negotiated level of significance. So if you're doing drug development, ultimately statisticians and statistics become your gods. And the p-value set by the FDA for all drugs, as near as I'm aware, is a p of 0.05. The lower the number, the more significant the results in a statistical sense. So that's different from a significance in terms of improving patients. So we were showing good improvement, but we didn't have the statistical power that the FDA wanted. And we saw remarkably good results for the sites within the United States and Canada. Here, we were going from about 10 months without treatment to over 2 years. So an unbelievably good statistics for this subset, and a great hazard ratio segment to a chance of having untoward event was basically halved. So we were very excited about this. And one of the other aspects that came out of this study was that the texaphyrin, as I said had the trade name of Xcytrin, was confirmed as being very safe. So unlike the chemotherapy I had where I was going home every night and vomiting, not so many adverse events were noted with the texaphyrin. So that was very pleasing. If you look at the data-and again, this is for the US and Canada-- on this slide, so whole brain radiation therapy under 10 months with a drug which use the generic name of motexafin gadolinium-- hence, the abbreviation MGD-- in the second line in red on the blue background. You can see that it's much higher than the other one. And if you go way out, then you see some patients that had not progressed. Whereas, with the control, they're all, unfortunately, either dead or progressed. In spite of two years of discussion, back and forth, with the Food and Drug Administration, the FDA, the new drug application for this compound was rejected. And that was basically the end of the story.

4.Battling Cancer
The texaphyrin story is my game. It's my molecule, my heart and soul, as is the passion for cancer. And you may have gathered, I have a personal vendetta against cancer. So it behooves me. And I'm fortunate to have great students and post-docs taking on the challenge of trying to make the next generation system. So let's go back and really think about what we learned as a result of this 15year, third of a billion dollar experiment with culminating with bad news from the FDA. And the one thing that is, I think, irrefutable is that texaphyrins localize very well to cancer. I don't think that's a subject of discussion anymore. It's been validated in the clinic now in over 1,000 patients. And I showed you some slides. And here's yet another slide where the difference between texaphyrin and no texaphyrin is demonstrable and visualized to even by those of us who lack technical training in radiology. So let's try and exploit that. And our thought was, let's use this to carry platinum to cancer. And I was lucky to team up, at this point, with Dr. Zahid Siddik, who is an expert on platinum drugs at M.D. Anderson. And the idea is to try and go after platinum drugs. Platinum drugs are potent. But for many diseases, you run into dose limiting toxicities. And lung cancer is an obvious example of that. You can cure lung cancer. But by the time you get the dose of platinum that you need, the patient is usually dead. And ovarian cancer sits kind of in the middle between lung cancer and testicular cancer. And Dr. Siddik, believes, as do other people, that if the amount of platinum could be increased by just a factor of two, the five year survival for ovarian cancer would go from about 20% of the patients up to about 80%. The trouble is, you can't do that with current platinum. It's too toxic. Patients die before they can get that benefit. On the other hand, if we have texaphyrin, maybe we can carry it straight to the cancer. And texaphyrin, of course, is different than platinum. And maybe instead of going out the kidneys, which is where a lot of the toxicity comes, it's more greasy. And maybe it will be subject to clearance through the liver. And that difference might lead to different toxicity, or, at least, spread it around. So to test this, a wonderful post-doc Jonathan Arambula took on the challenge of making a new conjugate. Those of you who are organic chemists can enjoy this slide. Those of you who are not, just look at the box. What we've done is combine the platinum with the texaphyrin. And this looks like the first generation platinum drug cis-platinum. And depending on what you use, this will either fall apart or stay together. If you use methanol, organic solvent, it sticks together. But if you put it in phosphate-buffered saline, like mimicking what you'd see in the blood, then it falls apart. And that's important because the idea is you want it to get to the cancer and then fall apart and release platinum. We're not trying to make a new drug. We want to exploit the existing platinum drugs. OK, so a lot of data here. What we found, long story short, is that this works pretty well for normal ovarian cancer in cells, as well as for cancer that's resistant to platinum drugs. And this was very exciting. So resistance to platinum comes from two major mechanisms-- pumping the platinum out, we're not getting it in in the first place. And the second is repair of DNA. And we're not going to solve that second problem with this, but we can at least bring it there and keep it there with the platinum. And you can see this by a number of techniques, how much platinum gets in there. If you look at the red and blue curves to your left, there's no difference between the resistant and normal cell lines, with a conjugate. And you look way out at the right, with just the normal platinum drugs, there's a big difference. So the blue is if you are susceptible to platinum. But lot of patients develop resistance. And they become the red group. Not as good. And there are other ways to see this. This isn't just the number of DNA adducts that have been modified. And again, for those of you who like the science, you can look at that in

