Obeticholic acid

Obeticholic acid (OCA), sold under the brand name Ocaliva, is a semi-synthetic bile acid analogue which has the chemical structure 6α-ethyl-chenodeoxycholic acid. It is used as a medication used to treat primary biliary cholangitis. Intercept Pharmaceuticals Inc. hold the worldwide rights to develop OCA outside Japan and China, where it is licensed to Dainippon Sumitomo Pharma.[2]

Obeticholic acid
Clinical data
Trade namesOcaliva
Other names6α-ethyl-chenodeoxycholic acid; INT-747
AHFS/Drugs.comMonograph
MedlinePlusa616033
License data
Pregnancy
category
  • AU: B1
Routes of
administration		By mouth
ATC code
Legal status
Legal status
  • AU: S4 (Prescription only)
  • UK: POM (Prescription only)
  • US: ℞-only
  • EU: Rx-only
Identifiers
IUPAC name
  • (3α,5β,6α,7α)-6-Ethyl-3,7-dihydroxycholan-24-oic acid
    OR
    (4R)-4-[(3R,5S,6R,7R,8S,9S,10S,13R,14S,17R)-6-ethyl-3,7-dihydroxy-10,13-dimethyl-2,3,4,5,6,7,8,9,11,12,14,15,16,17-tetradecahydro-1H-cyclopenta[a]phenanthren-17-yl]pentanoic acid
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.238.318
Chemical and physical data
FormulaC26H44O4
Molar mass420.634 g·mol−1
3D model (JSmol)
Melting point108–110 °C (226–230 °F) [1]
SMILES
  • CC[C@@H]1[C@@H]2C[C@@H](CC[C@@]2([C@H]3CC[C@]4([C@H]([C@@H]3[C@@H]1O)CC[C@@H]4[C@H](C)CCC(=O)O)C)C)O
InChI
  • InChI=1S/C26H44O4/c1-5-17-21-14-16(27)10-12-26(21,4)20-11-13-25(3)18(15(2)6-9-22(28)29)7-8-19(25)23(20)24(17)30/h15-21,23-24,27,30H,5-14H2,1-4H3,(H,28,29)/t15-,16-,17-,18-,19+,20+,21+,23+,24-,25-,26-/m1/s1
  • Key:ZXERDUOLZKYMJM-ZWECCWDJSA-N

Invention and development

The natural bile acid chenodeoxycholic acid was identified in 1999 as the most active physiological ligand for the farnesoid X receptor (FXR), which is involved in many physiological and pathological processes. A series of alkylated bile acid analogues were designed, studied and patented by Roberto Pellicciari and colleagues at the University of Perugia, with 6α-ethyl-chenodeoxycholic acid emerging as the most highly potent FXR agonist.[3] FXR-dependent processes in liver and intestine were proposed as therapeutic targets in human diseases.[4] Obeticholic acid is the first FXR agonist to be used in human drug studies.

Clinical studies

Obeticholic acid is undergoing development in phase II and III studies for specific liver and gastrointestinal conditions.[5] The U.S. Food and Drug Administration (FDA) approved obeticholic acid on May 27, 2016, for the treatment of primary biliary cholangitis. It was approved as an orphan drug based on its reduction in the level of the biomarker alkaline phosphatase as a surrogate endpoint for clinical benefit.[6] It is indicated for the treatment of primary biliary cholangitis in combination with ursodeoxycholic acid in adults with an inadequate response to UDCA, or as monotherapy in adults unable to tolerate UDCA.[7] Additional studies are being required to prove its clinical benefit.[8]

Primary biliary cholangitis

Primary biliary cholangitis (PBC), also known as primary biliary cirrhosis, is an auto-immune, inflammatory liver disease which produces bile duct injury, fibrosis, cholestasis and eventual cirrhosis.[9] It is much more common in women than men and can cause jaundice, itching (pruritus) and fatigue. Ursodeoxycholic acid therapy is beneficial, but the disease often progresses and may require liver transplantation.[10] Animal studies suggested that treatment with FXR agonists should be beneficial in cholestatic diseases such as PBC.[11] OCA at doses between 10 mg and 50 mg was shown to provide significant biochemical benefit, but pruritus was more frequent with higher doses.[12][13] The results of a randomized, double-blind phase III study of OCA, 5 mg or 10 mg, compared to placebo (POISE) were presented in April 2014, and showed that the drug met the trial's primary endpoint of a significant reduction in serum alkaline phosphatase, a biomarker predictive of disease progression, liver transplantation or death.[14]

Nonalcoholic steatohepatitis (NASH)

