key: cord-0817015-6mlz8cqb authors: Theise, Neil D.; Arment, Anthony R.; Chakravarty, Dimple; Gregg, John M. H.; Jacobson, Ira M.; Jung, Kie Hoon; Nair, Sujit S.; Tewari, Ashutosh; Thurston, Archie W.; Van Drie, John; Westover, Jonna B. title: PT150 is a modulator of glucocorticoid and androgen receptors with antiviral activity against SARS-CoV-2 date: 2020-07-13 journal: bioRxiv DOI: 10.1101/2020.07.12.199505 sha: 58d93687e89aa90228176d0461a87b9e5e097243 doc_id: 817015 cord_uid: 6mlz8cqb PT150 is a clinical stage molecule, taken orally, with a strong safety profile having completed Phase 1 and Phase 2 clinical trials for its original use as an anti-depressant. It has an active IND for COVID-19. Antiviral activities have been found for PT150 and other members of its class in a variety of virus families; thus, it was now tested against SARS-CoV-2 in human bronchial epithelial lining cells and showed effective 90% inhibitory antiviral concentration (EC90) of 5.55 μM. PT150 is a member of an extended platform of novel glucocorticoid receptor (GR) and androgen receptor (AR) binding molecules. In vivo, their predominant net effect is one of systemic glucocorticoid antagonism, but they also show direct downregulation of AR and minor GR agonism at the cellular level. We hypothesize that anti-SARS-CoV-2 activity depends in part on this AR downregulation through diminished TMPRSS2 expression and modulation of ACE2 activity. Given that hypercortisolemia is now suggested to be a significant co-factor for COVID-19 progression, we also postulate an additive role for its potent immunomodulatory effects through systemic antagonism of cortisol. PT150, developed initially for treatment of depression (completing Phase 2 clinical trials), is both a down-regulator of androgen receptor (AR) expression (1) and a potent glucocorticoid receptor (GR) antagonist (2, 3) . It is one of a suite of related compounds with similar hormonal receptor signaling functionalities which have demonstrated antiviral activity in a number of viruses across many virus families (unpublished data). Some effects are mediated by binding to viral genomic glucocorticoid response elements (GRE's; e.g. in HIV, Ebola, HBV, HCV) (4). Many viruses without GRE's have also been found to be potently inhibited by members of the platform. Two compounds, PT150 and PT156 were found to have some degree of in vitro antiviral activity against MERS virus. PT150, a clinical stage oral medication with a strong safety profile (5, 6) and an active IND for COVID-19, is now shown to have potency against SARS-CoV-2. Proposed mechanisms of action for the potential suppression of these viruses by these compounds and, in particular, for treatment of the clinical syndrome of COVID-19 include direct antiviral effects at the virus/cell level and systemic effects arising from the inflammatory modulating activities related to their potent antagonism of cortisol in humans. The direct antiviral effects may relate to AR suppression through subsequent down regulation of transmembrane serine protease 2 (TMPRSS2), an androgen-dependent membrane receptor that primes the SARS-CoV-2 spike protein, and ACE2, the major cell receptor for viral entry (7) (8) (9) (10) . Moreover, systemic elevation of circulating cortisol (11) and virus induced neuro-inflammation (12) are now considered possibly significant co-factors in COVID-19 disease severity and progression. The combination of antiviral and immune modulatory effects may provide significant therapeutic value for COVID-19 patients. There was a highly significant antiviral response with an average EC90 of 5.55 µM (3130 ng/mL). Data from a previously conducted depression Phase 1 MAD study in humans shows that following a 300 mg oral dose the mean Cmax concentration was 4100 ng/mL, with a half-life of approximately 10 hours (6) . Clinical dosing has been safely obtained up to 900 mg oral dose per day. These data suggest that a therapeutic concentration should be obtainable by daily oral dosing in an acceptably safe regimen. Since no cytotoxicity was seen at the highest PT150 dose given of 30 µM, additional studies are pending to further evaluate at what levels cytotoxicity might emerge, if any. Likewise, the surprising potency of Remdesivir in this model system requires further exploration. In one other report we have been able to identify, Remdesivir was found to have significantly higher potency in human epithelial airway cells compared to Vero and Calu-3 cells (22) . These further studies regarding Remdesivir potency in human cells are also pending. The antiviral effects of PT150 observed in this study may be related to its capacity for AR antagonism. SARS-CoV-2 infection is mediated in part by cellular expression of TMPRSS2 (6), a molecule which is primarily regulated by AR expression (21, 23) . The initiating steps for SARS-CoV-2 depend on priming of its spike protein by TMPRSS2 cleavage, which is therefore considered essential for viral spread and pathogenesis (7). Hoffman et al have recently provided confirmation that a protease inhibitor targeting TMPRSS2 neutralizes viral entry and that SARS-CoV-2 also depends on ACE2 as its