Impact of the clinically approved BTK inhibitors on the conformation of full-length BTK and analysis of the development of BTK resistance mutations in chronic lymphocytic leukemia

Reviewer #1 (Public Review):

Summary:

The work by Joseph et al "Impact of the clinically approved BTK inhibitors on the conformation of full-length BTK and analysis of the development of BTK resistance mutations in chronic lymphocytic leukemia" seeks to comparatively analyze the effect of a range of covalent and noncovalent clinical BTK inhibitors upon BTK conformation. The novel aspect of this manuscript is that it seeks to evaluate the differential resistance mutations that arise distinctly from each of the inhibitors.

Strengths:

This is an exciting study that builds upon the fundamental notion of ensemble behavior in solutions for enzymes such as BTK. The HDX-MS and NMR experiments are adequately and comprehensively presented.

Weaknesses:

While I commend the novelty of the study, the absence of important controls greatly tempers my enthusiasm for this work. As stated in the abstract, there are no broad takeaways for how resistance mutation bias operated from this study, although the mechanism of action of 2 common resistance mutations is useful. How these 2 resistance mutations connect to ensemble behavior, is not obvious. This is partly because BTK does not populate just binary "open"/"closed" conformations, but there are likely multiple intermediate conformations. Each inhibitor appears to preferentially "select" conformations by the authors' own assessment (line 236) and this carries implications for the emergence of resistance mutations. The most important control that would help is to use ADP or nonhydrolyzable and ATP as a baseline to establish the "inactive" and "active" conformations. All of the HDX-MS and NMR studies use protein that has no nucleotide present. A major question that remains is whether each of the inhibitors preferentially favors/blocks ADP or ATP binding. This then means it is not equivalent to correlate functional kinase assay conditions with either HDX-MS or NMR experiments.

Reviewer #2 (Public Review):

Summary:

Previous NMR and HDX-MS studies on full-length (FL) BTK showed that the covalent BTKi, ibrutinib, causes long-range effects on the conformation of BTK consistent with disruption of the autoinhibited conformation, based on HDX deuterium uptake patterns and NMR chemical shift perturbations. This study extends the analyses to four new covalent BTKi, acalabrutinib, zanubrutinib, tirabrutinib/ONO4059, and a noncovalent ATP competitive BTKi, pirtobrutinib/LOXO405.

The results show distinct conformational changes that occur upon binding each BTKi. The findings show consistent NMR and HDX changes with covalent inhibitors, which move helix aC to an 'out' position and disrupt SH3-kinase interactions, in agreement with X-ray structures of the BTKi complexed with the BTK kinase domain. In contrast, the solution measurements show that pirtobrutinib maintains and even stabilizes the helix aC-in and autoinhibited conformation, even though the BTK:pritobrutinib crystallizes with helix aC-out. This and unexpected variations in NMR and HDX behavior between inhibitors highlight the need for solution measurements to understand drug interactions with the full-length BTK. Overall the findings present good evidence for allosteric effects by each BTKi that induce distal conformational changes which are sensitive to differences in inhibitor structure.

The study goes on to examine BTK mutants T474I and L528W, which are known to confer resistance to pirtobrutinib, zanubritinib, and tirabrutinib. T474I reduces and L528W eliminates BTK autophosphorylation at pY551, while both FL-BTK-WT and FL-BTK-L528W increase HCK autophosphorylation and PLCg phosphorylation. These show that mutants partially or completely inactivate BTK and that inactive FL-BTK can activate HCK, potentially by direct BTK-HCK interactions. But they do not explain drug resistance. However, HDX and NMR show that each mutant alters the effects of BTKi binding compared to WT. In particular, T474I alters the effects of all three inhibitors around W395 and the activation loop, while L528W alters interactions around W395 with tirabrutinib and pirtobrutinib, and does not appear to bind zanubrutinib at all. The study concludes that the mutations might block drug efficacy by reducing affinity or altering binding mode.

Strengths:

The work presents convincing evidence that BTK inhibitors alter the conformation of regions distal to their binding sites, including those involved in the SH3-kinase interface, the activation loop, and a substrate binding surface between helix aF and helix aG. The findings add to the growing understanding of allosteric effects of kinase inhibitors, and their potential regulation of interactions between kinase and binding proteins.

Weaknesses:

The interpretation of HDX, NMR, and kinase assays is confusing in some places, due to ambiguity in quantifying how much kinase is bound to the inhibitor. It would be helpful to confirm binding occupancy, in order to clarify if mutants lower the amount of BTK complexed with BTKi as implied in certain places, or if they instead alter the binding mode. In addition, the interpretation of the mutant effects might benefit from a more detailed examination of how each inhibitor occupies the ATP pocket and how substitutions of T474 and L528 with Ile and Trp respectively might change the contacts with each inhibitor.