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AG-221, a First-in-Class Therapy Targeting Acute Myeloid Leukemia Harboring Oncogenic IDH2 Mutations
Published version of a preprint
Abstract
Somatic gain-of-function mutations in isocitrate dehydrogenases (IDH) 1 and 2 are found in multiple hematologic and solid tumors, leading to accumulation of the oncometabolite (R)-2-hydroxyglutarate (2HG). 2HG competitively inhibits α-ketoglutarate–dependent dioxygenases, including histone demethylases and methylcytosine dioxygenases of the TET family, causing epigenetic dysregulation and a block in cellular differentiation. In vitro studies have provided proof of concept for mutant IDH inhibition as a therapeutic approach. We report the discovery and characterization of AG-221, an orally available, selective, potent inhibitor of the mutant IDH2 enzyme. AG-221 suppressed 2HG production and induced cellular differentiation in primary human IDH2 mutation–positive acute myeloid leukemia (AML) cells ex vivo and in xenograft mouse models. AG-221 also provided a statistically significant survival benefit in an aggressive IDH2R140Q-mutant AML xenograft mouse model. These findings supported initiation of the ongoing clinical trials of AG-221 in patients with IDH2 mutation–positive advanced hematologic malignancies. Significance: Mutations in IDH1/2 are identified in approximately 20% of patients with AML and contribute to leukemia via a block in hematopoietic cell differentiation. We have shown that the targeted inhibitor AG-221 suppresses the mutant IDH2 enzyme in multiple preclinical models and induces differentiation of malignant blasts, supporting its clinical development. Cancer Discov; 7(5); 478–93. ©2017 AACR. See related commentary by Thomas and Majeti, p. 459. See related article by Shih et al., p. 494. This article is highlighted in the In This Issue feature, p. 443
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“A specific inhibitor of mutant IDH2, AG-221 (enasidenib) confers survival benefit in a mouse model of IDH2-mutant AML (Quivoron et al., 2014; Yen et al., 2017) and became the first compound targeting mutant IDH to enter clinical trials in 2014. Early results in IDH2-mutant AML patients have suggested enasidenib can provide clinical benefit (DiNardo et al., 2015; Stein et al., 2014), and this drug”
From Targeting Metabolism for Cancer Therapy (2017) · cites this paper as Yen et al., 2017
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“Enasidenib demonstrated a dosedependent survival benefit in xenograft mice compared to mice treated with cytarabine and demonstrated dosedependent reduction in R-2-HG, reduction in bone marrow blasts, as well as differentiation into mature granulocytes without impacting the IDH2 allele frequency.(15)”
BackgroundInfluentialTargeting IDH Mutations in AML: Wielding the Double-edged Sword of Differentiation
Becker, J. S., & Fathi, A. T. (2020) · Current Cancer Drug Targets · doi:10.2174/1568009620666200424145622 · Cited by 18
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“The efficacy of AG-221 has been well studied in a primary human AML xenograft model with an IDH2 mutation.”
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Epigenetic Therapies in Melanoma—Targeting DNA Methylation and Histone Modification
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“Inhibition of these enzymes results in epigenetic changes and blocks cellular differentiation [135].”
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“As disclosed cocrystal structure of enasidenib with IDH2 R140Q (PDB ID: 5I96), Enasidenib binding is anchored by multiple hydrogen bonds (H-bonds) formed with Q316 and many hydrophobic interactions 24 .”
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“Two articles in this issue of Cancer Discovery from Agios Pharmaceuticals in collaboration with INSERM (6) and from the laboratories of Ross Levine and Ari Melnick (7) use patient-derived xenografts and genetically engineered mouse models to investigate how this first-in-class epigenetic targeted therapy may be harnes…”
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Abundance of d ‐2‐hydroxyglutarate in G2/M is determined by FOXM1 in mutant IDH1‐expressing cells
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“Thus far, several epigenetic drugs with good efficacy have entered clinical trials, including the IDH inhibitor AG-221 [36], BET inhibitor OTX015 [37], HDAC inhibitor pracinostat [38], LSD1 inhibitor GSK2879552 [39], and DOT1L inhibitor pinometostat [40].”
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MethodIsocitrate Dehydrogenase Mutations in Cancer: Mechanisms of Transformation and Metabolic LiabilityPreprint
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Self-citationMechanisms of Resistance to Small Molecules in Acute Myeloid Leukemia
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“Inhibition of IDH1 or IDH2 in the presence of an oncogenic mutation, therefore, suppresses the production of the oncometabolite 2-HG and induces hematopoietic differentiation, making pharmacologic IDH inhibition a highly attractive therapeutic approach [70,71].”
