Benzoxazole Derivatives as Potent FXR and PPARα Dual Agonists With Anti-Fibrotic and Metabolic Regulatory Effects

Abstract

Fibrotic disease involves excessive fibrous connective tissue accumulation in organs, leading to dysfunction and irreversible damage. Metabolic alterations can sometimes contribute to fibrosis development. This study aimed to develop dual agonists for farnesoid X receptor (FXR) and peroxisome proliferator-activated receptor alpha (PPARα), targeting anti-fibrosis and metabolic regulation. Benzoxazole derivatives were found to potently activate both FXR and PPARα in hepatocytes. Among them, MHY5396 showed the most potent effects with low EC₅₀ values. MHY5396 reduced lipid synthesis and enhanced beta-oxidation in hepatocytes, decreasing lipid accumulation. It also suppressed TGFβ-induced fibrosis in hepatic stellate cells. In a methionine/choline-deficient diet mouse model, MHY5396 reduced lipid accumulation, liver damage, and fibrosis. In a thioacetamide-induced liver fibrosis model, MHY5396 had an anti-fibrotic effect comparable to obeticholic acid, a potent FXR agonist. MHY5396 also significantly reduced inflammation and fibrosis in renal cells and a folic acid-induced renal fibrosis mouse model. Pharmacokinetic studies showed that orally administered MHY5396 was well absorbed (F = 98.6%) and primarily metabolized by hepatic CYP1A2 with negligible urinary excretion. Overall, MHY5396, with dual FXR and PPARα agonist activity, exhibited significant anti-fibrotic and metabolic regulatory properties in liver and kidney fibrosis models, presenting a novel therapeutic potential for fibrotic diseases.

Keywords

dual agonist / farnesoid X receptor (FXR) / kidney fibrosis / liver fibrosis / peroxisome proliferator-activated receptor alpha (PPARα)

References

[1] T. A. Wynn and K. M. Vannella, “Macrophages in Tissue Repair, Regeneration, and Fibrosis,” Immunity 44, no. 3 (2016): 450-462.

[2] M. Xue and C. J. Jackson, “Extracellular Matrix Reorganization During Wound Healing and Its Impact on Abnormal Scarring,” Advances in Wound Care 4, no. 3 (2015): 119-136.

[3] N. C. Henderson, F. Rieder, and T. A. Wynn, “Fibrosis: From Mechanisms to Medicines,” Nature 587, no. 7835 (2020): 555-566.

[4] M. Zhao, L. Wang, M. Wang, et al., “Targeting Fibrosis, Mechanisms and Clinical Trials,” Signal Transduction and Targeted Therapy 7, no. 1 (2022): 206.

[5] S. Hwang and K. W. Chung, “Targeting Fatty Acid Metabolism for Fibrotic Disorders,” Archives of Pharmacal Research 44, no. 9-10 (2021): 839-856.

[6] S. A. Eming, P. J. Murray, and E. J. Pearce, “Metabolic Orchestration of the Wound Healing Response,” Cell Metabolism 33, no. 9 (2021): 1726-1743.

[7] P. Rada, A. Gonzalez-Rodriguez, C. Garcia-Monzon, and A. M. Valverde, “Understanding Lipotoxicity in NAFLD Pathogenesis: Is CD36 a Key Driver?,” Cell Death & Disease 11, no. 9 (2020): 802.

[8] J. A. Del Campo, P. Gallego, and L. Grande, “Role of Inflammatory Response in Liver Diseases: Therapeutic Strategies,” World Journal of Hepatology 10, no. 1 (2018): 1-7.

[9] H. Wobser, C. Dorn, T. S. Weiss, et al., “Lipid Accumulation in Hepatocytes Induces Fibrogenic Activation of Hepatic Stellate Cells,” Cell Research 19, no. 8 (2009): 996-1005.

[10] M. Pawlak, E. Bauge, W. Bourguet, et al., “The Transrepressive Activity of Peroxisome Proliferator-Activated Receptor Alpha Is Necessary and Sufficient to Prevent Liver Fibrosis in Mice,” Hepatology 60, no. 5 (2014): 1593-1606.

[11] J. Bates, A. Vijayakumar, S. Ghoshal, et al., “Acetyl-CoA Carboxylase Inhibition Disrupts Metabolic Reprogramming During Hepatic Stellate Cell Activation,” Journal of Hepatology 73, no. 4 (2020): 896-905.

[12] Z. Zhu, J. Hu, Z. Chen, et al., “Transition of Acute Kidney Injury to Chronic Kidney Disease: Role of Metabolic Reprogramming,” Metabolism 131 (2022): 155194.

