OAT1

Very low risk for drug-drug interactions (DDI) with Mazindol ER based upon results from in vitro metabolism and transporter studies Demonstrated pharmacological differentiation versus currently available medications used to treat narcolepsy which can have significant DDI effects preventing co-administration or requiring dose adjustments ZURICH, SWITZERLAND / ACCESSWIRE / June 14, 2023 / NLS Pharmaceutics Ltd. (Nasdaq:NLSP, NLSPW) ("NLS" or the "Company"), a Swiss clinical-stage biopharmaceutical company focused on the discovery and development of innovative therapies for patients with rare and complex central nervous system disorders, today announced positive data from five recently completed in vitro drug-drug interaction studies investigating the potential for DDI of mazindol, a triple monoamine reuptake inhibitor and partial orexin-2 agonist, as well as its hydrolyzed metabolite (M6). Typical DDI studies include Cytochrome P450 (CYP), UDP glucuronosyltransferase (UGT) and transporter inhibition and induction studies to evaluate whether mazindol affects the pharmacokinetic (PK) effect of other drugs (mazindol as a "perpetrator"). In addition, in vitro studies are conducted with CYP and transporter substrates to evaluate whether other drugs can affect mazindol PK (mazindol as a "victim"). Following U.S. Food and Drug Administration (FDA) guidelines, the in vitro DDI studies were designed to evaluate the drug interaction potential across a wide range of metabolic enzymes and transporters when co-administered with mazindol. The mazindol in vitro studies examined the following: CYP Inhibition in Human Liver Microsomes CYP Induction in Cultured Human Hepatocytes CYP and UGT Reaction Phenotyping UGT Inhibition in Human Liver Microsomes ATP-binding case (ABC) and solute carrier (SLC) Transporter Inhibition and Substrate Potential in Cells and Vesicles Results of the in vitro perpetrator studies showed that mazindol and its hydrolysis metabolite do not have the potential to inhibit or induce the metabolism/transport of concomitant medications. Based on these in vitro data, it can be concluded that mazindol and the hydrolysis metabolite are not inhibitors of CYPs, UGTs, or transporters (including P-glycoprotein, breast cancer resistance protein [BCRP], organic anion transporter [OAT]1, OAT3 and organic cation transporter [OCT]2 and mazindol does not induce metabolism. Therefore, mazindol does not affect the PK of concomitant medications. Results of the in vitro victim studies showed that mazindol is not metabolized by CYPs or UGTs and is not transported by BCRP, OAT1, OAT3 and OCT2. Only the hydrolysis metabolite (but not mazindol) is a P-glycoprotein (Pgp) substrate; thus a clinical DDI study of mazindol is planned to quantify the potential for an increase in the hydrolyzed metabolite (M6) exposure in the presence of a Pgp inhibitor (e.g., Itraconazole). Otherwise, concomitant medications are not expected to affect the PK of mazindol. "We are pleased to have seen these positive results from our DDI in vitro study with mazindol, which further demonstrated its differentiated pharmacological