receptor for cell entry (6) . Modulation of ACE2 expression and function by AR, directly by AR regulation of ACE2 expression itself (24) and/or indirectly by TMPRSS2 cleavage of ACE2, may further augment viral entry (25) . Thus, PT150 activity against SARS-CoV-2 may be a result of AR/GR downregulation through inhibition of TMPRSS2 expression and diminished ACE2 activity. The GR modulating effects of PT150 may also be of clinical benefit. The original clinical trials for depression showed that patients who showed signs of dysregulated cortisol, with elevated serum cortisol levels, most benefited from the drug (6) . Recent data indicate the important role that upregulation of cortisol is likely to play in progression of COVID-19 to severe disease (11) . The potential importance of cortisol had already been signaled by clinical aspects of patient populations at particular risk for SARS-CoV-2 infection and severe COVID-19 disease; individuals with advancing age (26) , obesity and metabolic syndrome (27) , and cardiovascular disease (28) also have strong associations for hypercortisolemia (29) . Of course, hypercortisolemia leads to immunosuppression, another risk factor for COVID-19 that is confirmed by the increased risk for COVID-19 in patients maintained on immunosuppression for solid organ transplants (30) . The viral infection itself may lead to hypercortisolemia and resultant immunosuppression, as was seen for SARS (31) . Finally, corticosteroid immunosuppressive therapies for COVID-19 have been associated with poorer outcomes (32) . We therefore speculate that in the early Pan-cancer analysis to identify a novel class of glucocorticoid and androgen receptor antagonists with potent anti-tumor activity Glucocorticoid receptor antagonists: new tools to investigate disorders characterized by cortisol hypersecretion The long-acting β2 -adrenoceptor agonist, indacaterol, enhances glucocorticoid receptor-mediated transcription in human airway epithelial cells in a gene-and agonist-dependent manner Retinazone inhibits certain blood-borne human viruses including Ebola virus Zaire A Phase 1 Clinical Trial to Evaluate Pharmacodynamic Interactions after Oral Coadministration of Alcohol and the Highly Selective Glucocorticoid Receptor Antagonist Investigator's Brochure on ORG 34517 SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor Androgen regulates SARS-COV-2 receptor levels and is associated with severe COVID-19 symptoms in men. Version 2. bioRxiv COVID-19 and androgen targeted therapy for prostate cancer patients Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is likely to be androgen meiated Association between high serum total cortisol concentrations and mortality from COVID-19 Immediate and longterm consequences of COVID-19 infections for the development of neurological disease A New Mouse-Adapted Strain of SARS-CoV as a Lethal Model for Evaluating Antiviral Agents in Vitro and in Vivo Virology A simple method of estimating fifty percent endpoints Effect of Chronic Administration of Selective Glucocorticoid Receptor Antagonists on the Rat Hypothalamic-Pituitary-Adrenocortical Axis Psychological Stress Increases Histone H3 Phosphorylation in Adult Dentate Gyrus Granule Neurons: Involvement in a Glucocorticoid Receptor-Dependent Behavioural Response Glucocorticoid receptor antagonists hasten and augment neurochemical responses to a selective serotonin reuptake inhibitor antidepressant CRF1 not glucocorticoid receptors mediate prepulse inhibition deficits in mice overexpressing CRF Repeated subcutaneous administration of PT150 has dose-dependent effects on sign tracking in male Japanese quail Acute oral administration of the novel, competitive and selective glucocorticoid receptor antagonist ORG 34517 reduces the severity of ethanol withdrawal and related hypothalamic-pituitary-adrenal axis activation National Institutes of Health. TMPRSS2 transmembrane serine protease 2 An orally bioavailable broad-spectrum antiviral inhibits SARS-CoV-2 in human airway epithelial cell cultures and multiple coronaviruses in mice The androgen-regulated protease TMPRSS2 activates a proteolytic cascade involving components of the tumor microenvironment and promotes prostate cancer metastasis Individual variation of the SARS-CoV-2 receptor ACE2 gene expression and regulation Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Obesity as a risk factor for greater severity of COVID-19 in patients with metabolic associated fatty liver disease Cardiovascular Disease, Drug Therapy, and Mortality in COVID-19 The human stress response COVID-19 in solid organ transplant recipients: a single-center case series from Spain Lymphopenia and neutrophilia in SARS are related to the prevailing serum cortisol Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury COVID-19: A Global Threat to the Nervous System Coronavirus breakthrough: dexamethasone is first drug shown to save lives Cathepsin L-selective inhibitors: a potentially promisng treament for COVID-19 patients The authors are grateful for guidance and advice provided by Drs. Javier Martinez- The research was funded by Palisades Therapeutics/Pop Test Oncology LLC.