Cited by 256Cystic Fibrosis Research AdvancesIon Transport and Channel RegulationInhalation and Respiratory Drug Delivery

The DOI matches its Crossref record; 59 of the 59 references it cites were found in a registry or an index; 24 of the 39 sources its claims cite were checked for support.

Allosteric folding correction of F508del and rare CFTR mutants by elexacaftor-tezacaftor-ivacaftor (Trikafta) combination

Open access
Veit, Guido, Roldan, Ariel, Hancock, Mark A., Da Fonte, Dillon F., Xu, Haijin, Hussein, Maytham, Frenkiel, Saul, Matouk, Elias, Velkov, Tony, Lukacs, Gergely L.·2020·JCI Insight

Abstract

Based on its clinical benefits, Trikafta — the combination of folding correctors VX-661 (tezacaftor), VX-445 (elexacaftor), and the gating potentiator VX-770 (ivacaftor) — was FDA approved for treatment of patients with cystic fibrosis (CF) carrying deletion of phenylalanine at position 508 (F508del) of the CF transmembrane conductance regulator ( CFTR ) on at least 1 allele. Neither the mechanism of action of VX-445 nor the susceptibility of rare CF folding mutants to Trikafta are known. Here, we show that, in human bronchial epithelial cells, VX-445 synergistically restores F508del-CFTR processing in combination with type I or II correctors that target the nucleotide binding domain 1 (NBD1) membrane spanning domains (MSDs) interface and NBD2, respectively, consistent with a type III corrector mechanism. This inference was supported by the VX-445 binding to and unfolding suppression of the isolated F508del-NBD1 of CFTR. The VX-661 plus VX-445 treatment restored F508del-CFTR chloride channel function in the presence of VX-770 to approximately 62% of WT CFTR in homozygous nasal epithelia. Substantial rescue of rare misprocessing mutations (S13F, R31C, G85E, E92K, V520F, M1101K, and N1303K), confined to MSD1, MSD2, NBD1, and NBD2 of CFTR, was also observed in airway epithelia, suggesting an allosteric correction mechanism and the possible application of Trikafta for patients with rare misfolding mutants of CFTR.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

VX-445 (elexacaftor) behaves as a type III CFTR corrector that binds F508del-NBD1, suppresses its unfolding/aggregation, and synergizes with type I/II correctors to restore F508del-CFTR processing and function. VX-661 plus VX-445 also rescued several rare CFTR folding mutants, reaching therapeutically relevant correction levels in airway epithelial models.

Key findings

  • VX-445 plus VX-661 increased F508del-CFTR plasma membrane density to ~45% of WT with an EC50 of ~0.28 μM; VX-445 alone reached ~15% and VX-661 alone ~3.5% of WT. The VX-445 enantiomer EN2 was less efficacious (~25% of WT, EC50 ~1.1 μM).
  • VX-445 bound F508del–NBD1-1S with a KD of ~80 μM, similar to WT–NBD1-1S, and decreased the rate/extent of F508del–NBD1-1S aggregation by 50% at 100 μM; VX-661 did not suppress aggregation and only partially suppressed thermal ellipticity loss.
  • In homozygous F508del human nasal epithelia, VX-661 plus VX-445 restored F508del-CFTR current to 76% of WT with acute VX-770 and 62% with chronic VX-770; VX-809 increased current from 9% to 25% of WT.
  • VX-661 plus VX-445 significantly increased PM density for 9 of 10 rare mutants tested, reaching >20% of WT for S13F, R31C, E92K, R352G, V520F, and L1077P; corrected Isc in HNE reached 20%, 41%, 50%, and 22% of WT for V520F, G85E, M1101K, and N1303K, respectively, with chronic VX-770.

Methods

  • CFBE41o- cells expressing inducible 3HA-tagged CFTR variants were used for PM density measurements by cell-surface ELISA, normalized to viability and CFTR mRNA; primary human nasal epithelia were differentiated at air-liquid interface and assayed by Ussing chamber short-circuit current.
  • Biophysical assays included surface plasmon resonance binding to biotinylated NBD1 constructs, NBD1 aggregation monitored by absorbance at 400 nm, and circular dichroism spectroscopy; corrector combinations were analyzed by combinatorial profiling and clustering.
  • VX-445 and ABBV-2222 were synthesized and validated; statistics used 1-way ANOVA with Tukey’s HSD, paired 2-tailed Student’s t test with Bonferroni’s FDR correction, dose-response fitting, and Heatmapper clustering.