[13] H. M. Kang, S. H. Ahn, P. Choi, et al., “Defective Fatty Acid Oxidation in Renal Tubular Epithelial Cells Has a Key Role in Kidney Fibrosis Development,” Nature Medicine 21, no. 1 (2015): 37-46.

[14] T. Jiang, S. E. Liebman, M. S. Lucia, J. Li, and M. Levi, “Role of Altered Renal Lipid Metabolism and the Sterol Regulatory Element Binding Proteins in the Pathogenesis of Age-Related Renal Disease,” Kidney International 68, no. 6 (2005): 2608-2620.

[15] C. Y. Han, “Update on FXR Biology: Promising Therapeutic Target?,” International Journal of Molecular Sciences 19, no. 7 (2018): 2069.

[16] R. Radun and M. Trauner, “Role of FXR in Bile Acid and Metabolic Homeostasis in NASH: Pathogenetic Concepts and Therapeutic Opportunities,” Seminars in Liver Disease 41, no. 4 (2021): 461-475.

[17] M. Watanabe, S. M. Houten, L. Wang, et al., “Bile Acids Lower Triglyceride Levels via a Pathway Involving FXR, SHP, and SREBP-1c,” Journal of Clinical Investigation 113, no. 10 (2004): 1408-1418.

[18] B. L. Clifford, L. R. Sedgeman, K. J. Williams, et al., “FXR Activation Protects Against NAFLD via Bile-Acid-Dependent Reductions in Lipid Absorption,” Cell Metabolism 33, no. 8 (2021): 1671-1684.

[19] S. Fiorucci, E. Antonelli, G. Rizzo, et al., “The Nuclear Receptor SHP Mediates Inhibition of Hepatic Stellate Cells by FXR and Protects Against Liver Fibrosis,” Gastroenterology 127, no. 5 (2004): 1497-1512.

[20] J. Zhou, S. Cui, Q. He, et al., “SUMOylation Inhibitors Synergize With FXR Agonists in Combating Liver Fibrosis,” Nature Communications 11, no. 1 (2020): 240.

[21] V. Ratziu, S. A. Harrison, V. Loustaud-Ratti, et al., “Hepatic and Renal Improvements With FXR Agonist Vonafexor in Individuals With Suspected Fibrotic NASH,” Journal of Hepatology 78, no. 3 (2023): 479-492.

[22] D. H. Kim, J. S. Park, H. I. Choi, et al., “The Role of the Farnesoid X Receptor in Kidney Health and Disease: A Potential Therapeutic Target in Kidney Diseases,” Experimental & Molecular Medicine 55, no. 2 (2023): 304-312.

[23] S. Xu, P. Jia, Y. Fang, et al., “Nuclear Farnesoid X Receptor Attenuates Acute Kidney Injury Through Fatty Acid Oxidation,” Kidney International 101, no. 5 (2022): 987-1002.

[24] S. Ha, Y. Yang, J. Won Kim, et al., “Diminished Tubule Epithelial Farnesoid X Receptor Expression Exacerbates Inflammation and Fibrosis Response in Aged Rat Kidney,” Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 78, no. 1 (2023): 60-68.

[25] M. Pawlak, P. Lefebvre, and B. Staels, “Molecular Mechanism of PPARalpha Action and Its Impact on Lipid Metabolism, Inflammation and Fibrosis in Non-Alcoholic Fatty Liver Disease,” Journal of Hepatology 62, no. 3 (2015): 720-733.

[26] M. Jiao, F. Ren, L. Zhou, et al., “Peroxisome Proliferator-Activated Receptor Alpha Activation Attenuates the Inflammatory Response to Protect the Liver From Acute Failure by Promoting the Autophagy Pathway,” Cell Death & Disease 5, no. 8 (2014): e1397.

[27] L. Gong, F. Wei, F. J. Gonzalez, and G. Li, “Hepatic Fibrosis: Targeting Peroxisome Proliferator-activated Receptor Alpha From Mechanism to Medicines,” Hepatology 78, no. 5 (2023): 1625-1653.

[28] K. W. Chung, E. K. Lee, M. K. Lee, G. T. Oh, B. P. Yu, and H. Y. Chung, “Impairment of PPARalpha and the Fatty Acid Oxidation Pathway Aggravates Renal Fibrosis During Aging,” Journal of the American Society of Nephrology 29, no. 4 (2018): 1223-1237.

[29] X. Zhao, J. Y. Y. Kwan, K. Yip, P. P. Liu, and F. F. Liu, “Targeting Metabolic Dysregulation for Fibrosis Therapy,” Nat Rev Drug Discovery 19, no. 1 (2020): 57-75.

[30] J. Henderson and S. O'Reilly, “The Emerging Role of Metabolism in Fibrosis,” Trends in Endocrinology and Metabolism 32, no. 8 (2021): 639-653.