depth. Unfortunately, if you give the DNA a chance, the other mechanism of resistance comes in. And that starts repairing the DNA. So the first problem is getting it there, or keeping it there. We solved that. But then we've modified DNA with platinum. That's well known. Steve Lippard at MIT has been one of the leaders in demonstrating that. And the trouble is you put these funny kinks in DNA with platinum. But there are proteins, mismatch repair proteins, that come along and repair that. And if we're just making cis-platinum, that same repair mechanism is going to operate. People have devoted a lot of effort to overcoming the mismatch repair resistance. And there's an FDAapproved drug called Oxaliplatin, where the platinum has been made a little bit more bulky. And that extra bulk, presumably, prevents the DNA from being repaired. So now Jonathan had the problem of making that. He did. So now he's made a texaphyrin that looks like oxaliplatinum. And guess what? We call this oxaliTEX, or oxalitexaphyrin, because we work at Texas. And we like the idea of making big things and calling them after our state. And this worked amazingly well. And we're just, as I said, with the benefit of Dr. Alan Watts, starting to study these in animals. And the good news is that we can bring at least two times, and, I think, as much as four times the amount of platinum into mice without evidence of toxicity. And so that's our primary goal, is to be able to bring more platinum to, first, mice and, ultimately, patients. As I said if we can double the amount of platinum that we can bring to ovarian cancer patients, we think that will take ovarian cancer from a very, very serious disease to one that's still very serious, but with a prognosis and five year survival that would be very pleasing for patients and their loved ones. And the good news is that we can get distribution. It goes all over, but a lot goes to the cancer. More goes out through the liver than would be expected for the oxaliplatinum. So we're just starting to look at tumor regrowth studies, which are necessary to establish efficacy. So there's always two legs to initial drug development-toxicity and efficacy. Toxicity looks very, very promising. The efficacy, here we're comparing various controls versus the conjugate, the oxalitexaphyrin. For the resistant cells, it's not so clear. This is for the normal, susceptible ovarian cancer. So there's a hint here, but certainly nothing that we would consider close to the definitive. But it's much too early to stop. We're very excited about this work, and we think it has promise for treating ovarian cancer. So to summarize this death-resurrection of texaphyrin, I think in spite of everything, deep mechanistic thinking has a role to play in drug development. And that's illustrated on this slide from [? Harris ?] where the husband is saying what's a nine-letter word for biotechnology? And his smart wife immediately pops up-- chemistry. And so that's what we think. It remains for me to summarize. We're enjoying Texas-inspired approach to making these bigger porphyrins and developing them for medicinal chemistry. And I have to thank a number of people, Jonathan Arambula, up on the top of the list to the left, has really driven this whole project. And we've benefited early on from the great expertise of Darren Magda, who was originally at Pharmacyclics and now works at Limiphore. Zahid Siddik, who, at MD Anderson, has been involved in this particular aspect of the project. And of course, Richard Miller, to whom I owe my life in science, both literally and figuratively. And of course, I thank you for being so kind to listen to this rather dry form of presentation. But I hope you've taken some lessons back from this. Number one, draw inspiration from your own life. Number two, it's hard, these are tough problems, but good people like you are the ones who are going to solve it. And third, no matter what, never, never, never surrender. Thank you very much.