Limitations

  • The paper does not include a dedicated limitations section. It states that the cause of the large variation in CFTR Isc across individuals is not known, and that WT and corrected F508del Isc values partly overlapped.
  • The paper states that combinatorial profiling was not possible for some mutant CFTRs because of nonresponse, high single-corrector PM density, or partial additivity.
  • The paper notes that the apparent discrepancy between only partially mitigated CF lung disease in adults and patient-derived epithelial cell data may be accounted for by long-term chronic infection, inflammation, and tissue damage; it also notes that VX-445’s increased in vivo potency may reflect intracellular accumulation and/or a binding surface modulated by full-length CFTR context.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1172/jci.insight.139983

Cites

59 of 59 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Figure 1 VX-445–mediated F508del correction is synergistic with type I and II correctors. (A) Dose-response of VX-445 (24 hours, 37°C) in presence of 3 μM VX-661 for the correction of F508del-CFTR PM density in CFBE41o- cells expressed as percentage of the WT-CFTR (n = 3). EN1, enantiomer 1; EN2, enantiomer 2. (B) PM density of F508del-CFTR after type I corrector (VX-661, VX-809, ABBV-2222, or FDL169; 3 μM, 24 hours, 37°C), VX-445 (2 μM, 24 hours, 37˚C) or type I plus VX-445 corrector combination treatment expressed as percentage of WT-CFTR in CFBE41o- (n = 3). (C) Heatmap of the effect of corrector combinations on the PM density of F508del-CFTR expressed in CFBE41o- (n = 3). (D) Heatmap of the combinatorial profiling established by calculating the dual corrector effect in relation to the theoretical additivity of the compounds. Combinatorial profiles were subsequently used to cluster compounds by average linkage analysis, and the distance was determined by Spearman’s rank correlation. The underlying data are depicted as bar plots in Supplemental Figure 1B. Data in A and B are means ± SEM of 3 independent experiments. *P < 0.05, **P < 0.01, by 1-way ANOVA followed by Turkey’s post hoc test.
Figure 1 VX-445–mediated F508del correction is synergistic with type I and II correctors. (A) Dose-response of VX-445 (24 hours, 37°C) in presence of 3 μM VX-661 for the correction of F508del-CFTR PM density in CFBE41o- cells expressed as percentage of the WT-CFTR (n = 3). EN1, enantiomer 1; EN2, enantiomer 2. (B) PM density of F508del-CFTR after type I corrector (VX-661, VX-809, ABBV-2222, or FDL169; 3 μM, 24 hours, 37°C), VX-445 (2 μM, 24 hours, 37˚C) or type I plus VX-445 corrector combination treatment expressed as percentage of WT-CFTR in CFBE41o- (n = 3). (C) Heatmap of the effect of corrector combinations on the PM density of F508del-CFTR expressed in CFBE41o- (n = 3). (D) Heatmap of the combinatorial profiling established by calculating the dual corrector effect in relation to the theoretical additivity of the compounds. Combinatorial profiles were subsequently used to cluster compounds by average linkage analysis, and the distance was determined by Spearman’s rank correlation. The underlying data are depicted as bar plots in Supplemental Figure 1B. Data in A and B are means ± SEM of 3 independent experiments. *P < 0.05, **P < 0.01, by 1-way ANOVA followed by Turkey’s post hoc test.CC BY · PubMed Central
Figure 2 VX-445 binds to and changes the unfolding trajectory of CFTR-NBD1. (A) Representative surface plasmon resonance (SPR) sensorgram for the binding of VX-445 (0–200 μM) to immobilized F508del–NBD1-1S. (B) Binding isotherms for VX-445 binding to immobilized F508del–NBD1-1S or WT–NBD1-1S as determined by SPR (n = 3). Curve fitting was performed as described in Methods. (C) Aggregation rates observed in NBD1 aggregation assays between 30 and 50 minutes for the different compounds were normalized by the rate observed for F508del–NBD1-1S in 1% DMSO (n = 4). Compound/chaperone concentrations were 50 or 100 μM VX-445, 10% glycerol, 100 μM VX-661, 100 μM 3151, 10 μM DnaK, or DnaK-DnaJ-GrpE at 10, 2, and 10 μM, respectively. (D) Protein secondary structure stability was studied by far-UV CD spectra