[31] M. Alves-Bezerra and D. E. Cohen, “Triglyceride Metabolism in the Liver,” Comprehensive Physiology 8, no. 1 (2017): 1-8.

[32] Z. Dong, Y. Wang, and W. Jin, “Liver Cirrhosis: Molecular Mechanisms and Therapeutic Interventions,” MedComm 5, no. 10 (2024): e721.

[33] M. R. Jain, S. R. Giri, B. Bhoi, et al., “Dual PPARalpha/Gamma Agonist Saroglitazar Improves Liver Histopathology and Biochemistry in Experimental NASH Models,” Liver International 38, no. 6 (2018): 1084-1094.

[34] S. Zhou, X. Ling, Y. Liang, et al., “Cannabinoid Receptor 2 Plays a Key Role in Renal Fibrosis Through Inhibiting Lipid Metabolism in Renal Tubular Cells,” Metabolism 159 (2024): 155978.

[35] K. W. Chung, P. Dhillon, S. Huang, et al., “Mitochondrial Damage and Activation of the STING Pathway Lead to Renal Inflammation and Fibrosis,” Cell Metabolism 30, no. 4 (2019): 784-799.

[36] W. Lai, R. Huang, B. Wang, et al., “Novel Aspect of Neprilysin in Kidney Fibrosis via ACSL4-Mediated Ferroptosis of Tubular Epithelial Cells,” MedComm 4, no. 4 (2023): e330.

[37] L. Adorini and M. Trauner, “FXR Agonists in NASH Treatment,” Journal of Hepatology 79, no. 5 (2023): 1317-1331.

[38] B. A. Neuschwander-Tetri, R. Loomba, A. J. Sanyal, et al., “Farnesoid X Nuclear Receptor Ligand Obeticholic Acid for Non-Cirrhotic, Non-Alcoholic Steatohepatitis (FLINT): A Multicentre, Randomised, Placebo-Controlled Trial,” Lancet 385, no. 9972 (2015): 956-965.

[39] K. Panzitt, G. Zollner, H. U. Marschall, and M. Wagner, “Recent Advances on FXR-Targeting Therapeutics,” Molecular and Cellular Endocrinology 552 (2022): 111678.

[40] A. J. Sanyal, V. Ratziu, R. Loomba, et al., “Results From a New Efficacy and Safety Analysis of the REGENERATE Trial of Obeticholic Acid for Treatment of Pre-Cirrhotic Fibrosis due to Non-Alcoholic Steatohepatitis,” Journal of Hepatology 79, no. 5 (2023): 1110-1120.

[41] A. J. Sanyal, P. Lopez, E. J. Lawitz, et al., “Tropifexor for Nonalcoholic Steatohepatitis: An Adaptive, Randomized, Placebo-Controlled Phase 2a/b Trial,” Nature Medicine 29, no. 2 (2023): 392-400.

[42] K. Patel, S. A. Harrison, M. Elkhashab, et al., “Cilofexor, a Nonsteroidal FXR Agonist, in Patients with Noncirrhotic NASH: A Phase 2 Randomized Controlled Trial,” Hepatology 72, no. 1 (2020): 58-71.

[43] K. Zhao, J. He, Y. Zhang, et al., “Activation of FXR Protects Against Renal Fibrosis via Suppressing Smad3 Expression,” Scientific Reports 6 (2016): 37234.

[44] D. H. Kim, H. I. Choi, J. S. Park, et al., “Src-Mediated Crosstalk Between FXR and YAP Protects Against Renal Fibrosis,” Faseb Journal 33, no. 10 (2019): 11109-11122.

[45] X. X. Wang, T. Jiang, Y. Shen, et al., “Diabetic Nephropathy Is Accelerated by Farnesoid X Receptor Deficiency and Inhibited by Farnesoid X Receptor Activation in a Type 1 Diabetes Model,” Diabetes 59, no. 11 (2010): 2916-2927.

[46] X. X. Wang, D. Wang, Y. Luo, et al., “FXR/TGR5 Dual Agonist Prevents Progression of Nephropathy in Diabetes and Obesity,” Journal of the American Society of Nephrology 29, no. 1 (2018): 118-137.

[47] S. Xu, P. Jia, Y. Fang, et al., “Nuclear Farnesoid X Receptor Attenuates Acute Kidney Injury Through Fatty Acid Oxidation,” Kidney International 101, no. 5 (2022): 987-1002.

RIGHTS & PERMISSIONS

2025 The Author(s). MedComm published by Sichuan International Medical Exchange & Promotion Association (SCIMEA) and John Wiley & Sons Australia, Ltd.