Discovering The Anthrax Antidote 1.The Anthrax Problem

Hello. My name is Brent Iverson. I'm the chairman of the Department of Chemistry and Biochemistry at the University of Texas at Austin. And today, I'm going to tell you about some work that we have done in the past to create a cure for anthrax based on an engineered antibody. What I hope you get out of this today is really two things. First, that number one, academic science can have a large role to play in discovering promising new drug candidates. And second, that academic commercial partnerships are absolutely required to fully test and develop any new drug. So we're going to be talking about anthrax. And many of you may remember that in the fall of 2001, there were some letters sent to a variety of people that contained weaponized anthrax spores. Five people died as a result of these mail attacks. And what I'm going to tell you about today is some technology that we used to develop a cure that probably would have helped save them had it been available. But before I do that, I want to talk about really why anthrax? Because when people talk about bioweapons and concerns about biological agents, anthrax usually comes to the top of the list and the question is why? Well, it relates to the life cycle of the anthrax bacterium. Anthrax itself is a very well evolved organism to live in the environments that have a lot of grazing types of animals. So the life cycle of anthrax is based on a spore state that is incredibly stable. It can live for probably centuries. And that spore state doesn't have any metabolism. The bacteria aren't in any way what you would call alive. But they are dormant. You can think about this as the state of the bacteria that's just waiting for a grazing animal to come along. It might eat some tainted leaves. It might inhale the spores. But what happens inside the animal is that those spores germinate into live bacteria. Those live bacteria invade the bloodstream of the animal and they release a deadly toxin. So the first important thing to remember is that it's not necessarily the bacteria themselves or the presence of the bacteria that's the problem when it comes to anthrax. It's the toxins that are released. And we're going to have a whole lot more to say about that. Because although antibiotics can kill the anthrax bacteria, it's the toxins that have to be dealt with to prevent people from dying after they've been exposed to anthrax. So let me get back to why it is we talk about anthrax. There are a lot of deadly viruses and bacteria. Anthrax is particularly of a concern because it turns out that this life cycle where you have a spore state that germinates into live bacteria, that then generate the toxin, that's unfortunately very easy to replicate in the laboratory. A standard fermenter, with some specific knowledge, can be combined to generate a very large amount of the anthrax spores. And it's a relatively straightforward manner to generate enough to do a great deal of harm. And so when you think about why do we always talk about anthrax, I think a lot of it has to do with the fact that it's fairly easy, with certain knowledge and equipment, it's fairly easy to manufacture large, deadly quantities. How deadly is this? Well, it turns out in 1979 in Russia, there was a plant that was manufacturing weaponized anthrax as part of a bioweapons program. And there was an accidental release. There are various stories about this. But it probably had to do with some ventilation workers who set the direction of the ventilation equipment the wrong way so that some live sports were released into the atmosphere. It turns out that over 70 people died as a result of this exposure. And a great number of farm animals that were farther away from the plant also died of anthrax. This wasn't widely reported in the Western media. But following the whole period of glasnost in the Soviet Union, there was a detailed investigation. And it was shown that all of the victims who died of anthrax were actually located directly downwind of this plant. My point in saying this is that even though the effects were felt for miles away, the best estimate is that only about as much as is in a normal aspirin tablet was released of the anthrax spores. So it just shows you how incredibly deadly this really is. The other thing we have to worry about is that although anthrax itself, the natural kind, is very easy to treat with antibiotics, it turns out that it's relatively straightforward unfortunately to

