Blood Adv. 2025 Oct 08. pii: bloodadvances.2025016683. [Epub ahead of print]
Sudipta Biswas,
Zeinab Zahran,
Xiaorong Gu,
Lisa Cardone,
Remuna Marti,
Nour Mouannes,
Maximillian Stich,
Akriti G Jain,
Kateryna Fedorov,
Benjamin K Tomlinson,
Mendel Goldfinger,
Amit Verma,
Yogen Saunthararajah.
Acute myeloid leukemias (AMLs) containing TP53 (p53) mutations are routinely treated with decitabine or 5-azacytidine which deplete DNA methyltransferase 1 (DNMT1)('hypomethylating agents', HMA). Unfortunately, resistance/relapse, characterized by preserved DNMT1, is rapid. HMA are pyrimidine analogs, and to deplete DNMT1, must compete with endogenous pyrimidines. These were substantially increased in HMA-resistant versus parental AML cells, together with upregulation of carbamoyl-phosphate-synthetase-2/aspartate transcarbamylase/dihydroorotase (CAD) that rate-limits de novo pyrimidine synthesis. Moreover, TP53-mutated AMLs appeared primed for such resistance with baseline higher CAD. Pyrimidine synthesis can be depowered by using the BCL2-inhibitor venetoclax to release BAX to depolarize mitochondrial membranes. However, BAX, a p53-target gene, was ~2-fold less expressed in TP53-mutated vs TP53-wildtype cells, and venetoclax impacts were correspondingly limited. Alternatively, pyrimidine synthesis can be inhibited directly at dihydroorotate dehydrogenase (DHODH) using the clinical drug teriflunomide. Contrasting with venetoclax, teriflunomide decreased pyrimidines several-fold, restored DNMT1-depletion, and cytoreduced HMA-resistant TP53-mutated AML cells via p53/apoptosis-independent terminal lineage-maturation. This non-cytotoxic pathway preserved viability and proliferation of normal hematopoietic stem/progenitor cells (HSPC). Inhibiting pyrimidine synthesis triggered automatic increases in pyrimidine salvage, such that schedules for teriflunomide combination with HMA, taken-up by salvage, mattered: in mice with TP53-mutated AML, teriflunomide scheduled day-before HMA was more efficacious than same-day or day-after. Chronic teriflunomide exposure paradoxically increased pyrimidines via sustained compensatory pyrimidine salvage, conferring resistance rather than sensitivity to HMA. In sum, DNMT1- and DHODH-targeting, administered by timed-intermittent (metronomic) schedules, can circumvent genetic-resistance caused by TP53-mutations, and adaptive-resistance caused by metabolic homeostasis, without cytotoxicity to normal HSPC.