1. Drug Transporters: Report from the International Transporter Consortium; Decisions, Impact and Future Directions Delaware Valley Drug Metabolism Discussion Group May 12th, 2010 Donald Tweedie Director, Drug Metabolism

2. NEDMDG, March 2010 2 Drug Transporter White Paper Nature Reviews Drug Discovery 9, 215 - 236, (2010) ‘Membrane Transporters in Drug Development’ The International Transporter Consortium. Corresponding Authors: Kathy.Giacomini@ucsf.edu ShiewMei.Huang@fda.hhs.gov Donald.tweedie@boehringer-ingelheim.com

3. NEDMDG, March 2010 3 Outline International Transporter Consortium (ITC) Genesis Goals White paper –How we got there –What it is –What it is not –Examples, MDR1, OATP, decisions tree(s) Current Issues, Challenges, and Actions Future Activities Conclusions Acknowledgements

4. NEDMDG, March 2010 4 Genesis – ITC PhRMAPharmaceutical and Research Manufacturers of America Advocacy forum for the industry to influence the FDA (PhRMA – America) Drug Metabolism Technical Group (DMTG) –Subgroup responsible for DMPK issues –(MIST, DDI, pharmacogenomics, time-dependent inhibition) 1 –Nov 2007, transporters identified as a key topic Academic group headed by Kathy Giacomini and Toshi Ishikawa were considering initiating a global committee to generate a white paper providing preferred approaches to conduct transporter studies 1 Baillie et al. (2002) Drug metabolites in safety testing Toxicol. Appl. Pharmacol. 182, 188-96 Bjornsson et al. (2004) The Conduct of In Vitro and In Vivo Drug-Drug Interaction Studies: A Pharmaceutical Research and Manufacturers of America (PhRMA) Perspective. Drug Metabolism and Disposition 31, 815-832 and Journal of Clinical Pharmacology 43, 443-469. Williams et al. (2008) PhRMA white paper on pharmacogenomics J Clin Pharmacol. 48(7), 849-89 Grimm SW et al. (2009) The conduct of in vitro studies to address time-dependent inhibition of drug-metabolizing enzymes: a perspective of the pharmaceutical research and manufacturers of America. Drug Metabolism and Disposition 37(7):1355-1370

5. NEDMDG, March 2010 5 Transporters Key goals for the ITC Provide an update on current thinking on transporters. For in vitro studies, provide a focus on studies that can have a viable clinical interpretation (avoid raising red flags with in vitro studies that cannot be addressed in vivo in the clinic). Explore gaps and suggest ways forward. Provide a coordinated approach (Academia, Industry and Regulatory). Help to move the science forward. –Decision trees to assist drug development and regulatory –Consensus on current scientific status

6. NEDMDG, March 2010 6 International Transporter Consortium Workshop Bethesda North Marriott October 2 nd and 3 rd, 2008 Sponsored by FDA Critical Path Workshop organized by Drug Information Association (DIA) Co-sponsorship by AAPS, ISSX, PhRMA Provide a focus to initiate a White Paper for completion in 2009

7. NEDMDG, March 2010 7 ITC Original Members Academia: Kim BrouwerUNC Kathy Giacomini UCSF Toshi Ishikawa OSC, Tokyo Dietrich KepplerHeidelberg Richard Kim W. Ontario Peter SwannMaryland Regulatory: Shiew Mei HuangFDA Lei ZhangFDA Industry: Raymond Evers Merck Volker Fischer Abbott Kate HillgrenLilly Joe PolliGSK Donald TweedieBI Joe WareGenentech

8. NEDMDG, March 2010 8 ITC author list Academia: Les BenetUCSF Kim BrouwerUNC Amber DahlinUCSF Kathy Giacomini UCSF Toshi Ishikawa OSC, Tokyo Dietrich KepplerHeidelberg Richard Kim W. Ontario Mikko NiemiHelsinki Yuichi SugiyamaTokyo Peter SwannMaryland Steve WrightArizona Sook Wah YeeUCSF Regulatory: Shiew Mei HuangFDA Lei ZhangFDA Industry: Xiaoyan ChuMerck Raymond Evers Merck Volker Fischer Abbott Kate HillgrenLilly Keith A. HoffmasterNovartis Caroline LeePfizer Joe PolliGSK Donald TweedieBI Joe WareGenentech Maciej Zamek- Gliszczynski Lilly