and safety profile. This latest set of data reinforce that mazindol may have the potential to provide an advantage over other current treatments for patients with narcolepsy taking multiple drugs, including hormonal contraceptives, proton-pump inhibitors and anti-epileptic drugs, who are at higher risk of experiencing adverse drug interactions or even discontinuation of their medications due to those interactions," said George Apostol, MD, MS, Chief Medical Officer of NLS. "Based on these data, once-daily Mazindol ER shows potential to meet yet another unmet need of narcolepsy patients, in addition to its strong efficacy, fast onset of action, well demonstrated long-term safety profile, low scheduling and its unique mechanism of actions." Alex Zwyer, Chief Executive Officer added, "Discussions with both physicians as well as patient advocacy groups at SLEEP 2023, the annual meeting of the American Academy of Sleep Medicine (AASM) and the Sleep Research Society (SRS), held on June 3 - 7, 2023, in Indianapolis, reinforced the importance a mazindol's DDI drug pro realize an unmet need for patients." Beginning in July 2023, NLS will initiate the AMAZE development program for Mazindol ER, consisting of two pivotal Phase 3, randomized, double-blind, placebo-controlled, multicenter studies in the U.S. designed to assess the safety and efficacy of mazindol in patients with narcolepsy type 1 (NT1) compared to placebo. These two studies will enroll a total of 100 NT1 patients. Mazindol ER will be administered at fixed doses of 3 mg once daily for a total of eight weeks. A 52-week open-label extension will further evaluate the long-term safety and tolerability of Mazindol ER in NT1 patients. Topline data from the double-blind studies are expected in late 2024. About DDI in vitro studies DDI studies are a standard and necessary step required by the FDA and other regulatory agencies globally for approving a new drug to market. DDI studies help identify potential adverse reactions that may be caused by interactions between multiple drugs, leading to unintended reactions, toxic side effects, or in some cases, a lack of therapeutic efficacy. With the rise in polypharmacy to treat comorbidities, alongside prevalent substance abuse, drug-drug interactions have become a critical factor to consider when treating narcolepsy. Approximately 50% of prescribed drugs currently on the market are known to cause drug interactions with CYP3A4 inhibitors and can lead to side effects. Findings from DDI studies help to inform drug labeling that is then used by healthcare providers to aid in therapeutic decision-making. Currently available medications used to treat narcolepsy can have significant DDI effects which prevent co-administration or require dose adjustments of drugs like hormonal contraceptives, proton-pump inhibitors or anti-epileptic drugs. About Mazindol ER The Company's lead product candidate, Mazindol ER, is a proprietary extended-release formulation of mazindol and is being developed for the treatment of narcolepsy, and potentially other sleep-wake disorders such as Idiopathic Hypersomnia (IH), for which