Non-alcoholic steatohepatitis is a common cause of abnormal liver function with histological features of fatty liver, inflammation and fibrosis. It may progress to cirrhosis and is becoming an increasing indication for liver transplantation. It is increasing in prevalence. OCA is proposed to treat NASH.[15] A phase II trial published in 2013, showed that administration of OCA at 25 mg or 50 mg daily for six weeks reduced markers of liver inflammation and fibrosis and increased insulin sensitivity.[16]

The Farnesoid X Receptor Ligand Obeticholic Acid in Nonalcoholic Steatohepatitis Treatment (FLINT) trial, sponsored by NIDDK, was halted early in January 2014, after about half of the 283 subjects had completed the study, when a planned interim analysis showed that a) the primary endpoint had been met and b) lipid abnormalities were detected and arose safety concerns. Treatment with OCA (25 mg/day for 72 weeks) resulted in a highly statistically significant improvement in the primary histological endpoint, defined as a decrease in the NAFLD Activity Score of at least two points, with no worsening of fibrosis. 45% (50 of 110) of the treated group had this improvement compared with 21% (23 of 109) of the placebo-treated controls.[17] However concerns about longterm safety issues such as increased cholesterol and adverse cardiovascular events may warrant the concomitant use of statins in OCA-treated patients.[18]

Portal hypertension

Animal studies suggest that OCA improves intrahepatic vascular resistance and so may be of therapeutic benefit in portal hypertension.[19] An open label phase IIa clinical study is under way.

Bile acid diarrhea

Bile acid diarrhea (also called bile acid malabsorption) can be secondary to Crohn's disease or be a primary condition. Reduced median levels of FGF19, an ileal hormone that regulates increased hepatic bile acid synthesis, have been found in this condition.[20] FGF19 is potently stimulated by bile acids and especially by OCA.[21] A proof of concept study of OCA (25 mg/d) has shown clinical and biochemical benefit.[22]

FDA Label Update

On February 1, 2018, the FDA updated label warnings for obeticholic acid to better explain recommended dosing. According to the agency, a misunderstanding led some health care professionals to improperly dose the drug on a daily basis rather than weekly, which can increase the risk of liver damage.[23]