9. NEDMDG, March 2010 9 ITC author list Academia: Les BenetUCSF Kim BrouwerUNC Amber DahlinUCSF Kathy Giacomini UCSF Toshi Ishikawa OSC, Tokyo Dietrich KepplerHeidelberg Richard Kim W. Ontario Mikko NiemiHelsinki Yuichi SugiyamaTokyo Peter SwannMaryland Steve WrightArizona Sook Wah YeeUCSF Regulatory: Shiew Mei HuangFDA Lei ZhangFDA Industry: Xiaoyan ChuMerck Raymond Evers Merck Volker Fischer Abbott Kate HillgrenLilly Keith A. HoffmasterNovartis Caroline LeePfizer Joe PolliGSK Donald TweedieBI Joe WareGenentech Maciej Zamek- Gliszczynski Lilly

10. NEDMDG, March 2010 10 ITC author list Academia: Les BenetUCSF Kim BrouwerUNC Amber DahlinUCSF Kathy Giacomini UCSF Toshi Ishikawa OSC, Tokyo Dietrich KepplerHeidelberg Richard Kim W. Ontario Mikko NiemiHelsinki Yuichi SugiyamaTokyo Peter SwannMaryland Steve WrightArizona Sook Wah YeeUCSF Regulatory: Shiew Mei HuangFDA Lei ZhangFDA Industry: Xiaoyan ChuMerck Raymond Evers Merck Volker Fischer Abbott Kate HillgrenLilly Keith A. HoffmasterNovartis Caroline LeePfizer Joe PolliGSK Donald TweedieBI Joe WareGenentech Maciej Zamek- Gliszczynski Lilly Kathy Giacomini UCSF

11. NEDMDG, March 2010 11 White paper 1.Basic Introduction and Summary of Transporters – Highlights what we know 2. Methods for Studying Transporters – Current solutions and future prospects 3. Drug Development Issues – Decision trees Drug Transporters in Drug Development The International Transporter Consortium, ITC

12. NEDMDG, March 2010 12 Section 1 Transporters covered Efflux: P-gp, BCRP Renal: OAT/OCT Hepatic uptake: OATP Other transporters not discussed in detail MRPs MATEs Considered less critical in the overall view But could be important for specific drugs?

14. NEDMDG, March 2010 14 Tables of Substrates and Inhibitors

15. NEDMDG, March 2010 15 Section 2. Methods for Studying Transporters A. Cell and Membrane Models B. Intact Organ/In Vivo Models C. Methods to Measure the Contribution of Transporters to Tissue Distribution and Excretion D. Interplay of Efflux Transporters and Enzymes E. Coordination of Influx and Efflux Transporters and Enzymes in the Clearance of Drugs F. Computational Models

16. NEDMDG, March 2010 16 Section 3. Drug Development Issues Box 2. Decision trees for P-gp or BCRP substrate interactions Box 3. Decision trees for P-gp or BCRP inhibitor interactions Box 4. Decision trees for OCT or OAT substrate interactions Box 5. Decision trees for OCT or OAT inhibitor interactions Box 6. Decision trees for OATP interactions Box 7. OATP1B1 Decision Analysis: Case Studies Summary and Conclusions

17. NEDMDG, March 2010 17 P-gp Substrate

18. NEDMDG, March 2010 18 Current issues? Decision Trees Pros evolution of concepts highlight discussion points offers flexibility Cons rigid interpretation – prescriptive and overly cautious insufficient knowledge to populate the decision points lack of selective substrates and inhibitors ‘The evolution and appropriate application of these decision trees will require constant monitoring. How can this be achieved with an assured and encompassing measure of success?’

