Preclinical discovery and development of fingolimod for the treatment of multiple sclerosis

Figures & data

Figure 1. Timeline of milestones in the discovery and development of fingolimod as disease-modifying drug for MS.

Figure 2. Discovery of FTY720 (3c) as a result of lead optimization efforts around the chemical structure of myriocin (1). IC₅₀ values are in vitro inhibition data of mouse allogeneic mixed lymphocyte reaction (MLR).

Figure 3. Chemical structures of FTY720 (3c), sphingosine (4) and their phosphate adducts (5, 6).

Table 1. Binding affinities of FTY720-phosphate (5) and S1P (6) at S1P receptors.

GPCR	FTY720-phosphate (5)	S1P (6)
S1P1	IC50 = 0.28 nM	IC50 = 0.67 nM
S1P2	IC50 > 10,000 nM	IC50 = 0.35 nM
S1P3	IC50 = 6.3 nM	IC50 = 0.26 nM
S1P4	IC50 = 15 nM	IC50 = 34 nM
S1P5	IC50 = 0.77 nM	IC50 = 0.55 nM

GPCR, G-protein coupled receptor

IC₅₀, concentration inhibiting the 50% of the effect

Figure 4. Mechanism of action of S1P and fingolimod-P. (a) In physiological conditions, naïve T lymphocytes and memory (both central and effector) T lymphocytes circulate in the blood; the egression from lymph nodes is activated by the signal induced by S1P via S1P₁R, overcoming the retention in lymph nodes mediated by the CCR7 receptor (CCR7R) signaling. (b) Fingolimod-P binding induces the internalization, and subsequent degradation, of S1P₁R, thus favoring the CCR7R-mediated retention of naïve and central memory T cells in lymph nodes. Effector memory cells lacking CCR7R are not affected by the drug and continue to egress from lymph nodes, ensuring an appropriate immune response, i.e. against microbial and/or danger insults.

Table 2. Features of key phase 3 trials of fingolimod.

CLINICAL STUDY	Refs	Sampling period	End point 1	End point 2	Sample size	Groups	Results	Adverse drug reactions (fingolimod)
FREEDOMS I	[62]	2 years	Annualized relapse rate at 24 months	Time to disability progression	1,272 patients (18–55 years of age) in 22 countries with RRMS	Placebo and 0.5 or 1.25 mg fingolimod (daily)	The annualized relapse rate was significantly lower in both groups receiving fingolimod than in the placebo group. Significant reduction in the disability progression in both fingolimod groups as compared to placebo.	Bradycardia and atrioventricular conduction block at the time of fingolimod initiation Macular edema Elevated liver-enzyme levels Mild hypertension
FREEDOMS II	[64]	2 years and 10 months	Annualized relapse rate at 24 months	Percentage brain volume change (PBVC) from baseline and time-to-disability-progression confirmed at 3 months.	1,083 patients (18–55 years of age) with RRMS (predominantly in USA)	Placebo and 0.5 or 1.25 mg fingolimod (daily; however patients on 1.25 mg were switched on 0.5 after few months)	The annualized relapse rate and mean PBVC were significantly lower in both groups receiving fingolimod than in the placebo group. No significant differences in disability progression.	Lymphopenia Increased alanine aminotransferase Herpes zoster infection Hypertension First-dose bradycardia First-degree atrioventricular block Basal-cell carcinoma Macular edema
TRANSFORMS	[49]	1 year	Annualized relapse rate at 12 months	Number of new or enlarged lesions on T(2)-weighted magnetic resonance imaging (MRI) scans at 12 months and progression of disability sustained for at least 3 months.	1,292 patients aged between 18 and 55 with RRMS	0.5 or 1.25 mg (daily) of fingolimod versus 30 µg IFN-β1a (weekly)	The annualized relapse rate was significantly lower in both groups receiving fingolimod than in the IFN group. No significant differences were seen among the study groups with respect to progression of disability.	Two fatal infections in the group that received the 1.25-mg dose of fingolimod: disseminated primary varicella zoster and herpes simplex encephalitis Nonfatal herpes virus infections Bradycardia and atrioventricular block Hypertension Macular edema Skin cancer Elevated liver-enzyme levels.
INFORMS	[65]	3–5 years	Composite endpoint based on change from baseline in Expanded Disability Status Scale (EDSS), 25ʹ Timed-Walk Test, or Nine-Hole Peg	Effect of fingolimod 0.5 mg versus placebo on delaying the time to 3-month confirmed disability progression as measured by EDSS, and effect of fingolimod 0.5 mg versus placebo on percent brain volume change	970 patients (25–65 years of age) with PPMS	147 patients to fingolimod 1.25 mg and 133 to placebo in cohort 1; 336 patients to fingolimod 0.5 mg and 354 to placebo in cohort 2	Fingolimod did not slow disease progression in PPMS.	Lymphopenia Bradycardia First-degree atrioventricular block Macular edema Basal-cell carcinoma
PARADIGMS	[66]	2 years	Annualized relapse rate	Annualized rate of new or newly enlarged lesions on T2-weighted magnetic resonance imaging (MRI)	215 patients 10–17 years of age with RRMS	Oral fingolimod at a dose of 0.5 mg per day (0.25 mg per day for patients with a body weight of ≤40 kg) or i.m. IFN -β1a at a dose of 30 μg per week	Fingolimod was associated with a lower rate of relapse and less accumulation of lesions on MRI over a 2-year period than IFN -β1a but was associated with a higher rate of serious adverse events	Infection Leukopenia Convulsions Supraventricular tachycardia