of F508del–NBD1-1S. CD scans between 250 and 195 nm were taken every minute at 32°C in the presence of vehicle control (1% 1,4-Dioxane), 100 μM VX-661, or 100 μM VX-445. CD scans obtained at different time intervals of 1 representative experiment were overlaid. (E) Quantification of the ellipticity values (in mDeg) observed at 207 nm. Values were plotted as a function of time in the presence of vehicle control (1% 1,4-Dioxane); 50, 100, or 200 μM VX-445; or 100 μM VX-661 (n = 2–3). Continuous lines were derived by 4-point smooth iteration. Data in B, C, and E are means ± SEM of the indicated number of independent experiments. *P < 0.05, **P < 0.01 by 1-way ANOVA followed by Turkey’s post hoc test.
Figure 2 VX-445 binds to and changes the unfolding trajectory of CFTR-NBD1. (A) Representative surface plasmon resonance (SPR) sensorgram for the binding of VX-445 (0–200 μM) to immobilized F508del–NBD1-1S. (B) Binding isotherms for VX-445 binding to immobilized F508del–NBD1-1S or WT–NBD1-1S as determined by SPR (n = 3). Curve fitting was performed as described in Methods. (C) Aggregation rates observed in NBD1 aggregation assays between 30 and 50 minutes for the different compounds were normalized by the rate observed for F508del–NBD1-1S in 1% DMSO (n = 4). Compound/chaperone concentrations were 50 or 100 μM VX-445, 10% glycerol, 100 μM VX-661, 100 μM 3151, 10 μM DnaK, or DnaK-DnaJ-GrpE at 10, 2, and 10 μM, respectively. (D) Protein secondary structure stability was studied by far-UV CD spectra of F508del–NBD1-1S. CD scans between 250 and 195 nm were taken every minute at 32°C in the presence of vehicle control (1% 1,4-Dioxane), 100 μM VX-661, or 100 μM VX-445. CD scans obtained at different time intervals of 1 representative experiment were overlaid. (E) Quantification of the ellipticity values (in mDeg) observed at 207 nm. Values were plotted as a function of time in the presence of vehicle control (1% 1,4-Dioxane); 50, 100, or 200 μM VX-445; or 100 μM VX-661 (n = 2–3). Continuous lines were derived by 4-point smooth iteration. Data in B, C, and E are means ± SEM of the indicated number of independent experiments. *P < 0.05, **P < 0.01 by 1-way ANOVA followed by Turkey’s post hoc test.CC BY · PubMed Central
Figure 3 Trikafta mediated correction of CFTRF508del/F508del in HNE. (A) Effect of indicated single correctors or corrector combinations on the Isc of human nasal epithelia with CFTRF508del/F508del genotype (CF-HNE). CFTR-mediated currents were induced by sequential acute addition of forskolin (Fsk, 20 μM, arrow) and VX-770 (770, 10 μM, filled arrowhead), followed by CFTR inhibition with CFTRinh-172 (Inh-172, 20 μM, open arrowhead) in intact monolayers with basolateral-to-apical chloride gradient. (B) Quantification of the CFTRinh-172 inhibited current, after stimulation as in A, in CF-HNE isolated from 5 different homozygous F508del CF patients after single correctors (VX-809 and VX-661, 3 μM; VX-445, 2 μM; 24 hours, 37°C), corrector plus chronic potentiator (cVX-770, 1 μM, 24 hours, 37°C) or corrector combination treatment expressed as percentage of WT-CFTR currents in WT-HNE from 10 donors. **P < 0.01 by paired 2-tailed Student’s t test. (C) The fraction of potentiator-independent (forskolin-induced) current in HNE treated with single corrector or corrector combination. **P < 0.01 by paired 2-tailed Student’s t test followed by Bonferroni’s FDR correction.
Figure 3 Trikafta mediated correction of CFTRF508del/F508del in HNE. (A) Effect of indicated single correctors or corrector combinations on the Isc of human nasal epithelia with CFTRF508del/F508del genotype (CF-HNE). CFTR-mediated currents were induced by sequential acute addition of forskolin (Fsk, 20 μM, arrow) and VX-770 (770, 10 μM, filled arrowhead), followed by CFTR inhibition with CFTRinh-172 (Inh-172, 20 μM, open arrowhead) in intact monolayers with basolateral-to-apical chloride gradient. (B) Quantification of the CFTRinh-172 inhibited current, after stimulation as in A, in CF-HNE isolated from 5 different homozygous F508del CF patients after single correctors (VX-809 and VX-661, 3 μM; VX-445, 2 μM; 24 hours, 37°C), corrector plus chronic potentiator (cVX-770, 1 μM, 24 hours, 37°C) or corrector combination treatment expressed as percentage of WT-CFTR currents in WT-HNE from 10 donors. **P < 0.01 by paired 2-tailed Student’s t test. (C) The fraction of potentiator-independent (forskolin-induced) current in HNE treated with single corrector or corrector combination. **P < 0.01 by paired 2-tailed Student’s t test followed by Bonferroni’s FDR correction.CC BY · PubMed Central