19. NEDMDG, March 2010 19 Decision Trees - Current issue with P-gp? False Positives (unnecessary clinical studies) Alert for [I] 1 /IC 50 ≥ 0.1 or [I] 2 /IC 50 ≥10, –[I] 1 is steady-state total Cmax at the highest clinical dose –[I] 2 is the GI concentration calculated as dose (mg)/250 mL [I] 2 /IC 50 > 10 will be exceeded at a dose of ~12 mg for a drug with an inhibition potency of ~10 µM in vitro (MW ~ 500). False Negatives (safety concerns)

20. NEDMDG, March 2010 20 White Paper - What it is A consensus view on the current thinking on drug transporters What are the current realities The known knowns What do we know about the relative importance of all transporters? Where do you put your effort? The known unknowns What facts are known to be untrue (dispelling myths)? Where are our gaps in knowledge (so where should we focus short and long term to increase our knowledge)? A guideline (not a guidance) towards what we should focus on currently What are we capable of addressing?

21. NEDMDG, March 2010 21 White Paper - What it is not A complete literature review. A prescriptive guidance on what to do and how to do it, with a clear description of what it will mean. A consensus document that everyone agrees to. A description of all of the exceptions. Your experience is important to you and we would certainly appreciate you sharing that with the scientific community to educate us all. The decision trees are clearly not definitive. Included to help move the science forward by acting as templates for discussion P-gp most mature but not perfect

22. NEDMDG, March 2010 22 What are some of the current issues? The issues presented by transporters are significantly more complex than for DMEs Involved in absorption, distribution and excretion, so multiple processes of concern Broad tissue distribution; different effects at different sites, e.g. P-gp at intestine and BBB Redundancy; different transporters (P-gp and BCRP) and different subfamilies (OATP1B1 and 1B3) Uptake and efflux transporters (need to consider both to assess the overall effect) Applicability of kinetic parameters and their interpretation

23. NEDMDG, March 2010 23 Ieiri et al. (2009) Expert Opinion in Drug Metabolism and Toxicology, 5: 703-729. Transporter Interaction Redundancy: Drugs that are shown to interact with one transporter typically interact with multiple transporters. Thus, multiple pathways for clearance are possible for transporter substrates. Slide courtesy of Dr. Mitchell Taub

24. NEDMDG, March 2010 24 Lack of selective inhibitors of drug transporters  Dantzig et al. (1999) JPET 290, 854-862  Hsiang et al. (1999) J Biol Chem 274, 37161-8  Abe et al. (1999) J Biol Chem 274, 17159-63  Konig et al. (2000) Am J Physiol Gastrointest Liver Physiol 278, G156-64  Hagenbuch. & Meier (2003) Biochim Biophys Acta 1609, 1-18  Oostendorp et al. (2009) DMD 37, 917-923 19991999 – 20032009 LY 335979 (zosuquidar) is a potent inhibitor/modulator of P-gp, but does not inhibit MRP1 or MRP2. Selectivity over inhibition of CYP3A4 is ~60-fold. [Reference 1] Discovery, cloning, and publication of OATP superfamily of uptake transporters [References 2-5] OATP1B1-mediated uptake of anticancer drugs gimatecan and BNP1350 were inhibited by zosuquidar. The effect of modulators on the plasma pharmacokinetics of OATP1B1 substrate drugs may not be solely ascribed to inhibition of P-gp [Reference 6] Slide courtesy of Dr. Mitchell Taub

25. NEDMDG, March 2010 25 P-gp at the Blood-Brain Barrier: Clinical DDI? Sadeque et al. (2000). Clin Pharmacol Ther 68(3): 231-7