create an antibiotic resistant set of strains. Papers have actually even been published on how to do this. But let me get back to what's really important here. And that is if we're going to treat somebody who's been exposed to anthrax, we have to worry about the toxins. Because it turns out that there is a point at which you can kill all the bacteria within an individual with an antibiotic, but there might be a lethal load of toxin already in their bloodstream. If you don't handle some sort of inactivation of the toxin as an approach to their treatment, they're going to die anyway, even if the bacteria are no longer living. So it turns out if we want to look at the toxins, there's three of them. This is known in biological circles as the standard AB toxin system. We have some lethal toxins, in particular the LF and EF toxins, that actually do the damage inside of an animal. But those are released into the bloodstream where they don't really cause any harm until they gain entry into cells. So the key part of our story is that you have to have the LF and the EF toxins enter host cells. And that is accomplished by a third toxin, called the PA toxin. And the PA toxin is going to be the star of our show. To try to put this in perspective, we can think about our host cells, and they turn out to be macrophages which are some of the command and control cells of our immune system, that are the target of the anthrax toxins. When released into the bloodstream, the PA toxin will bind to a specific receptor in a very strong interaction to those cells of our immune system. The LF and the EF toxins, the one that do the damage, are taken along with the PA toxin and transported into the cells. This whole process is understood in a great deal of detail. And it's a remarkable example of how different pathogenic bacteria, or in this case the toxins, have evolved to exactly take advantage of different processes within the living system, within living cells, and create a great deal of damage. What I'm showing here are four different views of the anthrax PA toxin. And the point I'm trying to make is these are very complex structures. So it's easy to make a cartoon that says, let's just derive an antibody that binds very strongly, specifically, and only to the anthrax toxin. But you can see by the complicated nature of this protein that that's going to be a relatively difficult challenge. I wish we could just design it on a computer and have it work. Unfortunately, it's not anywhere near that simple. So although it's really easy to say we're going to treat anthrax analogous to the way that we treat snake venoms, in fact there's a lot of work that has to be done. And that's what I'm going to describe to you over the next few minutes. Here is, putting in perspective, the problem. What I'm showing on the left is the anthrax PA toxin. The color coding there has to do with charge. Blue is associated with positive charge. Red is associated with negative charge. The PA toxin has that characteristic ring structure which allows entry into the host cells. What I'm showing on the right, the smaller protein, is hemoglobin. Obviously, hemoglobin is a very important molecule in the body. And this is just meant to represent all of the important protein molecules in the body. I've also shown its electrostatic surface, which is what this is called, where we're seeing the blue and the red positive and negative charges. And the point I'm making is that in the molecular world, it's easy to draw a cartoon that says we're going to make an antibody that binds only to the anthrax toxin. But when you put it in the context of all of the other molecules in the body and realize that that antibody cannot interact with any of those others because that will take it off course and inactivate its ability to work for us, you realize that this is a very complicated challenge indeed.

2.The Role Of AntiBodies

What we're going to be talking about now is an antibody molecule. Antibody molecules are the arm of the immune system that has the ability to recognize specifically foreign proteins. It's shaped like a "Y," as you can see. And the important part of the antibody from our point of view are the two tips of the Y. If you think about the two binding sites, they're at the ends of the arms of the antibody molecule. Each antibody molecule has two identical binding sites. Here's another view of the antibody, that's shown in the same four formats as we saw the anthrax PA protein. And again, it's the tips of the Y. It's the tips of the arms of the Y that's going to have the ability to recognize specifically that PA protein molecule. What I'm zooming in on here is the actual binding sites for a typical antibody molecule. And you can see that what we have is a surface that has various shapes, various valleys, various bumps, ridges. And it also has charge, the red for the negative charge, the blue for the positive charge. So the idea here is that we need to have an antibody molecule that perfectly complements the shape of the anthrax PA protein, but also has perfectly complementary charge. And the reason I keep showing these charges is because as you remember opposite charges attract. So if there is a blue color on the anthrax PA protein, we need to have a corresponding red color on the antibody. So it has to fit like a lock in a key in terms of the shapes. But it also has to be complementary in terms of the charges. Well, fortunately, we don't have to design this from scratch. Because it turns out if you immunize an animal with only the PA protein, you can in fact elicit antibodies through natural processes that will be specific to that PA protein. So this has been done. And it's been done by workers at USAMRIID. You probably know them more as The Hot Zone people. And it turns out that the best single antibody that they could develop, called 14B7, could delay time to death in experiments that tried to simulate an anthrax infection, but they couldn't prevent death. And this is where my laboratory enters the picture. Because what we had hypothesized is that the reason that this antibody, 14B7, could delay time to death, but not prevent death in experimental animal models was that it just didn't bind strongly enough. So the challenge became a simple one to explain and a difficult one to achieve. And that is take this antibody, 14B7, which already binds to the PA protein and make it stronger. This just kind of puts the three molecules we're talking about in perspective-- or the two molecules we're talking about. I've got the PA protein on the left, an antibody on the bottom right. And we have a hemoglobin molecule on the top right. So to put this in simple terms, we have to create an antibody based on 14B7 that binds more strongly to the PA protein and leaves everything else in the body that's supposed to be there, alone. And it's all going to be based on complementary shape and complementary charges. Well, it turns out we don't know how to design that from scratch. I would love to tell you that we went on a very sophisticated computer system, decided how to modify the protein sets that would be perfectly complementary and bind with a stronger "affinity." And that's the term that scientists use to describe two things interacting. The higher affinity is a stronger interaction. Well, it turns out we can't design yet for complicated reasons a better antibody. So the question is how are we going to take 14B7 and make it better? Well, we turn for inspiration to natural evolution. Because in natural evolution, what you have is a process of random mutation that occurs throughout a population. And if that random mutation in a given protein happens to have a fitness advantage for that organism, that organism will survive and it will even flourish. So the idea here is that even though we don't know how the 14B7 antibody works, if we can develop a technology that allows us to make random changes in the antibody molecule and then isolate the ones that happen to have beneficial changes,