BackgroundThe Elements of Translational Chemical Biology
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Bridging Cancer Biology with the Clinic: Comprehending and Exploiting IDH Gene Mutations in Gliomas
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Therapeutic targeting of chromatin alterations in leukemia and solid tumors
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“25,26 IDH anti-mutant treatments may also represent a therapeutic alternative for chondrosarcomas, however, the effect of these compounds in this type of tumours has been barely explored.”
BackgroundResultRecent Developments in Differentiation Therapy of Acute Myeloid Leukemia
Testa, U., Castelli, G., & Pelosi, E. (2025) · Cancers · doi:10.3390/cancers17071141 · Cited by 15
“Enasidenib potently inhibited 2HG production by IDH2 R140Q homodimer and IDH2 R140Q/WT heterodimer and displayed favorable pharmaceutical properties such as solubulity, slow clearance and oral bioavailability [50].”
InfluentialCHIRAL, FLUORINE-CONTAINING PHARMACEUTICALS
Han, J., Wzorek, A., Dhawan, G., Zhang, W., Sorochinsky, A. E., Baecker, D., Ono, T., Klika, K. D., & Soloshonok, V. A. (2025) · Ukrainian Chemistry Journal · doi:10.33609/2708-129x.91.2.2025.55-90 · Cited by 14
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“AG-221 exhibits excellent pharmaceutical characteristics, including proper solubility, low clearance, and good oral bioavailability, and powerfully inhibits 2-HG production by both the IDH2/R140Q-WT heterodimer and IDH2/R140Q homodimer.(29) Our data indicated that in IDH2-mutant AML cells, IDH2/R140Q expression in the…”
BackgroundResultInhibitor potency varies widely among tumor-relevant human isocitrate dehydrogenase 1 mutants
Matteo, D. A., Wells, G. A., Luna, L. A., Grunseth, A. J., Zagnitko, O. P., Scott, D. A., Hoang, A. D., Luthra, A., Swairjo, M. A., Schiffer, J. M., et al. (2018) · Biochemical Journal · doi:10.1042/bcj20180424 · Cited by 14
“Agios Pharmaceuticals has recently received FDA approval for mutant IDH1 [19,20] and IDH2 inhibitors [21,22].”
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Mutant Idh2 Cooperates with a NUP98-HOXD13 Fusion to Induce Early Immature Thymocyte Precursor ALL
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Targeting mitochondrial metabolism in acute myeloid leukemia
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“In addition, many PDXs have been extensively tested with various investigational therapies (Jiang et al., 2019; Plenker et al., 2017; Yen et al., 2017), including in the format of MCTs (Chen et al., 2015; Iwai et al., 2019; Janes et al., 2018; Zhang et al., 2013; Zhu et al., 2018).”
BackgroundWang, D., Zheng, L., Cheng, B. Y.-L., Sin, C., Li, R., Tsui, S. P., Yi, X., Ma, A. C. H., He, B. L., Leung, A. Y. H., et al. (2023) · Oncogene · doi:10.1038/s41388-023-02611-y · Cited by 13
“As proof-ofprinciple, both zebrafish embryos and adults carrying FLT3IDH2 and FLT3IDH2 mutations responded to quizartinib/gilteritinib, and enasidenib, which were effective agents for FLT3 [34, 35] and IDH2 mutant AML [36, 37].”
BackgroundHerold, R. A., Schofield, C. J., & Armstrong, F. A. (2023) · Angewandte Chemie International Edition · doi:10.1002/anie.202309149 · Cited by 12
Crosstalk between DNA methylation and hypoxia in acute myeloid leukaemia
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“By reducing 2-HG production, IDH inhibitors can trigger epigenetic reprogramming and restoration of myeloid differentiation in AML [108, 109].”
BackgroundTherapeutic biomarkers in acute myeloid leukemia: functional and genomic approaches
Bhatia, K. S., Sandhu, V., Wong, M. H., Iyer, P., & Bhatt, S. (2024) · Frontiers in Oncology · doi:10.3389/fonc.2024.1275251 · Cited by 13
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Synergizing metabolomics and artificial intelligence for advancing precision oncology
Xu, Y., Jiang, X.-J., & Hu, Z. (2025) · Trends in Molecular Medicine · doi:10.1016/j.molmed.2025.01.016 · Cited by 14
Self-citationAn evaluation of enasidenib for the treatment of acute myeloid leukemia
Principe, M. I. D., Paterno, G., Palmieri, R., Maurillo, L., Buccisano, F., & Venditti, A. (2019) · Expert Opinion on Pharmacotherapy · doi:10.1080/14656566.2019.1654456 · Cited by 14
“Bone marrow blasts from patients with mutant IDH2 AML exposed to enasidenib transform into mature, functioning neutrophils, confirming that the mature cells evolved from the IDH2 mutant blasts [45,46].”