26. NEDMDG, March 2010 26 P-gp at the Blood-Brain Barrier: Species Differences P-gp inhibitor P-gp inhibitor dosage Drug (P-gp substrate) Clinical usage of the drug CNS exposure index Plasma AUC and C max CNS effect Brain P-gp inhibition Reference Quinidine600 mgFentanylSynthetic opioidPupil diameter Oral AUC ↑ 171%, C max ↑162% Quinidine had no major influence on fentanyl pharmacodynamics in humans. No(1)(1) Quinidine600 mgLoperamide A peripherally acting opioid receptor agonist for treatment of chronic diarrhea Respiratory response to CO2 rebreathing AUC ↑ 148% Respiratory depression occurred when loperamide was given with quinidine. Yes?(2) Quinidine800 mgLoperamide A peripherally acting opioid receptor agonist for treatment of chronic diarrhea Pupil sizeAUC ↑ 80% Pupil size decreased with co- administration of quinidine. Yes?(3)(3) Quinidine600 mgMethadoneOpioidPupil diameter i.v. AUC and C max, no changes No effect on methadone miosis after i.v. administration No(4)(4) Quinidine 600 mgMorphineOpioidPupil diameter Oral AUC ↑60%, C max ↑88% No effect on i.v. morphine miosis, Difference in oral morphine miosis were commensurated with changes in plasma morphine concentration. No(5)(5) Quinidine800 mgMorphineOpioid Pupil diameter and respiratory response to CO2 rebreathing Plasma concentration, no change Not result in an enhancement of central nervous opioid effects. No(6)(6) Quinidine800 mg Morphine 6- glucuronide An active metabolite of morphine Pupil size No effect on the pharmacokinetics of morphine 6- glucuronide No effect.No(7)(7) (1) Kharasch et al. J Clin Pharmacol. 44:224-233 (2004) (2) Sadeque et al. Clin Pharmacol Ther. 68:231-237 (2000) (3) Skarke et al. Pharmacogenetics. 13:651-660 (2003) (4) Kharasch et al. Br J Clin Pharmacol. 57:600-610 (2004) (5) Kharasch et al. Clin Pharmacol Ther. 74:543-554 (2003) (6) Skarke et al. Clin Pharmacol Ther. 74:303-311 (2003) (7) Skarke et al. Anesthesiology. 101:1394-1399 (2004) Slide courtesy of Dr. Yongmei Li

27. NEDMDG, March 2010 27 Can digoxin be used as a clinical P-gp probe substrate? Narrow therapeutic window of digoxin requires close monitoring Abundant digoxin clinical DDI study data – especially for relatively new drugs Digoxin currently viewed as the “gold standard” probe for studying clinical P-gp– related DDIs recent data may indicate that digoxin interacts with other transporters; OATPs Fenner et al. (2009) CPT 85, 173- 181

28. NEDMDG, March 2010 28 11 C-verapamil and CsA dosed IV AUC brain /AUC blood of 11 C-radioactivity ↑ 88% in the presence of CsA ↑ 770% in similar study in mouse Human CNS P-gp localization: PET Imaging Sasongko et al CPT (2005) 77:503-514; Hendrikse et al Br. J. Pharmacol. (1998) 124:1413-1418 MRI - CsA+ CsA

29. NEDMDG, March 2010 29 P-gp at the Blood-Brain Barrier: Mouse KO A. Ayrton and P. Morgan. Role of transport proteins in drug absorption, distribution and excretion, Xenobiotica. 31:469-497 (2001)

30. NEDMDG, March 2010 30 ITC Transporter Workshop (2008) Mikko Niemi - University of Helsinki

31. 31 Transporter-Mediated Drug-Drug Interactions (DDIs) Lei Zhang, Ph.D. Special Assistant to Office Director Office of Clinical Pharmacology Office of Translational Sciences CDER, FDA Leik.zhang@fda.hhs.gov Clinical Pharmacology Advisory Committee Meeting Topic 4: Transporter-Mediated Drug-Drug Interactions Atlanta, GA, March 17, 2010

32. 32 Question 1 For evaluation of NMEs as potential substrates of transporters: a. Do you agree that P-gp, BCRP, OATP1B1/1B3, OAT1/3 and OCT2 are the major transporters that should be routinely evaluated based on the proposed flow chart during drug development? [VOTING] b. What transporter(s) should be included in the flow chart for routine study and why? c. What alternative criteria would you suggest to identify transporters that would have clinical significance and should be studied?

