Combination therapy with androgen receptor N‐terminal domain antagonist EPI‐7170 and enzalutamide yields synergistic activity in AR‐V7‐positive prostate cancer

Resistance of castration‐resistant prostate cancer (CRPC) to enzalutamide and abiraterone involves the expression of constitutively active, truncated androgen receptor (AR) splice variants (AR‐Vs) that lack a C‐terminal ligand‐binding domain (LBD). Both full‐length AR and truncated AR‐Vs require a functional N‐terminal domain (NTD) for transcriptional activity thereby providing rationale for the development of ralaniten (EPI‐002) as a first‐in‐class antagonist of the AR‐NTD. Here, we evaluated the antitumor effect of a next‐generation analog of ralaniten (EPI‐7170) as a monotherapy or in combination with enzalutamide in prostate cancer cells that express AR‐V7 that were resistant to enzalutamide. EPI‐7170 had 8–9 times improved potency compared to ralaniten. Enzalutamide increased levels of AR‐V7 and expression of its target genes. Knockdown of AR‐V7 restored sensitivity to enzalutamide, indicating a role for AR‐V7 in the mechanism of resistance. EPI‐7170 inhibited expression of genes transcriptionally regulated by full‐length AR and AR‐V7. A combination of EPI‐7170 and enzalutamide resulted in synergistic inhibition of proliferation of enzalutamide‐resistant cells that was consistent with results from cell cycle and clonogenic assays. In addition, this drug enhanced the antitumor effect of enzalutamide in enzalutamide‐resistant CRPC preclinical models. Thus, a combination therapy targeting both the NTD and LBD of AR, and thereby blocking both full‐length AR and AR‐Vs, has potential for the treatment of enzalutamide‐resistant CRPC.