NLS recently obtained Orphan Disease Designation (ODD) from the FDA and the European Medicines Agency (EMA). Mazindol is a triple monoamine reuptake inhibitor and partial Orexin-2 Receptor agonist, which was used for many years to treat patients diagnosed with narcolepsy in compassionate use programs. A Phase 2 multi-center U.S. clinical study evaluating Mazindol ER in adult patients suffering from narcolepsy met its primary endpoint with high statistical significance and demonstrated a favorable safety and tolerability profile. NLS also successfully completed a Phase 2 study in the U.S. evaluating Mazindol ER in adult patients suffering from Attention Deficit/Hyperactivity Disorder (ADHD). The study met all primary and secondary endpoints and well-tolerated. Mazindol ER has received ODD both in the U.S. and in Europe for the treatment of narcolepsy. Up to 1/3 of narcoleptic patients are also diagnosed with ADHD. The Phase 3 program for Mazindol ER, AMAZE, will commence in July 2023. More information on these studies can be found at or . About NLS Pharmaceutics Ltd. NLS Pharmaceutics Ltd. (Nasdaq:NLSP) is a global development-stage biopharmaceutical company, working with a network of world-class partners and internationally recognized scientists, focused on the discovery and development of innovative therapies for patients with rare and complex central nervous system disorders who have unmet medical needs. Headquartered in Switzerland and founded in 2015, NLS is led by an experienced management team with a track record of developing and commercializing product candidates. For more information, please visit . Safe Harbor Statement This press release contains expressed or implied forward-looking statements pursuant to U.S. federal securities laws. For example, NLS is using forward-looking statements when it discusses the potential benefits of Mazindol ER and the timing and expected format of the AMAZE Phase 3 clinical program. These forward-looking statements and their implications are based on the current expectations of the management of NLS only and are subject to a number of factors and uncertainties that could cause actual results to differ materially from those described in the forward-looking statements. The following factors, among others, could cause actual results to differ materially from those described in the forward-looking statements: changes in technology and market requirements; NLS may encounter delays or obstacles in launching and/or successfully completing its clinical trials; NLS' products may not be approved by regulatory agencies, NLS' technology may not be validated as it progresses further and its methods may not be accepted by the scientific community; NLS may be unable to retain or attract key employees whose knowledge is essential to the development of its products; unforeseen scientific difficulties may develop with NLS' process; NLS' products may wind up being more expensive than it anticipates; results in the laboratory may not translate to equally good results in real clinical settings; results of preclinical studies may not correlate with the results of