Table 3. Postmarketing reports of fingolimod safety.

Refs	Adverse drug reaction	Setting	Fingolimod treatment	Number of cases	Observations	Recommendation/Outcome
[79]	Delayed onset of cardiac adverse effects	USA (2015)	A 51-year-old female with multiple sclerosis was started on fingolimod therapy. Prior to the initiation of therapy, her baseline electrocardiogram (ECG) demonstrated a normal sinus rhythm with a resting heart rate of 58 to 68 bpm. The patient was then given her first dose of fingolimod 0.5 mg and was observed for the recommended 6-h cardiac monitoring interval.	1	During monitoring, the patient had palpitations without any other symptoms. She then developed a Mobitz Type 1 (Wenckebach) second-degree atrioventricular (AV) block with a ventricular rate between 43 and 68 bpm. The AV block and decreased ventricular rate continued to the end of the 6-h cardiac monitoring period. The patient was sent to the emergency department (ED) for further evaluation.	Extended cardiac monitoring may be needed in selected patients
https://www.hpra.ie/docs/default-source/Safety-Notices/gilenya-dhpc-nov-2013-pdf.pdf?sfvrsn=0	Haemophagocytic syndrome, HPS	Ireland (2013)	Drug treatment for 9 and 15 months	2 (fatal)	HPS developed during viral infections	An early diagnosis of HPS is required during treatment with fingolimod, particularly during viral infections
[80]	Progressive multifocal leukoencephalopathy (PML)	USA (2016)	A 51-year-old woman with RRMS since 1997 was previously treated for 15 years with glatiramer acetate and then interferon β-1b. During this time, she was also treated for inflammatory bowel disease and later for colon cancer. For inflammatory bowel disease, she received intermittent steroids for 10 years and azathioprine in 2005 for 2 months. In 2009, she was diagnosed with colon cancer and received chemotherapy with 6 cycles of capecitabine and a course of oxaliplatin over a period of 4 months. She also had radiation therapy and went into remission after surgical resection. In 2012, she was switched to fingolimod for RRMS because of clinical and radiologic disease progression. At that time, her absolute lymphocyte count (ALC) was 2,100 cells/mm3 and she was positive for JC virus (JCV) antibody, hence natalizumab was avoided.	1	In August 2015, she was referred to our institution with progressive cognitive dysfunction and dysarthria for 1 month. Neurologic examination revealed moderate dysarthria and impaired delayed recall and attention. Fingolimod had been discontinued by her community neurologist because of suspected PML. Her brain MRI showed several lesions that were suspicious for PML	This case raises important questions about predisposing factors for PML and the need for PML surveillance in patients treated with fingolimod. Of note, this JCV-seropositive patient had exposure to immunosuppressive therapy more than 5 years before fingolimod treatment.
https://www.ema.europa.eu/en/documents/scientific-conclusion/gilenya-h-c-psusa-00001393-201802-epar-scientific-conclusions-grounds-variation-terms-marketing_en.pdf	Scientific conclusions and grounds for the variation to the terms of the marketing authorisation(s)	European Medicine Agency (2018)	Cumulative review of post-marketing cases		Myalgia and arhtralgia Trend for an increased incidence rate of skin neoplasms and malignant lymphoma Possible infection of human papilloma virus (HPV)	Variation of the terms of the marketing authorization
[81]	Progressive multifocal leukoencephalopathy (PML)	USA (2016)			No elevated risk for PML in patients treated with fingolimod, compared to the incidence in the general population.
[82]	Macular edema	Canada (2013)	A 58-year-old woman with bilateral fingolimod-associated macular edema who was adamant that her medication be continued.	1	Successful treatment with triamcinolone acetonide without discontinuation of fingolimod	Macular edema induced by fingolimod treatment can be successfully treated
[83]	Macular edema	Germany (2016)	A diabetic MS patient who developed severe bilateral macular edema during fingolimod treatment	1	Successful treatment with anti-VEGF antibodies with discontinuation of fingolimod	Macular edema induced by fingolimod treatment can be successfully treated

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