Ibrutinib in Combination with Venetoclax Decreases Mitochondrial Bioenergetics through the Impaired BTK, AKT and AMPK/SIRT/PGC-1α Signaling Pathway in CLL

Objective: Chronic lymphocytic leukemia (CLL) is one of the most common types of leukemia in adults. Altered mitochondrial metabolism has been shown to be involved in the pathogenesis of CLL. Ibrutinib, an inhibitor of Bruton's tyrosine kinase (BTK), and venetoclax, an inhibitor of B-cell lymphoma 2 (Bcl-2) protein are approved therapies for CLL. The adenosine monophosphate-activated protein kinase (AMPK) and peroxisome proliferator-activated receptor γ coactivator-1α (PGC-1α) signaling axis senses the metabolic demands of cells and regulates mitochondrial function. Silent information regulator T1 (SIRT1) is a cytoplasmic enzyme that mediates NAD⁺-dependent deacetylation of target substrates. The importance of BTK, AKT, and AMPK/SIRT/PGC-1α signaling pathway have to be explored yet in CLL. Ibrutinib and venetoclax may trigger a switching off of AMPK and /or SIRT1 signaling leading to impaired PGC-1α expression/activity and diminished mitochondrial activity. The effects of these drugs on mitochondrial bioenergetics profile, cell viability, mitochondrial membrane potential (MMP), reactive oxygen species (ROS) and protein levels of p-BTK, p-AKT, Bcl-2, p-AMPK, SIRT1, and PGC-1α were analyzed. We hypothesize that ibrutinib, along with venetoclax, will alter CLL mitochondrial bioenergetics profiles and function, cell viability, and ROS levels through the involvement of BTK, AKT and AMPK/SIRT/PGC-1α signaling pathway and enable lower doses and profound effects for combination therapies rather than single agent therapy.

Methods: The high resolution Oroboros Oxygraph 2K (Oroboros Instruments, Austria), a Clarke-type oxygen electrode, is used to measure mitochondrial respiration rates of CLL cells at 37⁰C. Freshly isolated CLL cells (10 mil. cells/ml) were added to the chamber in 2 ml of RPMI. After the measurement of basal respiration rates, the following chemicals were added: oligomycin (2uM), FCCP: carbonylcyanide p-trifluoromethoxyphenylhydrazone (2-12 uM), and antimycin A (2 uM). Oxygen consumption rate is expressed in pmol oxygen/s /mil. cells. Protein levels in CLL cell lysates were determined by Western blotting. Cell viability, MMP, and ROS were assessed by the flow cytometer (NovoCyte).

Results: CLL cells obtained ex vivo from ibrutinib treated patients had decreased mitochondrial bioenergetics compared to pre-treatment samples. Primary CLL cells treated in vitro with sub-lethal doses of ibrutinib for 24 or 48h showed significantly decreased basal respiration rates, maximal respiration rates, and spare respiratory capacity compared to DMSO vehicle control. These parameters were also significantly affected by low doses (0.5 - 2 nM) of venetoclax. The combination treatment of ibrutinib with venetoclax for 24 or 48h significantly decreased these bioenergetics parameters compared to each individual drug alone except for the spare respiratory capacity vs venetoclax alone at 24 h. MMP was significantly decreased by these drug treatments and its combinations compared to DMSO. Cell viability was used to confirm a sub-lethal phenotype. ROS levels were significantly increased by venetoclax compared to DMSO, and in combination with ibrutinib vs ibrutinib alone. However, ROS levels by ibrutinib were not significantly changed compared to DMSO or venetoclax. Protein levels of p-BTK, p-AKT, p-AMPK, SIRT1, and PGC-1α were decreased by ibrutinib or venetoclax alone compared to DMSO and further decreased by the combination of these two drugs compared to single agent.

Conclusion: CLL cells from ibrutinib treated patients, a clinically approved BTK inhibitor, demonstrated decreased bioenergetics similar to normal B-lymphocytes suggesting ibrutinib treatment normalizes the mitochondrial bioenergetics in CLL. Ibrutinib and venetoclax affected bioenergetics profiles in CLL cells at low doses. The combined effect of these drugs on the mitochondrial bioenergetics profiles and cell viability is more profound than each BTK or Bcl-2 inhibitor agent alone. Protein levels of p-BTK, p-AKT, p-AMPK, SIRT1, and PGC-1α in ibrutinib and venetoclax treated samples were reduced compared to DMSO and each single agent inhibitor. These novel data suggest the involvement of BTK, AKT and AMPK/SIRT/PGC-1α signaling pathway to target mitochondrial metabolism and provide rational therapeutic combinations that may lead to reduced toxicity and increased drug efficacy in CLL.