human clinical trials; NLS' patents may not be sufficient; NLS' products may harm recipients; changes in legislation may adversely impact NLS; inability to timely develop and introduce new technologies, products and applications; and loss of market share and pressure on pricing resulting from competition, which could cause the actual results or performance of NLS to differ materially from those contemplated in such forward-looking statements. Except as otherwise required by law, NLS undertakes no obligation to publicly release any revisions to these forward-looking statements to reflect events or circumstances after the date hereof or to reflect the occurrence of unanticipated events. More detailed information about the risks and uncertainties affecting NLS is contained under the heading "Risk Factors" in NLS' annual report on Form 20-F for the year ended December 31, 2022 filed with the Securities and Exchange Commission (SEC), which is available on the SEC's website, , and in subsequent filings made by NLS with the SEC. For additional information: Marianne Lambertson (investors & media) NLS Pharmaceutics Ltd. +1 239.682.8500 ml@nls-pharma.com SOURCE: NLS Pharmaceutics AG View source version on accesswire.com:

6月27日，FDA发布题为《寡核苷酸疗法开发的临床药理学注意事项》的指南草案。以下摘编重点内容供参考，文件完整10页PDF点击小程序查看（点击下载PDF）。来源：FDA引 言本《指南》提供了帮助行业开发寡核苷酸疗法的建议，包括药代动力学、药理学和安全性评估：1）表征QTc间期延长的可能性；2）进行免疫原性风险评估；3）表征肝肾损害方面的影响；4）评估药物-药物相互作用的潜力。本《指南》就何时进行这些评估以及何种类型的评估适合解决这些问题提供了建议。寡核苷酸疗法是一种新兴的治疗方式，越来越多的药物在开发中。近年来，反义和小干扰RNA (siRNA)寡核苷酸疗法已被FDA批准用于治疗罕见病；此外，目前许多寡核苷酸疗法正被开发用于治疗常见慢性疾病。寡核苷酸疗法包括多种合成修饰的RNA或RNA/DNA 杂交体，专门设计与目标RNA序列结合，以改变RNA和/或蛋白质表达。在这种治疗模式（therapeutic modality）下，各类寡核苷酸疗法也在多个方面有所不同，包括但不限于:作用机制（如剪接调节、RNA干扰、RNase H介导的切割）结构（如单链RNA、双链RNA、RNA/DNA 杂交体）碱基和/或骨架的化学修饰大小序列递送策略【如脂质纳米颗粒（LNP）、脂质体、其他聚合物纳米颗粒、聚乙二醇(PEG)、N -乙酰半乳糖胺(GalNAc)】是否存在其他部分（如小分子、蛋白质、抗体）本《指南》中的建议一般适用于以RNA为作用机制中心（RNA-centric mechanism of action）的寡核苷酸疗法。以直接调控蛋白质为作用机制（如适体）或以免疫刺激为作用机制（如TLR9激动剂）的寡核苷酸疗法不在本《指南》的范围内。FDA鼓励申办方在pre-IND或IND阶段与适当的审评部门沟通，讨论这些疗法的开发。二、临床药理学注意事项一般来说，在药物开发早期，申办方应该描述单剂量和多剂量寡核苷酸治疗后的血浆药代动力学特征。然而，对于一些寡核苷酸疗法，血浆药代动力学可能不能反映靶组织分布、药效学、安全性或有效性。因此，在多剂量研究中，申办方应该包括适当的药效学生物标志物的评估(如靶mRNA、靶蛋白或能够反映靶蛋白调节的下游生物标志物)或考虑其他响应措施。这种评估在药效学变化独立于血浆药代动力学变化的情况下是重要的。药效学终点的选择应与适当的FDA评审人员讨论，特别是在药效学终点可能不能直接反映靶点敲低的情况下(例如，cerebrospinal fluid for central nervous system target)。与小分子或生物制品相比，寡核苷酸疗法具有某些独特的特征(例如，化学性质、结构、作用位点、药代动力学处置、药效学)，因此，申办方应参考下文A-to-D部分，考虑在寡核苷酸治疗开发期间应何时表征QTc间期延长、何时评估免疫原性风险、何时评估肝肾损害方面的影响以及评估潜在的药物-药物相互作用。应特别考虑化学性质(如骨架修饰、偶联)、药物靶点、血浆蛋白结合和给药途径，因为这些因素决定了寡核苷酸在肝脏、肾脏和其他组织中的分布，并决定了(局部或系统性)药物暴露。此外，应使用适当的生物分析方法来表征本体寡核苷酸和相关代谢物。A、表征QTc间期延长及促心律失常可能性迄今为止，在FDA审查的少数专门的QTc研究中，未观察到寡核苷酸疗法对QTc间期的重大mean effect。然而，鉴于寡核苷酸疗法是多种多样的一类药物，现有的临床经验不能充分支持就特定类型寡核苷酸疗法促心律失常可能性提供总体结论。如名为“E14 Clinical Evaluation of QT/QTc Interval Prolongation and Proarrhythmic Potential for Non-Antiarrhythmic Drugs (October 2012)”和“E14 Clinical Evaluation of QT/QTc Interval Prolongation and Proarrhythmic Potential for Non-Antiarrhythmic Drugs Questions and Answers (R3) (June 2017)”的FDA指南文件所述，所有寡核苷酸疗法开发项目都应提交QT延长风险评估和拟议的QT评估计划。QT评估计划中的所有提案都应向机构进行充分说明，并与机构进行充分讨论。临床QT评估的时间和范围取决于寡核苷酸疗法的总体效益/风险状况。B、进行免疫原性风险评估在寡核苷酸疗法开发中，载体、骨架、寡核苷酸序列或整个药物中（载体+寡核苷酸）的任何新表位都能够引发不想要的免疫反应。