Figure 4 Efficacy, combinatorial profiling, and clustering of mechanistic classes of correctors in rare CFTR folding mutants. (A) PM density of the indicated CFTR mutants alone and after VX-661 (3 μM), VX-445 (2 μM), or combination treatment expressed as percentage of WT-CFTR in CFBE41o- (n = 3). Data are means ± SEM. *P < 0.05 and **P < 0.01 by 1-way ANOVA followed by Turkey’s post hoc test. (B) Heatmaps of the combinatorial profiling established by calculating the dual corrector effect in relation to the theoretical additivity of the compounds for S13F, S492F, V520F, L1077P, and M1101K-CFTR in CFBE41o-. Combinatorial profiles were subsequently used to cluster compounds by average linkage analysis, and the distance was determined by Spearman’s rank correlation. The underlying data are depicted as bar plots in Supplemental Figure 5, A–E.
Figure 4 Efficacy, combinatorial profiling, and clustering of mechanistic classes of correctors in rare CFTR folding mutants. (A) PM density of the indicated CFTR mutants alone and after VX-661 (3 μM), VX-445 (2 μM), or combination treatment expressed as percentage of WT-CFTR in CFBE41o- (n = 3). Data are means ± SEM. *P < 0.05 and **P < 0.01 by 1-way ANOVA followed by Turkey’s post hoc test. (B) Heatmaps of the combinatorial profiling established by calculating the dual corrector effect in relation to the theoretical additivity of the compounds for S13F, S492F, V520F, L1077P, and M1101K-CFTR in CFBE41o-. Combinatorial profiles were subsequently used to cluster compounds by average linkage analysis, and the distance was determined by Spearman’s rank correlation. The underlying data are depicted as bar plots in Supplemental Figure 5, A–E.CC BY · PubMed Central
Figure 5 Efficacy of Trikafta for the functional correction of rare CFTR folding mutants in HNE. (A–E) Effect of indicated single correctors (VX-661, ABBV-2222, and FDL169, 3 μM; VX-445, 2 μM; 24 hours), corrector plus chronic potentiator (cVX-770, 1 μM, 24 hours), or corrector combinations on the Isc of HNE with CFTRG85E/G85E (A, n = 3), CFTRV520F/1717-1G->A (B, n = 3), CFTRY569D/Y569D (C, n = 3), CFTRM1101K/M1101K (D, n = 3), or CFTRN1303K/N1303K (E, n = 3) genotype. Representative traces (top panels) and quantification of the CFTRinh-172 inhibited current expressed as percentage of WT-CFTR currents in HNE from 10 donors (bottom panels). CFTR-mediated currents were induced by sequential acute addition of forskolin (Fsk, 20 μM) and VX-770 (10 μM) followed by CFTR inhibition with CFTRinh-172 (Inh-172, 20 μM) in an intact monolayer with basolateral-to-apical chloride gradient. Data are means ± SEM of 3 measurements. *P < 0.05 and **P < 0.01 by 1-way ANOVA followed by Turkey’s post hoc test.
Figure 5 Efficacy of Trikafta for the functional correction of rare CFTR folding mutants in HNE. (A–E) Effect of indicated single correctors (VX-661, ABBV-2222, and FDL169, 3 μM; VX-445, 2 μM; 24 hours), corrector plus chronic potentiator (cVX-770, 1 μM, 24 hours), or corrector combinations on the Isc of HNE with CFTRG85E/G85E (A, n = 3), CFTRV520F/1717-1G->A (B, n = 3), CFTRY569D/Y569D (C, n = 3), CFTRM1101K/M1101K (D, n = 3), or CFTRN1303K/N1303K (E, n = 3) genotype. Representative traces (top panels) and quantification of the CFTRinh-172 inhibited current expressed as percentage of WT-CFTR currents in HNE from 10 donors (bottom panels). CFTR-mediated currents were induced by sequential acute addition of forskolin (Fsk, 20 μM) and VX-770 (10 μM) followed by CFTR inhibition with CFTRinh-172 (Inh-172, 20 μM) in an intact monolayer with basolateral-to-apical chloride gradient. Data are means ± SEM of 3 measurements. *P < 0.05 and **P < 0.01 by 1-way ANOVA followed by Turkey’s post hoc test.CC BY · PubMed Central

