Berotralstat: an overlooked fragment-derived drug

At the end of 2023 I mentioned that a paper by Dean Brown listed berotralstat as a fragment-derived drug. Readers will notice this molecule does not appear on our “fragments in the clinic” list. Did we miss it? After reading a (2021!) J. Med. Chem. paper by Pravin Kotian and colleagues at BioCryst, I believe the answer is yes.

 

Hereditary angioedema (HAE) is a rare genetic disease caused primarily by deficiencies in a protein that inhibits a serine protease called plasma kallikrein, or PKal. Drugs had already been developed to replace the inhibitor protein, but these need to be injected or infused. Since PKal is an enzyme, the researchers sought to make a small molecule inhibitor that could be taken as a pill.

 

BioCryst had developed an earlier drug called BCX4161, which is potent but has poor oral bioavailability. To find a better molecule, the researchers turned to the rich literature around serine protease inhibitors, which led them to make compound 2, a fragment of previously reported inhibitors of other serine proteases. The protonated benzylamine was expected to bind in the S1 pocket of the enzyme, and indeed the molecule did show weak but measurable activity.

 

Fragment growing led to compound 4, with double-digit micromolar activity. Building off the new phenyl ring led to more potent molecules such as compound 13, with low micromolar activity. Further structure-based design eventually led to BCX7353, or berotralstat. The paper provides good descriptions of the design rationale. For example, the fluorine was added to improve permeability, and the nitrile was added to improve the ADME profile. Modeling was used both to improve potency as well as to gain selectivity over other serine proteases. This proved to be successful: berotralstat is a subnanomolar inhibitor of PKal and at least several thousand-fold selective over trypsin and other serine proteases such as thrombin and FXa.

 

The pharmacokinetic properties of berotralstat in rats and monkeys were also good, and according to clinicaltrials.gov the molecule first entered the clinic in 2015. In December of 2020 the FDA approved berotralstat for prophylactic treatment of HAE attacks.

 

This is a nice story, and I agree with Dean that the discovery of berotralstat was “based on a legacy clinical candidate and fragment approaches.” The earlier molecule BCX4161 contained a benzamidine moiety, which was in part responsible for the poor oral bioavailability. Replacing this with a benzylamine fragment from the literature is a classic fragment strategy, and compound 2 is fully compliant with the rule of three.

 

So how was it missed? The abstract only states that berotralstat was discovered “using a structure-guided drug design strategy.” Indeed, the word “fragment” appears precisely once in the paper, albeit in a very telling sentence: “We evaluated these fragments in our PKal^pur inhibitor assay…”

 

From a timeline perspective, the approval of berotralstat makes it the fifth approved fragment-derived drug, after pexidartinib and before sotorasib. I’ll include it in the next update of clinical compounds, along with my standard disclosure that “the list is almost certainly incomplete.” What else are we missing?