33. 33 Question 2 For evaluation of NMEs as potential inhibitors of transporters: a. Do you agree that P-gp, BCRP, OATP1B1/1B3, OAT1/3 and OCT2 are the major transporters that should be routinely evaluated based on the proposed flow chart during drug development? [VOTING] b. What transporter(s) should be included in the flow chart for routine study and why? c. What alternative criteria would you suggest to identify transporters that would have clinical significance and should be studied?

34. FDA advisory Board Meeting: ASCPT Conference: Atlanta, March 2010 NEDMDG, March 2010 34 FDA brought to the committee several voting questions …….. …the panel voted 12-4 that P-glycoprotein, BCRP and OATP1B1/1B3, OAT 1/3 and OCT 2 are the major transporters that mediate DDI and all NME should routinely be evaluated …. as substrates for these transporters…. Those voting no agreed the proposed transporters are reasonable, but cited the absence of appropriate tools to conduct the studies. "Throwing this out there to the pharmaceutical industry, it's just not ready for prime time yet. We need more tools," argued Gregory Kearns, Children's Mercy Hospitals & Clinics of Kansas City, Mo. Jerry Collins of the National Cancer Institute agreed, saying it would be better to invest in developing the tools - which garnered concurrence from other committee members. Citing the burden on industry, Howard McLeod, University of North Carolina, also suggested that "in the future, every time we want to add something, we should also identify something we want to take away." Caldwell, who supported the expanded testing, said "the tools are coming, and quickly," while Thummel, another proponent of the testing, contended that the preclinical tools are available. The vote was 11-5 on a question of routinely evaluating all NMEs as inhibitors of the same transporters

35. Future Interactions NEDMDG, March 2010 35 AAPS Website Intended to be active soon (Maciej J Zamek-Gliszczynski; Lilly) Email link to provide comments and questions@??mail.com Collate common questions Future chat rooms Collate thoughts and concerns for future white paper(s) Others?

36. NEDMDG, March 2010 36 Overall Conclusions/Impact Transporters are a very dynamic field – the white paper is intended to be a snapshot White paper will need to be updated (timeline?) White paper provides framework for FDA to add to current guidance(s) – DDI Emphasizes the need for flexibility which provides some realistic challenges for regulatory agencies Has identified areas of highest immediate need decision trees for other transporters relevance of unbound drug concentrations Never intended to be a panacea Focus group for collating new data

37. NEDMDG, March 2010 37 Moving Forward Committee of FDA and Pharma Lei Zhang ( leik.zhang@fda.hhs.gov ) and Donald Tweedie (donald.tweedie@boehringer-ingelheim.com ) leik.zhang@fda.hhs.govdonald.tweedie@boehringer-ingelheim.com Main committee with sub-committees for specific topics Identify experts for different transporters Identify experts for selected topics (P-gp and digoxin, kinetics) Outcome Provide feedback on discussions, action items Make recommendations –change current practices –monitor specific practices Publish mini-white papers

38. NEDMDG, March 2010 38 Acknowledgements ITC members Shiew Mei Huang, FDA Kathy Giacomini, UCSF DMTG, PhRMA Volker Fischer DIA (Drug Information Assocation) Mitch Taub, Boehringer Ingelheim Yongmei Li, Boehringer Ingelheim

39. NEDMDG, March 2010 39 Acknowledgements Academia: Les BenetUCSF Kim BrouwerUNC Amber DahlinUCSF Kathy Giacomini UCSF Toshi Ishikawa OSC, Tokyo Dietrich KepplerHeidelberg Richard Kim W. Ontario Mikko NiemiHelsinki Yuichi SugiyamaTokyo Peter SwannMaryland Steve WrightArizona Sook Wah YeeUCSF Regulatory: Shiew Mei HuangFDA Lei ZhangFDA Industry: Xiaoyan ChuMerck Raymond Evers Merck Volker Fischer Abbott Kate HillgrenLilly Keith A. HoffmasterNovartis Caroline LeePfizer Joe PolliGSK Donald TweedieBI Joe WareGenentech Maciej Zamek- Gliszczynski Lilly