Vertex Pharmaceuticals

A two-step deaminative C(sp2)-C(sp3) cross-electrophile coupling (XEC) protocol to enable late-stage parallel library diversification of medicinally relevant aryl halides is reported. In the first step, sodium pivalate facilitates the condensation of primary amines with pyryliums to enable the parallel synthesis of 2,4,6-triaryl-N-alkylpyridinium salts. In the second step, robust XEC conditions were developed to enable the use of telescoped N-alkylpyridinium salts. The utility of our two-step deaminative C(sp2)-C(sp3) XEC protocol for medicinal chemistry is demonstrated through the late-stage library diversification of the anticancer drug, trametinib, which proceeded with an 85% success rate. Several alkyl substrates that are challenging in deaminative C(sp2)-C(sp3) XEC, such as α-ester and β-quaternary substrates, were successfully coupled, exemplifying the generality of the reaction conditions. The utility of our XEC conditions is further showcased through the coupling of a diverse set of medicinally relevant aryl halides. Given the value of primary amines as a substrate pool and the importance of C(sp2)-C(sp3) bond-forming reactions in drug discovery, our two-step deaminative Ni-catalyzed C(sp2)-C(sp3) XEC protocol could find utility within the medicinal chemistry community. Furthermore, the conditions reported herein for parallel N-alkylpyridinium salt synthesis could enable the development of parallel synthesis-compatible protocols for new and existing deaminative transformations.

Free energy perturbation (FEP) methods provide a robust computational framework for predicting protein-ligand binding affinities and have seen increased adoption in drug discovery workflows. Among these, absolute binding free energy (ABFE) calculations are especially valuable as they enable affinity prediction for novel compounds without prior experimental data. However, their broader adoption is limited by setup complexity, sampling challenges, and variable performance across systems. These challenges are particularly pronounced in therapeutically relevant complex membrane protein systems such as G protein-coupled receptors (GPCRs). This underscores the need to evaluate ABFE performance in GPCR systems and to develop strategies to mitigate these errors. Here, we evaluate ABFE calculations across three GPCR systems: the adenosine A2A receptor (A2AR), the dopamine D3 receptor (D3R), and the metabotropic glutamate receptor 5 (mGlu5). We focus on three sources of systematic error in these systems: (i) inadequate resolvation of the binding pocket in apo-like alchemical states, (ii) inconsistent treatment of metal ions, and (iii) insufficient sampling of receptor conformational transitions between holo-like and apo-like ensembles. To address these issues, we introduce two methodological improvements: a biased grand-canonical-like water transport scheme to improve binding pocket resolvation, and a replica-exchange umbrella sampling (REUS)-based framework to quantify and correct the free energy associated with receptor relaxation to apo-like conformations. Together, these approaches reduce the systematic overestimation of binding affinities, improving agreement with experimental data while maintaining ranking performance. Overall, our results highlight the importance of accurately representing the apo state in ABFE calculations and provide a practical framework for applying high-accuracy free energy methods to membrane protein targets.

Apparent treatment-resistant hypertension (aTRH) is common in chronic kidney disease (CKD) with type 2 diabetes and predicts worse outcomes. Spironolactone, the established fourth-line agent, is limited by hyperkalemia in CKD. This analysis assessed whether finerenone plus empagliflozin lowers blood pressure (BP) meaningfully in aTRH, and whether aTRH modifies these agents' efficacy and safety. Post hoc analysis of CONFIDENCE (NCT05254002), a double-blind randomized trial of finerenone, empagliflozin, or both in CKD with albuminuria and type 2 diabetes. aTRH was BP ≥130/80 mm Hg on 3 antihypertensive drugs, or ≥4 drugs regardless of BP. Mixed models and logistic regression identified predictors of BP response. Of the 796 participants, 307 (39%) had aTRH; they were older, more obese, and had more atherosclerotic cardiovascular disease, higher albuminuria, and higher systolic BP (140.9 vs 131.5 mm Hg) but similar estimated glomerular filtration rate (53 vs 55 mL/min/1.73 m2). Combination therapy lowered systolic BP more than either monotherapy. Independent predictors of a ≥10 mm Hg systolic BP fall were aTRH (OR: 1.56; 95% CI: 1.08-2.25) and higher baseline estimated glomerular filtration rate (OR: 1.15 per 10 mL/min/1.73 m2; 95% CI: 1.05-1.26); diuretic use and albuminuria were not. The aTRH effect was treatment-independent (interaction P = 0.21). Adverse events were more frequent with aTRH (63.8% vs 51.1%), yet on combination therapy hyperkalemia was less frequent (11.2% vs 17.5%). aTRH affected approximately 40% of participants and marked a higher-risk phenotype responsive to finerenone-empagliflozin, with BP reductions comparable to spironolactone but without the excess hyperkalemia that limits its use in CKD.