we can generate a better antibody. And that's the approach that we have taken. Now, I don't have time to go through all the different scientists who have contributed to this kind of idea. Workers like Frances Arnold at the California Institute of Technology have made major contributions in this area. But the idea is really a powerful one. We develop molecular biological, in other words, genetic engineering methods, to make random changes in a protein that's already pretty good. Remember, the 14B7 antibody is already pretty good. And we need to make random changes throughout that protein and then develop a technology that allows us to isolate the changes that happen to be beneficial, in other words, create stronger binding. This becomes a numbers game. The more of random changes, we call these libraries or pools of changes in our gene for the antibody, the larger the number of these that we can put through a selection system, the more likely we are to find an unlikely but beneficial change.

3.The Approach
So, inspired by natural evolution, the approach that we're going to take is we're going to generate random mutations in the 14B7 antibody gene. And then Dr. George Georgiou and myself at the University of Texas of Austin develop technologies that allow us to screen large pools of these genes with random changes in them to identify only those antibodies that happened to bind the PA protein better. So even though we don't necessarily understand or are able to design better antibodies, if we screen millions of different possibilities and isolate the very best, we end up with better antibodies. They bind more strongly. So I'm not going to take you through the details of how this technology works. You can Google my name or you can Google that of Dr. Georgiou and you'll be able to read some papers that will help you understand how we actually accomplish this. What I want to do, though, is tell you the results of this work. We were able to take the 14B7 antibody, and in our first generation of experiments, create a version of that that we call 1H that binds to the PA protein 20 times more strongly than 14B7. And remember the key hypothesis that we had. 14B7 was already pretty good. What we needed to do was to create a stronger version of that, and hopefully, we could transition from just delaying death to preventing death in a process. Having a 20-fold higher affinity or stronger binding version that we call 1H seemed like a promising thing to start with. Well, it turned out it was. Because using an animal model-- in this case, we were using laboratory rats injected with both the PA protein and the lethal factor, which ordinarily causes death-- we were able to show that the modified antibody, the 1H, the higher affinity antibody, was able to prevent death, while the 14B7 confirming experiments that were carried out at USAMRIID, in fact, only delayed time to death. So it looked as though our hypothesis of making the antibody stronger was correct. That's where we leave academic science. Because the University of Texas at Austin is not equipped to carry out studies with live anthrax or anthrax spores, none of the experiments that involved testing this material were carried out here. In addition, there are a number of other very important considerations that are very difficult to address in an academic environment, mostly because of the costs and the expertise involved. So if we're thinking about an actual therapeutic protein, we have to go far beyond the kinds of materials that we're going to generate in an academic laboratory. We need to have manufacturing processes in place that ensure very high quality large amounts of a very pure material. Of the many reasons that this can't be done in an academic laboratory effectively is that we don't have the expertise or the equipment to scale up the manufacture of a protein like this antibody molecule. As a result, it was very important to hand this off to a commercial entity. Elusys Incorporated in New Jersey licensed the mutations that we had identified that created a 20-fold higher affinity antibody and started investigating the use of this material as a true treatment for anthrax.