寡核苷酸疗法的发展日新月异，新的化学特性、修饰等会显著影响特定产品的免疫原性风险和临床免疫原性评估。寡核苷酸疗法的临床免疫原性评估应遵循基于风险的方法，并应被纳入FDA指南《治疗性蛋白质产品的免疫原性评估（2014年8月）》所述的产品特异性免疫原性风险评估中。在确定寡核苷酸疗法的免疫原性风险时，需要考虑的方面包括但不限于:——产品因素：碱基序列、碱基修饰、骨架修饰、链型（strandedness）、纯度、修饰核苷酸、二级和三级结构以及载体成分（如聚乙二醇化脂质纳米粒）——产品药理学：作用机制、细胞/组织靶点、表达谱、给药途径、给药方案——患者特征：人群的免疫激活状态（如自身免疫或炎症状态）、伴随药物（如免疫抑制剂）寡核苷酸疗法免疫原性的临床评估通常包括FDA指南中概述的多层免疫原性评估。对于免疫原性风险评估，可以采用多种免疫原性分析方法来测量对寡核苷酸疗法不同成分的免疫反应，如载体成分 (如聚乙二醇化脂质纳米颗粒) 和/或寡核苷酸所偶联的蛋白靶向配体 (如Fab片段)。此外，一些寡核苷酸疗法的作用机制是产生修饰的蛋白质（如剪接改变、外显子跳跃寡核苷酸疗法），在这种情况下，申办方应考虑免疫原性分析，以评估针对修饰蛋白的抗体。在适当的情况下，还应测量不必要的先天性免疫激活，如寡核苷酸疗法诱导的细胞因子的释放、已知在人类中具有免疫原性的序列的存在（如GU、CpG或5’-P）、具有2’-deoxy, 2’-OH or unmethylated C 的天然核苷的存在。对于临床免疫原性评估，免疫原性样本采集应与药代动力学和药效学采样时间点一致，以评估ADA是否影响寡核苷酸疗法的药代动力学、药效学和任何免疫介导的不良事件。评估样本以确定寡核苷酸疗法是否干扰ADA检测也很重要。值得注意的是，对于评估免疫原性风险，如果有改变药代动力学、药效学或免疫介导的不良事件的新证据，在早期开发中（如I期/首次人体研究）储存样本以备后续测试可能是足够的。申办方应与机构讨论其免疫原性风险评估，以及他们如何用于某款特定产品的临床免疫原性评估。在某些情况下，FDA还可以建议评估核苷酸序列特异性抗体和/或生物活性。C、表征器官损伤对药代动力学、药效学和安全性的影响为了确定适当方法来表征器官功能对寡核苷酸药物的药代动力学、药效学、安全性的影响，申办方应通过考虑体外、临床前、早期临床I期数据确定肝脏和肾脏在寡核苷酸药物的处置和消除中的作用。这些早期评估项目与安全性和耐受性信息一起，应被用于在后期临床试验中招募具有一系列不同肾脏和/或肝脏功能的受试者中提供信息。此外，在器官受损的受试者中，考虑以下因素的表达和更新（turnover）影响很重要：1）药物的靶点；2) 偶联寡核苷酸药物中，偶联物靶点决定了药物在肝脏或肾脏的处置（例如，表达在肝脏或肾脏的受体使偶联药物靶向这些器官）。当寡核苷酸药物并不是主要通过肝脏清除，或者并不靶向肝脏，申办方应根据非临床实验与早期临床经验，在后期临床试验中分别招募一系列不同的肾功能或肝功能的受试者。若受试者因肾功能或肝功能问题从后期临床试验中排除，申办方应提供适当的理由。（参阅FDA《增强临床试验人群的多样性——资格标准、入组实践和试验设计》指南，2020年11月）当寡核苷酸药物基本通过肝脏清除【即超过30%（含）的药物（systemically available drug）以原形从尿中排出】，需进一步评估肾损害的影响。此时，可以采用不同的策略研究肾损伤对响应和暴露量的影响。可以采用简化药动学（reduced pharmacokinetic study）研究设计评估多种肾损伤对寡核苷酸药物药代动力学、药效学、耐受性、安全性的影响。情况适当时，该研究应采用多剂量研究，充分表征药效学作用。研究的发现可为额外表征和后期临床试验的纳入/排除标准提供信息。如有适当理由，也可考虑其他替代方法。当寡核苷酸疗法靶向肝脏，申办方应考虑替代方法，允许在耐受性、安全性、药效学的早期研究中开始序贯或自适应入组。（更多信息请参考Sahre MD et al. Evaluating Patients With Impaired Renal Function During Drug Development: Highlights From the 2019 US FDA Pharmaceutical Science and Clinical Pharmacology Advisory Committee Meeting. Clinical Pharmacology & Therapeutics. 2021.）在这些研究中，申办方应考虑肝脏门静脉高压症和血液分流。这些信息可帮助后期临床试验中招募具有一系列肝功能的受试者。由于脏器功能改变可以导致独立于药代动力学的药效学改变，在适当且可行的情况下，申办方应进行药效学评估。适当时，群体药动学-药效学模型可以帮助评估脏器损伤与药效学、其他生物标志物、药效数据间的相关性。除非有充足的理由（如安全性问题），必须在整个药物开发项目中招募足够数量的一系列器官功能各不相同的受试者，获取所有类别器官功能的有意义的数据。D、评估药物相关作用的注意事项1.与细胞色素P450酶和转运体的药代动力学相互作用a．寡核苷酸药物作为细胞色素P450和转运体的底物通常情况下，寡核苷酸药物不被细胞色素P450（CYP450）酶代谢。这些药物主要由核酸内切酶和核酸外切酶代谢，或经过化学修饰抵抗降解。因此，预计寡核苷酸药物的处置不会受到CYP酶抑制剂或诱导剂的影响。此外，预计外排转运体（如P-gp和BCRP）、肝脏摄取转运体（如OATP1B1、OATP1B3）、肾摄取或外排转运体（如OAT1、OAT3、OCT2、MATE1、MATE2/K）不会对寡核苷酸类药物的药代动力学产生明显的作用。如果寡核苷酸药物主要通过肾脏以原形排除，在体外评估寡核苷酸药物是否为肾脏转运体底物非常重要。b．寡核苷酸药物作为细胞色素P450和转运体的调节剂针对寡核苷酸药物是否为CYP酶或药物转运体的抑制剂或诱导剂的药物相互作用倾向研究通常从体外开始。有关进行体外实验和数据解释的一般注意事项，请参阅FDA《体外药物相互作用研究——细胞色素 P450 酶和转运体介导的药物相互作用》（2020年1月）。由于已经报道了体外系统的各种差异，申办方应仔细选择合适的体外系统评估药物相互作用。根据目前的经验，寡核苷酸药物对主要的CYP酶和药物转运体要么不调节，要么调节作用较小。然而，目前还无法提供针对特定类型寡核苷酸药物的总体建议。如果申办方未对寡核苷酸药物导致药物-药物相互作用进行体外评估，则应给出充分的建议。在寡核苷酸药物与CYP酶活转运体间可能还存在其他机制的相互作用。寡核苷酸药物直接调节（如通过与CYP酶或转运体mRNA转录本的脱靶杂交）或间接调节（通过干扰血红素的合成或降解，或调节细胞因子）CYP酶或转运体的可能应予以评估。如果研究表明寡核苷酸药物可以调节CYP酶或转运体，申办方应考虑在临床试验中评估体内药物相互作用。对于研究设计和实施的一般注意事项，请参阅FDA《临床药物相互作用研究——细胞色素 P450 酶和转运体介导的药物相互作用行业指南》（2020年1月）。2.药效学相互作用当药理作用被另外一种药物的药理作用改变时，寡核苷酸药物可能与伴随药物产生药效学相互作用。由于此类相互作用可能是个别药物独有的，鼓励申办方就药效学相互作用的评估咨询相关审查部门。点击下载PDF点亮“在看”，好文相伴