References
  1. Gioiello, Antimo; Macchiarulo, Antonio; Carotti, Andrea; Filipponi, Paolo; Costantino, Gabriele; Rizzo, Giovanni; Adorini, Luciano; Pellicciari, Roberto (April 2011). "Extending SAR of bile acids as FXR ligands: Discovery of 23-N-(carbocinnamyloxy)-3α,7α-dihydroxy-6α-ethyl-24-nor-5β-cholan-23-amine". Bioorganic & Medicinal Chemistry. 19 (8): 2650–2658. doi:10.1016/j.bmc.2011.03.004. PMID 21459580.
  2. The Wall Street Journal. "A $4 Billion Surprise for 45-Person Biotech". Retrieved 10 January 2014.
  3. Pellicciari R, Fiorucci S, Camaioni E, Clerici C, Costantino G, Maloney PR, Morelli A, Parks DJ, Willson TM (August 2002). "6alpha-ethyl-chenodeoxycholic acid (6-ECDCA), a potent and selective FXR agonist endowed with anticholestatic activity". J. Med. Chem. 45 (17): 3569–72. doi:10.1021/jm025529g. PMID 12166927.
  4. Rizzo G, Renga B, Mencarelli A, Pellicciari R, Fiorucci S (September 2005). "Role of FXR in regulating bile acid homeostasis and relevance for human diseases". Curr. Drug Targets Immune Endocr. Metabol. Disord. 5 (3): 289–303. doi:10.2174/1568008054863781. PMID 16178789.
  5. "ClinicalTrials.gov".
  6. "FDA Approves Ocaliva for Rare, Chronic Liver Disease" (Press release). U.S. Food and Drug Administration (FDA). May 31, 2016. Archived from the original on 10 November 2016. Retrieved 15 November 2016.
  7. "Ocaliva- obeticholic acid tablet, film coated". DailyMed. Retrieved 17 December 2020.
  8. Egan, Amy G.(Deputy Director, Center for Drug Evaluation and Research). "Letter from Food and Drug Administration to Intercept Pharmaceuticals" (PDF). U.S. Food and Drug Administration (FDA). Retrieved 15 November 2016.
  9. "Cirrhosis". The Lecturio Medical Concept Library. Retrieved 9 July 2021.
  10. Hirschfield GM, Gershwin ME (January 2013). "The immunobiology and pathophysiology of primary biliary cirrhosis". Annu Rev Pathol. 8: 303–30. doi:10.1146/annurev-pathol-020712-164014. PMID 23347352.
  11. Lindor, KD (May 2011). "Farnesoid X receptor agonists for primary biliary cirrhosis". Current Opinion in Gastroenterology. 27 (3): 285–8. doi:10.1097/MOG.0b013e32834452c8. PMID 21297469. S2CID 43806943.
  12. Fiorucci S, Cipriani S, Mencarelli A, Baldelli F, Bifulco G, Zampella A (August 2011). "Farnesoid X receptor agonist for the treatment of liver and metabolic disorders: focus on 6-ethyl-CDCA". Mini Rev Med Chem. 11 (9): 753–62. doi:10.2174/138955711796355258. PMID 21707532.
  13. Hirschfield GM, Mason A, Luketic V, Lindor K, Gordon SC, Mayo M, Kowdley KV, Vincent C, Bodhenheimer HC, Parés A, Trauner M, Marschall HU, Adorini L, Sciacca C, Beecher-Jones T, Castelloe E, Böhm O, Shapiro D (2015). "Efficacy of obeticholic acid in patients with primary biliary cirrhosis and inadequate response to ursodeoxycholic acid". Gastroenterology. 148 (4): 751–61.e8. doi:10.1053/j.gastro.2014.12.005. PMID 25500425.
  14. Intercept Pharma. "Press release: Intercept Announces Positive Pivotal Phase 3 POISE Trial Results". Archived from the original on March 26, 2014. Retrieved March 27, 2014.
  15. Adorini L, Pruzanski M, Shapiro D (September 2012). "Farnesoid X receptor targeting to treat nonalcoholic steatohepatitis". Drug Discov. Today. 17 (17–18): 988–97. doi:10.1016/j.drudis.2012.05.012. PMID 22652341.
  16. Mudaliar S, Henry RR, Sanyal AJ, Morrow L, Marschall HU, Kipnes M, Adorini L, Sciacca CI, Clopton P, Castelloe E, Dillon P, Pruzanski M, Shapiro D (September 2013). "Efficacy and safety of the farnesoid X receptor agonist obeticholic acid in patients with type 2 diabetes and nonalcoholic fatty liver disease". Gastroenterology. 145 (3): 574–82.e1. doi:10.1053/j.gastro.2013.05.042. PMID 23727264.
  17. Neuschwander-Tetri BA, Loomba R, Sanyal AJ, Lavine JE, Van Natta ML, Abdelmalek MF, Chalasani N, Dasarathy S, Diehl AM, Hameed B, Kowdley KV, McCullough A, Terrault N, Clark JM, Tonascia J, Brunt EM, Kleiner DE, Doo E (2015). "Farnesoid X nuclear receptor ligand obeticholic acid for non-cirrhotic, non-alcoholic steatohepatitis (FLINT): a multicentre, randomised, placebo-controlled trial". Lancet. 385 (9972): 956–65. doi:10.1016/S0140-6736(14)61933-4. PMC 4447192. PMID 25468160.
  18. "Intercept Pharma, Government Scientists Spar over Negative Safety of Liver Drug, Emails Show". 2014-05-20.
  19. Verbeke L, Farre R, Trebicka J, Komuta M, Roskams T, Klein S, Vander Elst I, Windmolders P, Vanuytsel T, Nevens F, Laleman W (November 2013). "Obeticholic acid, a farnesoid-X receptor agonist, improves portal hypertension by two distinct pathways in cirrhotic rats". Hepatology. 59 (6): 2286–98. doi:10.1002/hep.26939. PMID 24259407. S2CID 205891475.
  20. Walters JR, Tasleem AM, Omer OS, Brydon WG, Dew T, le Roux CW (November 2009). "A new mechanism for bile acid diarrhea: defective feedback inhibition of bile acid biosynthesis". Clin. Gastroenterol. Hepatol. 7 (11): 1189–94. doi:10.1016/j.cgh.2009.04.024. PMID 19426836.
  21. Zhang JH, Nolan JD, Kennie SL, Johnston IM, Dew T, Dixon PH, Williamson C, Walters JR (May 2013). "Potent stimulation of fibroblast growth factor 19 expression in the human ileum by bile acids". Am. J. Physiol. Gastrointest. Liver Physiol. 304 (10): G940–8. doi:10.1152/ajpgi.00398.2012. PMC 3652069. PMID 23518683.
  22. Walters JR, Johnston IM, Nolan JD, Vassie C, Pruzanski ME, Shapiro DA (January 2015). "The response of patients with bile acid diarrhoea to the farnesoid X receptor agonist obeticholic acid". Aliment. Pharmacol. Ther. 41 (1): 54–64. doi:10.1111/apt.12999. hdl:10044/1/21617. PMID 25329562. S2CID 44661338.
  23. Schroeder, C. "FDA Warns of Liver Injury from Improper Ocaliva Dosing". DrugNews. Retrieved 20 February 2018.
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