Verification

Claims the paper makes

37 Own result · 15 Own interpretation · 10 Partly supported · 8 Own method · 4 Supported · 3 No full text of the sources · 3 Not checked yet · 2 Supported so far · 1 No basis given · accuracy not yet measured

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Show all 48 claims

  • It may state two separate claims as one. 27
  • Probably not a substantial claim. 11
35 of 35
  • The paper relies on this without support.

    Heterozygous carriers of F508del lack disease symptoms.

    “since heterozygous carriers lack disease symptoms.”
  • The paper relies on this without support.

    A CFTR PM density of >20% of WT is therapeutically significant.

    “reaching therapeutically significant levels of > 20% of WT in S13F-, R31C-, E92K-, R352G-, V520F-, and L1077P-CFTR (Figure 4A).”
  • The paper relies on this without support.

    A CFTR activity correction reaching 20%–50% of WT Isc is associated with therapeutic benefit.

    “indicating that the fraction of CFTR activity correction of these mutants would likely be associated with therapeutic benefit.”
  • The paper relies on this without support.

    Correction levels of >20% of WT CFTR are therapeutically relevant.

    “reaching therapeutically relevant correction levels of > 20% of the WT in CFBE41o- cells or HNE”
  • The paper relies on this without support.

    Binding of VX-445 to isolated F508del–NBD1-1S reflects its interaction with full-length F508del-CFTR.

    “The increased in vivo potency of VX-445, however, may indicate its intracellular accumulation similar to that observed for VX-770 (36) and/or the exposure of a VX-445 binding surface, which is either modulated by or also constitutes the MSD1/2 and/or NBD2 segments in the context of the full-length F508del-CFTR.”
  • The paper relies on this without support.

    Selection of modulator combinations requires knowledge of the mechanism of action of individual CFTR modulators.

    “Selection of modulator combinations, however, requires the knowledge of the mechanism of action of individual CFTR modulators.”
6 of 6

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1 of 1

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Metadata

Authors
Veit, G., Roldan, A., Hancock, M. A., Da Fonte, D. F., Xu, H., Hussein, M., Frenkiel, S., Matouk, E., Velkov, T., & Lukacs, G. L.
Affiliations
  • Department of Physiology and
  • McGill University (CA)
  • The University of Melbourne (AU)
  • Department of Otolaryngology-Head and Neck Surgery,
  • Montreal Chest Institute (CA)
Corresponding author
Veit, Guido
Venue
JCI Insight
Published
2020-09-17
Volume
5
Issue
18
ISSN
2379-3708 (ISSN-L)
OpenAlex
W3081438953
Cited by
250
References
59
Citations by year
2026: 18 · 2025: 45 · 2024: 39 · 2023: 38 · 2022: 58 · 2021: 48 · 2020: 4
FWCI
21.23
Type
journal article
Language
en
Open access
Locations
  • JCI Insight (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Minerva Access (University of Melbourne) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • Canadian Institutes of Health Research (MOP-142221,PJT-153095)
  • National Institute of Diabetes & Digestive & Kidney Diseases (5R01DK075302)
Topics
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cystic Fibrosis Research Advances
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Ion Transport and Channel Regulation
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Inhalation and Respiratory Drug Delivery
Keywords
cystic fibrosis, CFTR, F508del mutation, elexacaftor/tezacaftor/ivacaftor, elexacaftor, tezacaftor, ivacaftor, NBD1, transmembrane domain, protein folding, chloride channel function, airway epithelium
MeSH terms
Aminophenols, Bronchi, Cells, Cultured, Cystic Fibrosis, Drug Combinations, Humans, Indoles, Mutation, Pyrazoles, Pyridines, Quinolines, Protein Folding, Cystic Fibrosis Transmembrane Conductance Regulator, Benzodioxoles

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