Targeting Autophagy Triggers Apoptosis and Complements the Action of Venetoclax in Chronic Lymphocytic Leukemia Cells

SIMPLE SUMMARY: Venetoclax is an antagonist of the antiapoptotic protein Bcl-2, and is currently approved for treatment of chronic lymphocytic leukemia (CLL). Recently, clinical use has shown that patients develop resistance to venetoclax. Therefore, the demand for novel targets for treatment of CLL remains high. One such target is autophagy, an evolutionarily old system for degradation of long-lived proteins and organelles that recovers the energy for normal cellular functions. Here, the antileukemic potential of different autophagy inhibitors was evaluated in patient-derived CLL cells. Among these, inhibitors of the AMPK/ULK1 pathway and late-stage autophagy were the most potent, with selective cytotoxic activities seen. They also show activity against CLL cells with unfavorable genetic characteristics. These inhibitors complement the cytotoxic action of venetoclax. In conclusion, targeting autophagy shows potential as a novel approach for treatment of patients with CLL. ABSTRACT: Continuous treatment of patients with chronic lymphocytic leukemia (CLL) with venetoclax, an antagonist of the anti-apoptotic protein Bcl-2, can result in resistance, which highlights the need for novel targets to trigger cell death in CLL. Venetoclax also induces autophagy by perturbing the Bcl-2/Beclin-1 complex, so autophagy might represent a target in CLL. Diverse autophagy inhibitors were assessed for cytotoxic activities against patient-derived CLL cells. The AMPK inhibitor dorsomorphin, the ULK1/2 inhibitor MRT68921, and the autophagosome–lysosome fusion inhibitor chloroquine demonstrated concentration-dependent and time-dependent cytotoxicity against CLL cells, even in those from hard-to-treat patients who carried del(11q) and del(17p). Dorsomorphin and MRT68921 but not chloroquine triggered caspase-dependent cell death. According to the metabolic activities of CLL cells and PBMCs following treatments with 10 µM dorsomorphin (13% vs. 84%), 10 µM MRT68921 (7% vs. 78%), and 25 µM chloroquine (41% vs. 107%), these autophagy inhibitors are selective toward CLL cells. In these CLL cells, venetoclax induced autophagy, and addition of dorsomorphin, MRT68921, or chloroquine showed potent synergistic cytotoxicities. Additionally, MRT68921 alone induced G2 arrest, but when combined with venetoclax, it triggered caspase-dependent cytotoxicity. These data provide the rationale to target autophagy and for autophagy inhibitors as potential treatments for patients with CLL.