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“In 2017, enasidenib (ENA; trade name Idhifa) was the first selective inhibitor of IDH2 mutants (R140Q and R172K) approved by the FDA for relapsed/refractory IDH2-mutated AML (Yen et al.”
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“…Panobinostat treatment of a mouse model of AML bearing the AML1/ETO fusion triggered terminal myeloid dif-ferentiationwitharemarkableanti-leukemicresponse 19 ,andtreatment with small-molecule inhibitors against IDH1/2 also induced myeloid differentiation in AML models with mutant IDH1/2 20,21 .”
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“…IDH inhibition by AGI-5198 reduces (R)−2-HG formation, causing epigenetic dysregulation and a block in cellular differentiation [274]; enasidenib and vorasidenib are FDA-approved for the treatment of acute myelogenous leukemia and glioma with IDH2 and IDH1/2 mutations, respectively [257, 275].”
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“Enasidenib inhibits both R140Q- and R172K-mutated IDH2 [41].”
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“Enasidenib is a selective allosteric inhibitor of IDH2 which binds to open conformation of the enzyme and stabilizes it, thereby blocking the conversion of a-KG to 2-HG [223].”
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Metadata
- Authors
- Yen, K., Travins, J., Wang, F., David, M. D., Artin, E., Straley, K., Padyana, A., Gross, S., DeLaBarre, B., Tobin, E., Chen, Y., Nagaraja, R., Choe, S., Jin, L., Konteatis, Z., Cianchetta, G., Saunders, J. O., Salituro, F. G., Quivoron, C., Opolon, P., Bawa, O., Saada, V., Paci, A., Broutin, S., Bernard, O. A., de Botton, S., Marteyn, B. S., Pilichowska, M., Xu, Y., Fang, C., Jiang, F., Wei, W., Jin, S., Silverman, L., Liu, W., Yang, H., Dang, L., Dorsch, M., Penard-Lacronique, V., Biller, S. A., & Su, S.-S. M.
- Affiliations
- Agios Pharmaceuticals (United States) (US)
- Inserm (FR)
- 1Agios Pharmaceuticals, Inc., Cambridge, Massachusetts.
- Université Paris-Saclay (FR)
- 6Service de Pharmacologie, Département de Biologie et Pathologie Médicales, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
- 2INSERM U1170, Villejuif, France.
- Tufts Medical Center (US)
- 11ShangPharma, Shanghai, China.
- Viva Biotech (China) (CN)
- Corresponding author
- Su, Shin-San Michael
- ORCID
- Yen, Katharine
- Wang, Fang
- David, Muriel D.
- Padyana, Anil
- Tobin, Erica
- Chen, Yue
- Choe, Sung
- Jin, Lei
- Konteatis, Zenon
- Salituro, Francesco G.
- Quivoron, Cyril
- Opolon, Paule
- Bawa, Olivia
- Saada, Véronique
- Broutin, Sophie
- Bernard, Olivier A.
- Marteyn, Benoît S.
- Pilichowska, Monika
- Jiang, Fan
- Wei, Wentao
- Liu, Wei
- Yang, Hua
- Dang, Lenny
- Venue
- Cancer Discovery
- Published
- 2017-04-30
- Volume
- 7
- Issue
- 5
- Pages
- 478-493
- ISSN
- 2159-8274 (ISSN-L)
- 2159-8290
- OpenAlex
- W2588385654
- Cited by
- 471
- References
- 52
- Citations by year
- 2026: 35 · 2025: 47 · 2024: 51 · 2023: 46 · 2022: 48 · 2021: 78 · 2020: 55 · 2019: 37 · 2018: 51 · 2017: 23
- FWCI
- 34.99
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Cancer Discovery (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Cancer Institute (INCa-DGOS-Inserm_6043 and INCa 2012-1-RT-09)
- Association pour la Recherche sur le Cancer (SL220130607089)
- Institut National Du Cancer (INCa-DGOS_5733)
- Topics
- Health Sciences › Medicine › Hematology › Acute Myeloid Leukemia Research
- Health Sciences › Medicine › Oncology › Glioma Diagnosis and Treatment
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Chromatin Remodeling and Cancer
- Keywords
- IDH2 inhibitors, acute myeloid leukemia, IDH2 mutation, 2-hydroxyglutarate, oncometabolites, hematopoietic differentiation, TET methylcytosine dioxygenases, histone demethylase, xenograft mouse model
- MeSH terms
- Aminopyridines, Animals, Antineoplastic Agents, Humans, Isocitrate Dehydrogenase, Mutation, Triazines, Leukemia, Myeloid, Acute, Xenograft Model Antitumor Assays, Cell Line, Tumor, Mice
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