Cathepsin K inhibitors: a novel target for osteoporosis therapy

New treatment targets in osteoporosis

Postmenopausal osteoporosis is characterized by bone remodeling alterations with an imbalance between excessive bone resorption and inadequate bone formation. At present, osteoporosis treatment rests on bone resorption inhibitors and, more specifically, on bisphosphonates. However, the introduction of anabolic agents such as parathyroid hormone that stimulate bone formation has expanded the range of treatment options. New treatment targets have been identified via improved knowledge on bone pathophysiology, bone remodeling, bone cells and intracellular signaling pathways. RANKL inhibition by anti-RANKL antibodies is undergoing considerable development as a treatment for osteoporosis. Also under development are anti-catabolic drugs that target the molecular mechanisms involved in bone resorption, including cathepsin K inhibitors and integrin alpha(v)beta(3) antagonists. The identification of new pathways involved in bone formation is directing clinical research efforts toward the development of anabolic agents. The signaling pathways involved in bone formation, most notably the Wnt-pathway, hold considerable promise as treatment targets in conditions characterized by insufficient bone formation. Current focuses of interest include antibodies against naturally occurring Wnt-pathway antagonists (e.g., sclerostin and Dkk1) and modulators of parathyroid hormone production (calcilytic agents). Thus, active research is ongoing to improve the treatment of osteoporosis, a disease whose high prevalence and considerable functional and socioeconomic impact will raise formidable challenges in the near future.

Multiplex N-terminome analysis of MMP-2 and MMP-9 substrate degradomes by iTRAQ-TAILS quantitative proteomics

Proteolysis is a major protein posttranslational modification that, by altering protein structure, affects protein function and, by truncating the protein sequence, alters peptide signatures of proteins analyzed by proteomics. To identify such modified and shortened protease-generated neo-N-termini on a proteome-wide basis, we developed a whole protein isobaric tag for relative and absolute quantitation (iTRAQ) labeling method that simultaneously labels and blocks all primary amines including protein N- termini and lysine side chains. Blocking lysines limits trypsin cleavage to arginine, which effectively elongates the proteolytically truncated peptides for improved MS/MS analysis and peptide identification. Incorporating iTRAQ whole protein labeling with terminal amine isotopic labeling of substrates (iTRAQ-TAILS) to enrich the N-terminome by negative selection of the blocked mature original N-termini and neo-N-termini has many advantages. It enables simultaneous characterization of the natural N-termini of proteins, their N-terminal modifications, and proteolysis product and cleavage site identification. Furthermore, iTRAQ-TAILS also enables multiplex N-terminomics analysis of up to eight samples and allows for quantification in MS2 mode, thus preventing an increase in spectral complexity and extending proteome coverage by signal amplification of low abundance proteins. We compared the substrate degradomes of two closely related matrix metalloproteinases, MMP-2 (gelatinase A) and MMP-9 (gelatinase B), in fibroblast secreted proteins. Among 3,152 unique N-terminal peptides identified corresponding to 1,054 proteins, we detected 201 cleavage products for MMP-2 and unexpectedly only 19 for the homologous MMP-9 under identical conditions. Novel substrates identified and biochemically validated include insulin-like growth factor binding protein-4, complement C1r component A, galectin-1, dickkopf-related protein-3, and thrombospondin-2. Hence, N-terminomics analyses using iTRAQ-TAILS links gelatinases with new mechanisms of action in angiogenesis and reveals unpredicted restrictions in substrate repertoires for these two very similar proteases.

Pharmacological inhibitors to identify roles of cathepsin K in cell-based studies: a comparison of available tools

Cathepsin K (Cat K) degrades bone type I collagen and is a target for the pharmacological treatment of osteoporosis. Further roles for Cat K have been recently described, some of which are supported by the use of purportedly selective Cat K inhibitors in human and rodent cell-based assays. Twelve commercial and non-commercial Cat K inhibitors were profiled against a panel of purified human, rat, and mouse cysteine cathepsins and in two cell-based enzyme occupancy assays for activity against Cat K, B, and L. Ten inhibitors, including the carbohydrazide Cat K inhibitor II (Boc-Phe-Leu-NHNH-CO-NHNH-Leu-Z), the non-covalent K4b, and the epoxide NC-2300, have either little Cat K selectivity, or appear poorly cell penetrant. The amino-acetonitrile-containing inhibitors L-873724 and odanacatib show greater than 100-fold human Cat K enzyme selectivity and have similar IC(50) values against each cathepsin in cell-based and enzyme assays. The basic inhibitor balicatib has greater cellular potencies than expected on the basis of purified enzyme assays. The accumulation of [(14)C]-balicatib in fibroblasts is blocked by prior treatment of the cells with NH(4)Cl, consistent with balicatib having lysosomotropic properties. These results support the use of L-873724 and odanacatib as tools to identify novel roles for Cat K using human cell-based systems, but suggest using caution in the interpretation of studies employing the other compounds.

The global cysteine peptidase landscape in parasites

The accumulation of sequenced genomes has expanded the already sizeable population of cysteine peptidases from parasites. Characterization of a few of these enzymes has ascribed key roles to peptidases in parasite life cycles and has also shed light on mechanisms of pathogenesis. Here we discuss recent observations on the physiological activities of cysteine peptidases of parasitic organisms, paired with a global view of all cysteine peptidases from the MEROPS database grouped by similarity. This snapshot of the landscape of parasite cysteine peptidases is complex and highly populated, suggesting that expansion of research beyond the few 'model' parasite peptidases is now timely.

Progress in osteoporosis and fracture prevention: focus on postmenopausal women

In the past decade, we have witnessed a revolution in osteoporosis diagnosis and therapeutics. This includes enhanced understanding of basic bone biology, recognizing the severe consequences of fractures in terms of morbidity and short-term re-fracture and mortality risk and case finding based on clinical risks, bone mineral density, new imaging approaches, and contributors to secondary osteoporosis. Medical interventions that reduce fracture risk include sufficient calcium and vitamin D together with a wide spectrum of drug therapies (with antiresorptive, anabolic, or mixed effects). Emerging therapeutic options that target molecules of bone metabolism indicate that the next decade should offer even greater promise for further improving our diagnostic and treatment approaches.

New and emerging treatments for osteoporosis

A variety of new treatments for osteoporosis have become available within the last several years, and a number of emerging treatments remain in late clinical stage development. New and emerging treatments include more potent members, or more convenient formulations, of existing classes of therapy, but a number of the emerging treatments are first-generation compounds addressing specific therapeutic targets based on recent advances in understanding of basic bone biology. These new and emerging treatments include agents with anticatabolic effects, compounds with anabolic effects, and one agent possibly containing both anticatabolic and anabolic effects. The increasing variety of new and emerging treatments increases the possibility that effective therapy will be targeted to the specific needs of the individual patient.

Future therapeutic targets in osteoporosis

PURPOSE OF REVIEW

To describe new agents for the treatment of osteoporosis, discuss a conceptual framework of agents that are antiresorptive or anabolic, and review pathways that affect bone turnover and steps in those pathways that are targets for new therapeutic agents.

RECENT FINDINGS

Novel antiresorptive agents are being developed. Denosumab, a fully human mononoclonal antibody to receptor activator of nuclear factor kappa B ligand, has completed its major fracture trial. Assessment of odanacatib, an inhibitor of cathepsin K, an osteoclast enzyme required for resorption of bone matrix, is underway. Glucagon-like peptide 2 is an intestinal peptide that prevents the nocturnal rise in bone resorption. Anabolic agents act by stimulating new bone formation. Novel anabolic agents in development include antibodies that target molecules (sclerostin and Dkk1) involved in Wnt signaling, a pathway that regulates gene transcription of proteins that are important for osteoblast function. An antagonist to the calcium-sensing receptor and an activin receptor fusion protein, which functions as an activin antagonist, have shown promise as anabolic agents in early human trials.

SUMMARY

This review discusses potential future advances in drug therapy for osteoporosis including novel antiresorptive and anabolic agents that may become available in the coming years.

Clinical assessment of fracture risk and novel therapeutic strategies to combat osteoporosis

OBJECTIVE

To review the latest tools in the clinical assessment of fracture risk and to review new and emerging options for osteoporosis therapy.

DESIGN

Retrospective analysis of published studies regarding the diagnosis and treatment of osteoporosis.

RESULT(S)

Large-scale epidemiologic data were recently assembled by the World Health Organization to produce a Web-based clinical assessment tool, FRAX, which uses clinical and historical data to provide prompt assessment and quantitation of fracture risk. The FRAX models were developed from studying population-based cohorts in Europe, North America, Asia, and Australia. The FRAX algorithms indicate the 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (at the clinical spine, forearm, hip, or shoulder) on which to base treatment decisions. Recent progress in the study of bone metabolism including anabolic pathways that enhance bone maintenance, is anticipated to improve the ways in which skeletal health can be maintained and osteoporosis can be treated.

CONCLUSION(S)

Using FRAX, fracture risk in now easily assessed in the clinical setting. New and emerging treatment strategies for bone maintenance are reviewed. Improved assessment of fracture risk, combined with tailored therapies for at-risk patients, will increase the number of patients who receive appropriate bone-sparing therapies.

Extracellular matrix molecules: potential targets in pharmacotherapy

The extracellular matrix (ECM) consists of numerous macromolecules classified traditionally into collagens, elastin, and microfibrillar proteins, proteoglycans including hyaluronan, and noncollagenous glycoproteins. In addition to being necessary structural components, ECM molecules exhibit important functional roles in the control of key cellular events such as adhesion, migration, proliferation, differentiation, and survival. Any structural inherited or acquired defect and/or metabolic disturbance in the ECM may cause cellular and tissue alterations that can lead to the development or progression of disease. Consequently, ECM molecules are important targets for pharmacotherapy. Specific agents that prevent the excess accumulation of ECM molecules in the vascular system, liver, kidney, skin, and lung; alternatively, agents that inhibit the degradation of the ECM in degenerative diseases such as osteoarthritis would be clinically beneficial. Unfortunately, until recently, the ECM in drug discovery has been largely ignored. However, several of today's drugs that act on various primary targets affect the ECM as a byproduct of the drugs' actions, and this activity may in part be beneficial to the drugs' disease-modifying properties. In the future, agents and compounds targeting directly the ECM will significantly advance the treatment of various human diseases, even those for which efficient therapies are not yet available.

Effect of the cathepsin K inhibitor odanacatib on bone resorption biomarkers in healthy postmenopausal women: two double-blind, randomized, placebo-controlled phase I studies

Inhibition of cathepsin K (CatK) is a potential new treatment for osteoporosis. In two double-blind, randomized, placebo-controlled phase I studies, postmenopausal female subjects received odanacatib (ODN), an orally active, potent, and selective CatK inhibitor, once weekly for 3 weeks or once daily for 21 days. Bone turnover biomarkers, safety monitoring, and plasma ODN concentrations were assessed. These studies showed ODN to be well tolerated. Pharmacokinetic (PK) analysis revealed a long half-life (t(1/2); 66-93 h) consistent with once-weekly dosing. Pronounced reductions in C-terminal telopeptide of type I collagen (approximately 62%) and N-terminal telopeptide of type I collagen normalized to creatinine (NTx/Cr) (approximately 62%) at trough (C(168 h)) were seen following weekly administration. Robust reductions in CTx (up to 81%) and NTx/Cr (up to 81%) were seen following daily administration. ODN exhibits robust and sustained suppression of bone resorption biomarkers (CTx and NTx/Cr) at weekly doses > or = 25 mg and daily doses > or = 2.5 mg.

Cathepsin K inhibitors for osteoporosis and potential off-target effects

Cathepsin K is a highly potent collagenase and the predominant papain-like cysteine protease expressed in osteoclasts. Cathepsin K deficiencies in humans and mice have underlined the central role of this protease in bone resorption and, thus, have rendered the enzyme as an attractive target for anti-resorptive osteoporosis therapy. In the past decade, a lot of efforts have been made in developing highly potent, selective and orally applicable cathepsin K inhibitors. Some of these inhibitors have passed preclinical studies and are presently in clinical trials at different stages of advancement. The development of the inhibitors and preliminary results of the clinical trials revealed problems and lessons concerning the in situ specificity of the compounds and their tissue targeting. In this review, we briefly summarize the history of cathepsin K research and discuss the current development of cathepsin K inhibitors as novel anti-resorptives for the treatment of osteoporosis. We also discuss potential off-target effects of cathepsin K inhibition and alternative applications of cathepsin K inhibitors in arthritis, atherosclerosis, blood pressure regulation, obesity and cancer.

Current and future treatments of bone metastases

Bone metastases contribute to a significant degree of morbidity in patients with common cancers through the development of skeletal related events (SRE) such as bone pain and pathological fracture. Traditional therapy has relied on surgical removal of lesions and, with the advent of adjuvant therapies, has been combined with radiotherapy, chemotherapy, and more recently osteoclast inhibiting agents like bisphosphonates. Although these therapeutic combinations can achieve a degree of local control, and rarely cure, across the vast majority of metastatic cancers they provide only palliation. Newer molecular agents currently under investigation, combined with innovations in surgery and radiation therapy offer a more targeted approach to bone metastasis. These utilise our understanding of key steps in the metastatic cascade including chemotactic attraction to bone, secretion of proteases, the cancer supporting microenvironment of bone matrix and the RANK-RANKL interaction for osteoclast activation. Direct inhibition of metastasis progression and osteolysis with less reliance on cytotoxic agents and invasive therapy should result in improved metastatic control, longer survival and less overall morbidity.

Phase III randomized, placebo-controlled, double-blind trial of risedronate for the prevention of bone loss in premenopausal women undergoing chemotherapy for primary breast cancer

PURPOSE

Risedronate prevents bone loss in postmenopausal women. The purpose of this study was to determine whether risedronate prevents bone loss in premenopausal women undergoing chemotherapy for breast cancer.

PATIENTS AND METHODS

Premenopausal women undergoing chemotherapy for breast cancer were treated with oral calcium 600 mg and vitamin D 400 U daily and randomly assigned to receive oral risedronate 35 mg weekly or placebo, with all these therapies beginning within a month of the start of chemotherapy. Most chemotherapy regimens included anthracyclines, taxanes, or cyclophosphamide. Bone mineral density (BMD) was measured at baseline and 1 year. The primary end point was the change in lumbar spine (LS) BMD from baseline to 1 year.

RESULTS

A total of 216 women enrolled; 170 women provided BMD data at 1 year. There was no difference in the mean change or percent change in LS BMD between groups, with a loss of 4.3% in the risedronate arm and 5.4% for placebo at 1 year (P = .18). Loss of BMD at the femoral neck and total hip were also similar between treatment groups. Risedronate was well tolerated, with no significant differences in adverse events compared with placebo, except that arthralgias and chest pain were worse in those receiving the placebos.

CONCLUSION

Risedronate did not prevent bone loss in premenopausal women undergoing adjuvant chemotherapy for breast cancer.

Development of protease inhibitors for protozoan infections

PURPOSE OF REVIEW

To highlight the promise of parasite proteases as targets for development of new antiparasitic chemotherapy. Proteolytic enzymes play key roles in the life cycle of protozoan parasites or the pathogenesis of diseases they produce. These roles include processing of host or parasite surface proteins for invasion of host cells, digestion of host proteins for nutrition, and inactivation of host immune defense mediators.

RECENT FINDINGS

Drug development for other markets has shown that proteases are druggable targets, and protease inhibitors are now licensed or in clinical development to treat hypertension, diabetes, thrombosis, osteoporosis, infectious diseases, and cancer. Several protease targets have been validated by genetic or chemical knockout in protozoan parasites. Many other parasite proteases appear promising as targets, but require more work for validation, or to identify viable drug leads. Because homologous proteases function as key enzymes in several parasites, targeting these proteases may allow development of a single compound, or a set of similar compounds, that target multiple diseases including malaria, trypanosomiasis, leishmaniasis, toxoplasmosis, cryptosporidiosis, and amebiasis.

SUMMARY

Proteases have been validated as targets in a number of parasitic infections. Proteases are druggable targets as evidenced by effective antiprotease drugs for the treatment of many human diseases including hypertension and AIDS. Future drug development targeting parasite proteases will be aided by the strong foundation of biochemical, structural, and computational databases already published or available online.

Cathepsin K inhibitors as treatment of bone metastasis

PURPOSE OF REVIEW

Cancer cells that metastasize to the skeleton are, on their own, rarely able to destroy bone. Instead, they stimulate the function of bone-degrading cells, the osteoclasts, leading to the formation of osteolytic lesions. The purpose of this review is to consider cathepsin K, a cysteine protease produced by osteoclasts, as a therapeutic target for the treatment of patients with osteolytic bone metastases.

RECENT FINDINGS

Cathepsin K plays a key role in osteoclast-mediated bone degradation. It is also produced by cancer cells that metastasize to bone where it functions in proteolytic pathways that promote cancer cell invasion. Highly selective and potent cathepsin K inhibitors have been recently developed and shown to be useful antiresorptive agents to treat osteoporosis. Moreover, preclinical studies show that cathepsin K inhibitors reduce breast cancer-induced osteolysis and skeletal tumor burden. This reduction of skeletal tumor burden is due to the antiresorptive activity of cathepsin K inhibitors, which in turn, deprive cancer cells of bone-derived growth factors that are required for tumor growth.

SUMMARY

Cathepsin K inhibitors are appropriate drugs to treat diseases associated with increased bone loss. However, their chronic use in treating osteoporosis may result in adverse effects because basic nitrogen-containing cathepsin K inhibitors accumulate within acidic organelles such as lysosomes, thereby inhibiting the activity of other cathepsins. These adverse effects should not, however, preclude the use of these drugs in life-threatening diseases such as bone metastasis.

Chemical mechanism of a cysteine protease, cathepsin C, as revealed by integration of both steady-state and pre-steady-state solvent kinetic isotope effects

Cathepsin C, or dipeptidyl peptidase I, is a lysosomal cysteine protease of the papain family that catalyzes the sequential removal of dipeptides from the free N-termini of proteins and peptides. Using the dipeptide substrate Ser-Tyr-AMC, cathepsin C was characterized in both steady-state and pre-steady-state kinetic modes. The pH(D) rate profiles for both log k cat/ K m and log k cat conformed to bell-shaped curves for which an inverse solvent kinetic isotope effect (sKIE) of 0.71 +/- 0.14 for (D)( k cat/ K a) and a normal sKIE of 2.76 +/- 0.03 for (D) k cat were obtained. Pre-steady-state kinetics exhibited a single-exponential burst of AMC formation in which the maximal acylation rate ( k ac = 397 +/- 5 s (-1)) was found to be nearly 30-fold greater than the rate-limiting deacylation rate ( k dac = 13.95 +/- 0.013 s (-1)) and turnover number ( k cat = 13.92 +/- 0.001 s (-1)). Analysis of pre-steady-state burst kinetics in D 2O allowed abstraction of a normal sKIE for the acylation half-reaction that was not observed in steady-state kinetics. Since normal sKIEs were obtained for all measurable acylation steps in the presteady state [ (D) k ac = 1.31 +/- 0.04, and the transient kinetic isotope effect at time zero (tKIE (0)) = 2.3 +/- 0.2], the kinetic step(s) contributing to the inverse sKIE of (D)( k cat/ K a) must occur more rapidly than the experimental time frame of the transient kinetics. Results are consistent with a chemical mechanism in which acylation occurs via a two-step process: the thiolate form of Cys-234, which is enriched in D 2O and gives rise to the inverse value of (D)( k cat/ K a), attacks the substrate to form a tetrahedral intermediate that proceeds to form an acyl-enzyme intermediate during a proton transfer step expressing a normal sKIE. The subsequent deacylation half-reaction is rate-limiting, with proton transfers exhibiting normal sKIEs. Through derivation of 12 equations describing all kinetic parameters and sKIEs for the proposed cathepsin C mechanism, integration of both steady-state and pre-steady-state kinetics with sKIEs allowed the provision of at least one self-consistent set of values for all 13 rate constants in this cysteine protease's chemical mechanism. Simulation of the resulting kinetic profile showed that at steady state approximately 80% of the enzyme exists in an active-site cysteine-acylated form in the mechanistic pathway. The chemical and kinetic details deduced from this work provide a potential roadmap to help steer drug discovery efforts for this and other disease-relevant cysteine proteases.