4.Commercial Development Of the Antidote

So everything I'm about to tell you from now on did not take place at the University of Texas at Austin. It was actually completely under the control of Elusys the direction and control of Elusys Incorporated and the scientists there. Elusys effectively scaled up the preparation and purification of the antibody, and what we now are going to call it is Anthim, because that's the name that they chose for the antibody that originated in our laboratory that we called 1H. So from now on, I'm going to be referring to Anthim, which is their antibody product that they manufacture. With a large quantity of the antibody available, Elusys carried out a series of animal studies, and what they were able to show was even when a 300 times of a lethal dose of anthrax spores are used, the antibody, Anthim, could prevent death of the exposed animals. In other words, it appears to be a cure. A number of different animal models were used, and in each case, it looks as though this idea that we originally had of increasing the strength of the binding of the antibody was all that was needed to turn a molecule, the 14b7 antibody, from an agent that could delay time to death, actually turned into one that could prevent death. Currently, Anthim is awaiting final approval before it can be used. There's a part of this story that I feel compelled to tell you because I find it one of the most interesting. An important lesson in this work comes down to the fact that this idea of using an antibody to treat a deadly bacterial infection is not a new idea. In fact, it's a very, very old idea. An interesting aspect of this story is that even though it may look like a modern tale, we were using developed technology that was very recent and only enabled by all of the things we know of as

genetic engineering and some other high tech devices. In fact, the ideas date back almost a century. It turns out that in the 1920s, it was very common to use antibody preparations, in particular antitoxin antibody preparations, to treat bacterial infections. I'll remind you that back in the 1920s there were no penicillins or the other kinds of modern antibiotics that we're used to. So treating bacterial infections was a very difficult task indeed. For example, diphtheria toxin is usually fatal for children under the age of seven. It was common practice to inject farm animals, sheep or goats, with a crew preparation of diphtheria toxin, isolate the [? sera, ?] in other words, the crude antibody preparations from those farm animals, and inject kids directly if they were infected with diphtheria. In fact, in 1925 in Nome, Alaska, there was an outbreak of diphtheria in an orphanage, and this was particularly critical because there was no anti-diphtheria toxin serum available. Unfortunately, it was the middle of winter, and from what I understand, there were some pretty bad weather, even by Alaska standards, happening at the time. A call was put out by telegraph and some anti-toxin, antidiphtheria anti-toxin, was delivered from Seattle to Nome, Alaska. The last part of the journey was accomplished by dogsled. It was the only means available for travel at the time. It turns out that there is a popular Disney video that memorializes this, and it's called Balto. Balto was the lead dog in that story. Not only in the story, but the lead dog that brought the diphtheria anti-toxin into Nome, Alaska, was actually named Balto, and he became a very famous animal. So my point in telling you this, is that even though it seems like this was a modern story, using everything at our disposal to create an engineered antibody to treat anthrax, the ideas date back to the 1920s. And there's an important lesson there for scientists. Because our parents, grandparents, and great grandparents had really good ideas, they just didn't have the technology and the other things that we now have to create solutions to scientific problems. But it's always a good idea to look back at how they were approaching problems and see if we can't put a modern spin on their ideas. As a poignant reminder of this, it turns out that there's a statue of Balto, the dog that brought the diphtheria antitoxins into Nome, Alaska. And by the way, I didn't say it. I don't want to spoil the Disney video, but in fact, all the kid survived because of this. The dog is immortalized with a bronze statue in Central Park, and what I find most remarkable about this is if you look at the inscription on the bronze statue, it actually uses the word anti-toxin. So at the dawn of the new century, workers in my laboratory created an approach to an engineered antibody that cured something that we were very much afraid of, a biological threat, anthrax. But the seeds, the ideas for that, can be found on a statue that dates back to the 1920s in Central Park in New York. So in many ways, I consider this almost a Back to the Future story. There's an old idea that dates back to the 1920s, but by using modern technology, we are able to overcome the deadly anthrax toxin by engineering an antibody. So again, to finish where we started. Academic science can have a large role to play in discovering promising new drug candidates. In this case, the engineered 1h antibody. Developing an actual drug though cannot be accomplished, for a whole variety of reasons, in an academic laboratory. It was then essential to have Elusys Incorporated take this molecule and develop an actual drug. It's important to recognize that this was not carried out in my laboratory alone, but my colleague from the departments of biomedical engineering and chemical engineering, Dr. George Georgiou, has been a collaborator from the very beginning of this work.