Systemic CYP3A inhibition by ritonavir enables selective targeting of hypoxic tumour cells by prodrugs of DNA-PK inhibitors

Hypoxic tumour cells are resistant to many forms of cancer therapy, particularly radiotherapy. Hypoxia-activated prodrugs (HAPs) can potentially address this problem through selective release of drugs ( effectors) in oxygen-deficient microenvironments, via metabolic reduction of a nitro(hetero)aromatic trigger moiety. While many such HAPs show marked selectivity for hypoxia in cell culture, none have yet been approved for clinical use. Here, we report HAPs that release a novel inhibitor of the DNA repair enzyme DNA-dependent protein kinase (DNA-PK) which, like hypoxia, is a major contributor to radioresistance. These ether-linked HAPs provide hypoxia-dependent radiosensitisation in cell culture, but in mice systemic generation of the DNA-PK inhibitor is observed. Using in vitro hepatic metabolism models we demonstrate hypoxia-independent metabolic activation of HAP 4 via oxidation of its linker, which is mediated exclusively by CYP3A. We extend this finding to HAPs with other triggers, linkers and effectors. The clinically used CYP3A-specific inhibitor ritonavir suppressed hepatic metabolism of 4 under oxia without interfering with its hypoxia-dependent activation. In mice, ritonavir markedly enhanced oral bioavailability of the HAP, suppressed systemic formation of the DNA-PK inhibitor, and selectively radiosensitised HCT116 tumours but not the gastrointestinal tract in the radiation field. This combination offers the prospect of increasing the therapeutic ratio of DNA-PK inhibitor-mediated radiosensitisation in patients.