Elucidation of Mechanism of Action in Drug Invention: Using Stable Isotope Tracers to Unravel Biochemical Kinetics.

The invention of a therapeutic begins by characterizing features that differentiate healthy versus diseased states; this often presents as changes in the concentration of an analyte. Examples include elevated blood glucose in diabetes, high cholesterol in heart disease, and protein aggregation in neurodegeneration. Analyte concentrations reflect the (im)balance of synthetic and degradation rates; as such, aberrant biochemical kinetics drive the changes in endpoint concentration that define disease biology. Therapeutics aim to reset the concentration of a disease marker via modulation of biochemical kinetics. This is easy to understand for drugs directly targeting an enzyme in a pathway but, although less obvious, this can also be at the core of protein: protein interactions. For instance, stimulation of the insulin receptor changes the flux of several biochemical substrates (across multiple tissues); similarly, modulation of proprotein convertase subtilisin/kexin type 9-low density lipoprotein (PCSK9-LDL) receptor interactions alters cholesterol trafficking. These classic examples underscore the importance of studying biochemical kinetics at a clinical level. Here, we discuss how kinetic studies link disease biology with mechanism of action elucidation and screening. This has an immediate impact on (i) enabling in vitro-in vivo correlations in early discovery, (ii) enhancing exposure-response models aiding in human dose prediction, and (iii) providing support for biomarker plans, including clinical diagnostics. Mechanism of action studies can also influence modality selection; e.g., knowledge regarding target kinetics is needed when making decisions surrounding the development of a reversible inhibitor vs. an irreversible covalent modifier, or an intervention that affects target levels such as those which enhance protein degradation or reduce protein synthesis.