Conspectus
Botulinum neurotoxin serotype A (BoNT/A), marketed
commercially
as Botox, is the most toxic substance known to man with an estimated
intravenous lethal dose (LD50) of 1–2 ng/kg in humans.
Despite its widespread use in cosmetic and medicinal applications,
no postexposure therapeutics are available for the reversal of intoxication
in the event of medical malpractice or bioterrorism. Accordingly,
the Centers for Disease Control and Prevention categorizes BoNT/A
as a Category A pathogen, posing the highest risk to national security
and public health as a result of the ease with which BoNT/A can be
weaponized and disseminated. BoNT/A-mediated lethality results from
neurons impeded from releasing acetylcholine, which ultimately causes
muscle paralysis and possible death by asphyxiation with the loss
of diaphragm function. Currently, the only available respite for BoNT/A
poisoning is antibody-based therapy; however, this intervention is
only effective within 12–24 h postexposure. Small molecule
therapeutics remain the only opportunity to reverse BoNT/A intoxication
after neuronal poisoning and are urgently needed. Nevertheless, no
small molecule BoNT/A inhibitors have reached the clinic or even advanced
to clinical trials.
This Account highlights the accomplishments
and existing challenges
facing BoNT/A drug discovery today. Using the comprehensive body of
work from our laboratory, we illustrate our nearly two-decade endeavor
to discover a clinically relevant BoNT/A inhibitor. Specifically,
a discussion on the identification and characterization of new chemical
leads, the development of in vitro and in
vivo assays, and pertinent discoveries in BoNT/A structural
biology related to small molecule inhibition is presented. Lead discovery
efforts in our laboratory have leveraged both in vitro high-throughput screening and rational design, and an array of mechanistic
strategies for inhibiting BoNT/A has been discovered, including noncovalent
inhibition, metal-binding active site inhibition, covalent inhibition,
and α- and β-exosite inhibition. We contrast the strengths
and weaknesses of each of these mechanistic strategies and propose
the most favorable approach for success. Finally, we discuss multiple
serendipitous discoveries of antibotulism small molecules with alternative
mechanisms of action. Remaining challenges facing clinically relevant
BoNT/A inhibition are presented and analyzed, including the current
inability to reconcile toxin half-life (months to greater than one
year) in neurons with in vivo pharmaceutical lifetimes
and reoccurring inconsistencies between in vitro,
cellular, and in vivo translation.
Our Account
of BoNT/A chemical research emphasizes the present
accomplishments and critically analyzes the remaining obstacles for
drug discovery. Importantly, we call for an increased focus on the
discovery of safe and effective covalent inhibitors of BoNT/A that
compete with the inherent half-life of the toxin.