The Vaccine Safety Datalink (VSD) detected a statistical signal for ischemic events (ischemic stroke or transient ischemic attack) following bivalent mRNA COVID-19 vaccination through prospective surveillance during 2022-2023. Although multiple studies from other surveillance systems and countries reported no increased risk, important methodological limitations remained. This U.S. study addressed those limitations by evaluating the ischemic stroke risk following bivalent mRNA COVID-19 vaccination, influenza vaccination, and their same-day coadministration using an event-dependent self-controlled case series (SCCS) design. Study outcomes included first-ever ischemic stroke (primary outcome), first-in-1-year ischemic stroke (secondary outcome), and ischemic events (exploratory outcomes), identified using ICD-10-CM codes in inpatient and emergency department settings during September 1, 2022-March 31, 2023, among individuals aged ≥12 years across eight VSD sites. Analyses were conducted separately for Pfizer-BioNTech and Moderna bivalent vaccines, with relative incidences (RI) and 95% confidence intervals (CI) estimated for 1-21-day and 1-42-day risk intervals, using person-time outside these intervals as the control period. Subgroup analyses were performed by age group (12-64, ≥65 years) and history of documented SARS-CoV-2 infection. A total of 6510 first-ever ischemic strokes were identified among more than 6.8 million participants. Among recipients of Pfizer-BioNTech bivalent COVID-19 and influenza vaccines, no statistically significant increased risk of first-ever ischemic stroke was observed following bivalent COVID-19 vaccination (RI = 0.94; 95% CI: 0.63-1.41), influenza vaccination (RI = 0.95; 95% CI: 0.82-1.10), or same-day coadministration (RI = 1.15; 95% CI: 0.88-1.49) within 1-21-day risk intervals; findings were similar for 1-42-day intervals. Comparable null results were observed for Moderna vaccine and across all subgroups, secondary, and exploratory outcomes. No increased risk of ischemic stroke was found following bivalent mRNA COVID-19 vaccination, influenza vaccination, or their coadministration in this multi-site SCCS study. These findings are consistent with previous studies and underscore the importance of continued vaccine safety monitoring.

Persistent haemolytic anaemia and recurrent vaso-occlusion drive complications and accelerate mortality in sickle cell disease. Mitapivat, an oral allosteric activator of pyruvate kinase, increases ATP and decreases 2,3-DPG with the potential to improve haemolytic anaemia and reduce sickling. We aimed to evaluate the efficacy and safety of mitapivat in patients with sickle cell disease. We report results from RISE UP, a phase 3, double-blind, global, randomised, placebo-controlled trial from 69 sites across 15 countries. Patients older than 16 years with anaemia and recurrent sickle cell pain crises were randomly assigned (2:1) to either mitapivat 100 mg or placebo twice a day using permuted-block randomisation. Primary endpoints, assessed in all randomly assigned patients, were haemoglobin response (≥1·0 g/dL increase in average haemoglobin concentration from week 24 to week 52 compared with baseline) and annualised rate of sickle cell pain crises. This study is registered with ClinicalTrials.gov, NCT05031780, and the open-label extension is ongoing. A total of 207 patients were randomly assigned to mitapivat (138 [67%]) or placebo (69 [33%]). 56 (41%) of 138 patients in the mitapivat group had a haemoglobin response, compared with two (3%) of 69 patients on placebo (adjusted difference 38%, 95% CI 29-47; two-sided p<0·0001). The annualised rate (95% CI) of sickle cell pain crises was 2·6 (2·3-3·0) for mitapivat and 3·1 (2·6-3·6) for placebo (two-sided p=0·1213). Serious adverse events were reported in 28 (20%) patients on mitapivat and 20 (29%) patients on placebo; one (1%) patient and 0 patients, respectively, were deemed treatment related. Mitapivat, an oral pyruvate kinase activator, with a novel mechanism that ameliorates haemolytic anaemia, has the potential to be an effective and convenient disease-modifying treatment for people with sickle cell disease. Agios Pharmaceuticals.

B-cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL) have distinct roles in IgA-producing B-cell populations and appear to be central to the pathogenesis of IgA nephropathy. Povetacicept, an enhanced, variant transmembrane activator and calcium-modulator and cyclophilin-ligand interactor (TACI)-Fc fragment fusion therapeutic, is engineered for dual inhibition of BAFF and APRIL. In this ongoing, phase 3, double-blind, placebo-controlled trial, participants with biopsy-proven IgA nephropathy receiving stable background therapy were randomly assigned in a 2:1 ratio to receive povetacicept at a dose of 80 mg or placebo subcutaneously every 4 weeks. The primary end point of this prespecified interim analysis was the change in the 24-hour urinary protein-to-creatinine ratio at week 36. Secondary end points were the change at week 36 in galactose-deficient IgA1 levels and hematuria resolution at week 36 among participants with baseline hematuria. A total of 557 participants received povetacicept (372 participants) or placebo (185 participants). Efficacy analyses included the first 199 participants who had undergone randomization (131 in the povetacicept group and 68 in the placebo group). The 24-hour urinary protein-to-creatinine ratio decreased by 52.0% with povetacicept and by 4.3% with placebo by week 36 (adjusted difference, -49.8 percentage points; 95% confidence interval [CI], -58.6 to -39.2; P<0.001). Galactose-deficient IgA1 levels decreased by 77.4% with povetacicept and increased by 9.1% with placebo (adjusted difference, -79.3 percentage points; 95% CI, -82.2 to -75.9; P<0.001). Among the participants with baseline hematuria, resolution occurred in 85% with povetacicept and in 23% with placebo (adjusted difference, 62 percentage points; 95% CI, 45 to 78; P<0.001). The incidence of adverse events (75% with povetacicept and 78% with placebo) and serious adverse events (3% and 4%, respectively) were similar in the trial groups. Povetacicept led to a significantly greater reduction in the 24-hour urinary protein-to-creatinine ratio than placebo by week 36 in participants with IgA nephropathy. (Funded by Vertex Pharmaceuticals; RAINIER AIS-D08 ClinicalTrials.gov number, NCT06564142.).