Pyrimethamine, a STAT3 Inhibitor, Synergizes with Venetoclax and Shows Efficacy in Hypomethylating Agent Resistant MDS and AML

Myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) arise after accumulation of multiple genetic and epigenetic alterations in hematopoietic stem cells (HSCs). Alterations in HSCs promote malignant transformation and give rise to leukemic stem cells (LSCs). Current therapies for MDS and AML, including recently FDA approved agents such as venetoclax (Ven), a Bcl-2 inhibitor, have failed to eliminate LSCs, therefore, molecular targeting of aberrant LSCs may be a potential strategy for developing targeted drugs capable of eliminating LSCs.

Studies have shown that aberrant HSCs exhibit multiple disrupted cellular pathways, including overexpression of the signal transducer and activator of transcription 3 (STAT3) (Shastri, 2017). Elevated levels of STAT3 are observed in MDS and AML patient samples. Interestingly, an increased level of STAT3 in MDS and AML patients is predictive of a significantly adverse prognosis, thus supporting a critical role of STAT3 signaling in MDS and AML. We have previously shown that an antisense oligonucleotide inhibitor of STAT3, gets rapidly incorporated into HSCs and induces apoptosis and downregulation of STAT3 when compared to health controls (Shastri, JCI 2018). An initial screen to identify compounds that could target STAT3 revealed that pyrimethamine (PYR), an FDA approved anti-parasitic drug, inhibits STAT3 transcriptional activity at concentrations readily achieved in patients (Nelson, 2011). Therefore, we are further evaluating the efficacy of PYR for treatment of MDS and AML. HMA and Ven resistance is a critical issue in MDS/AML and can occur due to the persistence of relapse associated aberrant stem and progenitor cells that overexpress STAT3. Hence, we are evaluating the efficacy of PYR in a hypomethylating agent (HMA) and venetoclax (Ven) resistant model.

Our in vitro studies show that PYR can inhibit viability by inducing apoptosis in multiple leukemic cells within its therapeutic index. Western blot analysis reveals that STAT3 protein is overexpressed in a Ven resistant MOLM13 AML line, and in a HMA resistant cell THP1 AML cell line. In HMA and Ven resistant leukemia cell lines, PYR can significantly decrease proliferation when combined with azacytidine (P= 0.0109) (Fig 1A) or venetoclax (P= 0.0271) treatments. Remarkably, PYR and Ven drug combination show a strong synergistic interaction in HMA resistant cell line (Z score = 14.523) and Ven resistant cell line (Z score = 11.065). An in vivo study to evaluate the efficacy of PYR shows that PYR treatment leads to a significant decrease of blasts counts in a cell-line derived xenograft (CDX) leukemic mouse model (Fig 1B) compared to a PBS control. In addition, primary MDS patient samples treated with PYR show increased myeloid differentiation compared to healthy controls.

Our results show that MDS/AML cell lines, including HMA and Ven resistant leukemia cell lines, are sensitive to PYR treatment, in a dose dependent manner within the therapeutic index of STAT3 inhibition (5-10 uM). Interestingly, PYR with Ven drug combination shows significant reduction in cell proliferation and likely synergy. Our current findings support PYR synergy with Ven and the combination as a possible therapeutic option for patients with MDS/AML after prior treatment with hypomethylating agents for MDS and AML.

Konopleva:Agios: Other: grant support, Research Funding; Ascentage: Other: grant support, Research Funding; AstraZeneca: Other: grant support, Research Funding; Sanofi: Other: grant support, Research Funding; Rafael Pharmaceutical: Other: grant support, Research Funding; Novartis: Patents & Royalties, Research Funding; Ablynx: Other: Grant support, Research Funding; Calithera: Other: Grant Support, Research Funding; Cellectis: Consultancy, Other: Grant support, Research Funding; Eli Lilly: Consultancy, Patents & Royalties, Research Funding; Reata Pharmaceuticals: Current equity holder in private company, Patents & Royalties; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Kisoji: Consultancy, Honoraria; Forty-Seven: Consultancy, Honoraria, Other: Grant support; Amgen: Consultancy; Stemline Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; F. Hoffman La Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Grant support, Research Funding; Genentech: Consultancy, Other: grant support, Research Funding; AbbVie: Consultancy, Other: grant support, Research Funding. Saunthararajah:EpiDestiny: Consultancy, Current equity holder in private company, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties: intellectual property with royalty rights ; Novo Nordisk: Consultancy. Verma:Stelexis Therapeutics: Current equity holder in private company, Honoraria; Medpacto: Research Funding; Eli Lilly: Research Funding; Jannsen: Consultancy, Research Funding; Throws Exception: Current holder of stock options in a privately-held company; BMS: Research Funding; Bakx Therapeutics: Consultancy, Current equity holder in private company; Novartis: Consultancy; Prelude: Research Funding; Curis: Consultancy, Research Funding; Ionctura: Research Funding. Shastri:Janssen: Consultancy; Rigel Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; NACE: Honoraria; Kymera Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding.