Faculty of pharmacy Cairo university

Department of pharmaceutical
chemistry
FOURTH YEAR STUDENTs (205-227 ,
190)
code(802)

RECEPTOR TYROSINE KINASE

INHIBITORS
AS CHEMOTHERAPEUTICS

Difference between normal &

cancer cell

:Traditional anti-cancer drugs Side effects

Receptor tyrosine kinases

CLASSIFICATION OF RTKs

Differentiation

RTKs which have significant role in cancer

pathogenesis
EGF

RTKs which have significant role in cancer pathogenesis

LAPATINIB
Gefitinib

Gefitinib

EGFRI
s

LAPATINIB

ERLOTINIB

LA

SUNITINIB

Multi
RTKIs

SORAFENI
B

pazopanib

Structure of receptor tyrosine

kinase
ATP

Hinge

N-terminal lobe

Bi-lobial structure
N-termial lobe
Helix
C-terminal lobe
C

Both lobes
joined by a loop
Activation
called hinge.
loop
ATP binding pocket
is in the interface
between the lobes
Activation loop
C-terminal
lobe

GxGxxG

C-Helix

C-Helix
Plays an important
role in catalysis
Hinge
Adenosine moiety of
the ATP makes
bidentate H-bond
with this region
Activation loop
Starts with conserved
sequence DFG and
ends with APE.

Hing
e

ATP

DFGAPE loop
(ASP-PHEGLY)

DFG-IN vs. DFG-OUT

Helix-C
DFG
Gly rich loop

DFGOut

(ASP-PHEGLY)
Activation
loop

DFG-In

C-helix
C-helix

ATP

C-helix
out

DFG OUT

DFG IN

c-helix
in

Close up of the catalytic

machinery

N-terminal lobe

Lys
Helix-C
ATP

e
Salt
bridge l
Glu
AspWater

C-terminal lobe

Metal

In the active conformation of the kinases, a conserved Lys residue

makes a salt bridge with a conserved Glu. residue in the middle of
the helix-C.
This interaction ensures the positioning of the amino acid
Asp .(of the DFG motif) to coordinate with the -phosphate, the
divalent metal ion and catalytic water molecule to facilitate catalysis

SCHEMATIC STRUCTURE OF
ATP BINDING IN ACTIVE SITE
Hydropho
bic
pocket

cleft
H

N
1

6
N

H
N

O
O

Hydrophob
ic pocket l

OH

H
OH

O
O

P
O

O
O

Ribose
pocket

Receptor tyrosine kinase

inhibitors
TYPE III
C-Helix
ATP binding
region

A
Loop
C-HELIX ,ALOOP
REGION

TYPE I
TYPEII

Type I inhibitor

ATP competitive
Usually locking the kinase in an active
conformation

SCHEMATIC STRUCTURE OF
ATP BINDING IN ACTIVE SITE
Hydropho
bic
pocket

cleft
H

N
1

6
N

H
N

O
O

Hydrophob
ic pocket l

OH

H
OH

O
O

P
O

O
O

Ribose
pocket

SAR of type I inhibitors

At least one hydrogen bond(1-3) in

adenine region(hinge region).
This actually mostly achieved by 5 or 6
membered aromatic or heteroaromatic
separate or fused ring .

Hydrophobic substituent either in

hydrophobic pocket I or hydrophobic
pocket II or both (extra binding region)
selectivity .

tri phosphate binding region and ribose

binding region (hydrophilic region)
usually not occupied

SCHEMATIC STRUCTURE OF
TYPE I INHIBITOR
Gln767
H2NOC

H3C

Leu768

H3C

Met769
H3C

HN

Thr766

H
N

O
O

empty
pocket

Hbondinteraction

O
N
NH

O
HN

ribose' pocket'

EXAMPLE FOR TYPE I RTKIs

EGFRI:

Erlotinib

MULTI RTKIs :
Dasatinib

GENERAL nucleus FOR

EGFRIs

4- anlinoquinazoline

essential for

activity
the aniline imparts selectivity to EGFR
family

Erlotinib
Lack of polar functional gp Decreases H2O
solubility

The ethynyl gp enhances affinity through

binding with hydrophobic pocket of active
enzyme

DASATINIB(PDGFR,SRC,ABL1)

thiazolylaminopyrimidine

TypeII inhibitor

ATP competitive ,in addition to binding

to the hydrophobic pocket that open up
between DFG motif and c-helix upon
DFG flip to the inactive conformation
(DFG out).

This hydrophobic pocket is so called

ALLOSTERIC DFG-OUT POCKET.
Lock up the kinase in an inactive
conformation .

HYDROPHOBIC
REGION
Y

DFG loop in OUT position will clash with phosphate of ATP.

When DFG moves to OUT helix-C also moves away creating
HYDROPHOBIC pocket shown by bold red arrow.

DRUG binds toTHE RECEPTOR in the Phe-out

conformation.
The doublet of H-bonds with E-GLU (helix-C) and
D-ASP (DFG loop) backbone is very important.
Hence a urea or amide is the common feature
in these inhibitors.

SAR
O

R
N
H

2og8
Lck DFG out

Some Known DFG OUT

Inhibitors

2p4i
Tie DFG out

2osc
Tie DFG out

2p2i
KDR DFGout
O

R
N
H

EXAMPLE OF TYPEII RTKIs

EGFRI
LAPATINIB

MULTI RTKIs
SORAFENIB

SORAFENIB(VEGFR,PDGFR)

SAR OF SORAFENIB

Urea functional group :

Acts as a binding anchor that H-bonds to catalytic Asp and Glu

The pyridine ring

5-fold increase in activity (the unionized form H-bond to Cys919 in

the hinge region

Increase in aqueous solubility and cLogP

The 4-chloro-3-trifluoromethylphenyl moeity:

Binds in a hydrophobic pocket and increase activity.

The methyl acetamide Involved essential in H-bonding with

Cys919
4-chloro-3-trifluoromethylphenyl moeity + methyl acetamide,
enhanced activity by 1000 fold.

LAPATINIB(EGFR,HER2)

SAR OF LAPATINIB

The fluorobenzyloxy substituent forms

extra hydrophobic interactions with the
additional exposed hydrophobic pocket in
the inactive conf.

and results in potent activity for an

additional kinase called ErbB2 ( HER-2 ).

The chain containing the amine and the

sulfonyl group increases aqueous
solubility

Allosteric Kinase Inhibition

Type III

Do not compete with ATP .

bind solely to purely allosteric pockets.
They mainly act either by :
stabilizing the DFG-out
conformation
displacing the C helix from
its active conformation

locks kinase either in active or

inactive conformation

Allosteric Kinase Inhibition

Type III
Helix-C

ATP
DFG
loop
ALLOSTERIC
INHIBITOR

most allosteric kinase inhibitors have been

discovered serendipitously, and currently
there is no general strategy for identifying
such compounds other than appropriately
designed screening strategies .

The main challenge is that either the type

III binding site is not present in crystal
structures in the absence of the specific
type III ligand or it is not known that
targeting a certain binding cavity will
result in kinase inhibition.

First generation
MEK INHIBITOR

Second generation
Trametinib (MEK inhibitor)

Promising allosteric inhibitors

(second generation)
still not approved

azd6244
(selumetinib)

BAY869766

TAK73

Type iv?

It is a promising type not actually

exist
Inhibitor in allosteric site faraway
from the catalytic cavity .

type I

Selectivity
Selectivity

?Multi single or Single multi

.Vs

Multi single or Single multi ?

consideration is based on :

efficacy

PHARMACODYNAMIC
PDGFR

VEGFR

SORAFENIB(VEGFR SORAFENIB(VEGFR&RAF&M
&RAF&MEK&ERK)
EK&ERK)
AXITINIB(VEGFR&C AXITINIB(VEGFR&C-KIT)
-KIT)

EGFER
ERLOTINIB
LAPATINIB(EGFER&HER2)

PHRMACOKINETIC

Overall, these TKIs reach their peak

plasma concentrations relatively fast.
are extensively distributed and highly
protein bound (> 90%).
are primarily metabolized by CYP3A4;
most are heavily influenced by CYP3A4
inhibitors or inducers except for
sorafenib.
are mainly excreted with feces and only
a minor fraction is eliminated with the
urine .


Sorafenib

Absorption
Bioavailability: 38-49%, reduced by high fat diet
Peak Plasma Time: 3 hr
Distribution
Protein Bound: 99.5%
Metabolism
Metabolism in liver by CYP3A4
Elimination
Half-Life Elimination: 25-48 hr
Excretion: Feces 77%; urine 19%

Erlotinib
Absorption:
Bioavailability: 60% (increased by food to almost 100%)
Peak Plasma: Time: 4 hr
Distribution :
Protein Bound: 93%
Metabolism:
primarily by CYP3A4; to a lesser extent by CYP1A2, and
the extra hepatic isoform CYP1A1
Elimination:
Half-life: 36 hr
Clearance: 24% higher in smokers
Excretion: Feces 83%; urine 8%

Case study

A 63-yr-old male patient presented with

symptoms of fever and weight loss (S3),
hypertension (Charlson score 1), and
ECOG PS of 0. Chest and abdominal CT
scans revealed a right renal mass, 7 cm
in size, with renal vein involvement. No
lymph nodes were involved, and the
contralateral kidney was normal. The
patient also had synchronous multiple
liver metastases.

Following open cytoreductive radical

nephrectomy, the tumor was identified as
clear-cell RCC with sarcomatoid
differentiation. The primary tumor
extended to the perirenal fat and the renal
vein. One of the 20 lymph nodes removed
during extended paracaval and
interaortocaval lymphadenectomy was
also positive for metastatic disease (cT3b
N1 M1). The Fuhrman nuclear grade was
IV, and coagulative necrosis was present.

The patient achieved a SSIGN score of 15,

suggesting a poor prognosis in terms of
cancer-specific survival. MSKCC risk factor
analysis revealed corrected serum calcium
levels of 9.3 mg/dl, hemoglobin 9.5 g/dl,
LDH 180 U/l and Karnofsky PS of 7080,
with a time from diagnosis to systemic
treatment of <12mo,suggesting that the
patient could be stratified into the poor
risk category.

The patient was considered to be a suitable candidate for

first-line systemic therapy, and sunitinib 50 mg per day
(schedule 4/2) was initiated. After 3 mo of treatment with
sunitinib, there was significant regression of liver
metastases(from 10 cm to 6 cm). Further regression of
metastases (from 6 cm to 2.5 cm) occurred after a total of
10 mo of treatment with sunitinib (Fig. 2). The patient
experienced grade 1 leucopenia, diarrhea, and petechial
bleeding. Grade 1/2 handfoot syndrome was also observed,
but no sunitinib dose reductions were required. The hand
foot syndrome was managed through effective pedicures
and local painkillers as well as the use of moisturizing lotion,
cotton socks, and soft shoes. Despite unfavorable histology
(sarcomatoid differentiation) and poor prognosis, this patient
achieved a partial response. The patient has been receiving
sunitinib for 13 mo with minimal toxicity. The patients
quality of life, evaluated by means of the Short Form-36 (SF36) health survey questionnaire at the start of treatment,
remains similar to that recorded at treatment initiation in
both the emotional and the physical domains.

Conclusion
Sunitinib has demonstrated clinical efficacy in the
treatment of patients with mRCC and is generally
well tolerated with most adverse events being grade
1 or 2 in intensity. The case studies reported in this
paper confirm the effectiveness of sunitinib for the
treatment of mRCC with manageable adverse events
such that no dose reduction or interruptions were
required. In addition, the cases reported in this
paper demonstrate that sunitinib may be used in
patients with differing prognostic-risk-factor profiles,
including those stratified into the MSKCC poor risk
group. The new targeted therapies appear to act
differently on tumors compared to chemotherapy or
cytokines. As a result, there is a need for new
definitions for tumor responses for the new targeted
therapies

REFERENCE

MEDSCAPE
NATIONAL CANCER INSTITUTE
NATURE BIOTECHNOLOGY
INERNATIONAL JOURNAL OF MEDICAL
SCIENCES .