TMC 207(BEDAQUILINE): A NEW WEAPON AGAINST MDR AND XDR-TB

PRESENTED BY MOHIT KUMAR DWIVEDI MS.PHARM 1ST SEM BIOTECHNOLOGY

FLOW OF SEMINAR
INTRODUCTION CHEMISTRY MECHANISM OF ACTION PHARMACOKINETICS AND METABOLISM CLINICAL ASPECTS OF BEDAQUILINE MATERIALSAND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

INTRODUCTION
The diarylquinoline, TMC207 (formerly R207190), is a new antituberculosis drug1 under assessment in a phase II clinical trial in which it was added to a background regimen for the treatment ofmulti-drug resistant (MDR) pulmonary tuberculosis.2 In this trial, sputum conversion to negativity has occurred after 8 weeks of treatment in 48% of 23 patients on TMC207 background drugs compared to 9% of 24 on placebo + background drugs. Peak plasma concentrations of 3.2 g/ml and 1.7 g/ml and trough concentrations of 1.0 and 0.7 g/ml were found during dosage with 400 mg daily or 200 mg thrice weekly, respectively. TMC207 acts by selective inhibition of mycobacterial ATP synthase. The factors that will affect its antibacterial activity in comparing intracellular and extra-cellular activity are (1) the concentration of ATP and the energy pool present in each of the bacterial populations at the start of its activity. The available concentration of TMC207. We therefore compared the extra-cellular activity of TMC207 with its activity on the J774 macrophage- like cell line.

CHEMISTRY

DIARYLQUINOLINE DERIVATIVE IT SHOWS ACTIVITY DUE TO THE PRESENCE OF TERTIARY AMINE AND TERTIARY ALCOHOL

MECHANISM OF ACTION

PHARMACOKINETICS AND METABOLISM

AFTER ORAL DOSE OF 400mg tmax = 4 hours Cmax = 5.5 mg/l

AUC = 65 mghr/l Clearance = 6.2 l/hr t1/2 = 173hr Plasma protein binding = >99.9% These factors makes it suitable for intermittent drug action. CYP3A4 is the majour isoenzyme involved in its metabolism. Drug is mainly excreted through faeces.

CLINICAL ASPECTS OF BEDAQUILINE

CONTD.

DOSE:
400mg for first two weeks 200mg three times per week for 22 week

ADRs:
QT prolongation Nausea Diarrhoea Arthralgia Hyperuricemia Eye Disorders

MATERIALS AND METHODS

CULTURE MEDIA AND DRUGS

The broth used in extra-cellular studies was Middlebrook 7H9 +ADC supplement. Colony counts were done on Middlebrook 7H11 oleic acid-agar medium . Mycobacterium tuberculosis, strain H37Rv, was kept as stock strain in liquid nitrogen and serially transferred at weekly intervals in 7H9 broth + ADC. Pure powder TMC207, was dissolved and diluted in dimethyl sulphoxide at a concentration of 10 mg/ml and stored at -20 C. Final dilutions in the range 0.006-1.0 mg/ml or 0.25-32 mg/ml, as well as a control without drug were made in the culture media.

EXTRA-CELLULAR ACTIVITY
A 6 ml volume of a 7-day culture of M. tuberculosis, H37Rv in 7H9 broth was added to 200 ml 7H9 broth. After incubation for 4 days, the inoculated medium was dispensed into 30-ml screw capped universal containers and TMC207 added Immediately (day-0). After 7, 15 and 22 days of incubation at 37 C, samples were ultrasonicated briefly and viable counts set up.

J774 CELL LINE(INTRA-CELLULAR ACTIVITY)

The J774A.1 cell line derived from mouse .This was kept at stock concentrations in liquid nitrogen, thawed at 37 C and aliquoted into filtered 25 cm flasks with warmed RPMI 1640 +10% FCS medium. Cells were allowed to adhere until confluent and the flasks split twice a week to maintain the cell line. Splitting was carried out once the cells were confluent by discarding the medium and adding 4 ml of RPMI 1640 +10% FCS. The cells were gently taken off the flask by pipetting up and down till the medium becomes cloudy and the back of the flask became clear. From this suspension, 0.5 ml was added into a new flask with medium for maintenance. A cell count was carried out on this suspension and 5 10 cells were added into 24 well plates and allowed to adhere for 48 h with daily medium changes before infecting with M. tuberculosis. Drugs were added (day-0) after phagocytosis for 2.5 h. Colony counts were done after incubation for 5 and 7 days.

EXPERIMENTAL DESIGN

There were two experiments in each of which a comparison was made between the activities of TMC207 in the range of 0.006-1.0 g/ml on M. tuberculosis in each of the two conditions: extra-cellular and J774 cell line In further single experiments in each condition, the range of TMC207 was increased to 0.25-32 g/ml. In each experiment, test cultures were set up in duplicate for extra-cellular cultures and in triplicate with the J774 cells. Serial 10-fold dilutions were made from each culture, and an inoculum of 0.1 ml from each was added to a one-third segment of a 7H11 plate in duplicate. Plates were packed into polyethylene bags and incubated for 3-4 weeks at 37 C before colony forming units (cfu) were counted.

RESULTS

DISCUSSION

Our data present evidence that TMC207, in combination with a five-drug secondline regimen, had an acceptable side-effect profile; reduced the time to sputumculture conversion in patients with newly diagnosed, smear-positive, multidrugresistant tuberculosis; and significantly increased the proportion of patients with negative sputum cultures after 8 weeks. The inhibition of the bacterial ATP synthase by TMC207 reduces the internal energy pool until it reaches a specific lethal level, perhaps causing membrane instability. The sputum cfu counts after treatment of patients with TMC207 alone for 7 days in the early bactericidal activity study.

CONCLUSION

Bedaquiline has shown definite beneficial effects in combination with other anti-TB drugs. Bedaquiline is the first new anti-TB drug to be approved by the FDA (on 28thDecember, 2012) in more than 40 years. It was approved under the FDAs accelerated review program that allows promising drugs to be brought to market more Quickly\ It is an attractive option for MDR and XDR- TB and shortening the duration of anti- TB therapy. Careful use of this drug along with monitoring of the potential adverse effects and drug interactions becomes very important.

REFERENCE
1. Andries K, Verhasselt P, Guillemont J, Ghlmann HWH, Nefs J-M, Winkler J, et al. A diarylquinoline drug active on the ATP synthase of mycobacterium tuberculosis. Science 2005;307:223e7. 2. Diacon AH, Pym A, Grosbusch M, Patienta R, Rustomjee R, Page-Shipp L, et al. The diarylquinoline TMC207 for multidrug-resistant tuberculosis. N Engl J Med 2009;360:2397e405. 3. Canetti G. The tubercle bacillus in the tuberculous cavity. In: The tubercle bacillus in the pulmonary lesion of man: histobacteriology and its bearing on the therapy of pulmonary tuberculosis. New York: Springer; 1955. p. 62e8. 4. Grosset J. Mycobacterium tuberculosis in the extracellular compartment: an underestimated adversary. Antimicrob Agents Chemother 2003;47:833e6. 5. Mwandumba HC, Russell DG, Nyirenda MHJ, Anderson SA, White ME, Molyneux ME, et al. Mycobacterium tuberculosis resides in nonacidified vacuoles in endocytically competent alveolar macrophages from patients with tuberculosis and HIV infection. J Immunol 2004;172:4592e8. 6. Dhillon J, Mitchison DA. Activity and penetration of anti-tuberculosis drugs in mouse peritoneal macrophages infected with Mycobacterium microti OV254. Antimicrob Agents Chemother 1989;33:1255e9