TREATMENTS OF ANGIOEDEMA
20220226293 · 2022-07-21
Inventors
- Edward Paul FEENER (North Reading, MA, US)
- Sally Louise MARSH (Salisbury, GB)
- Andreas MAETZEL (Chapel Hill, NC, US)
- Michael David SMITH (Salt Lake City, UT, US)
- Christopher Martyn YEA (Salisbury, GB)
Cpc classification
A61K9/0053
HUMAN NECESSITIES
A61K31/444
HUMAN NECESSITIES
A61K31/4439
HUMAN NECESSITIES
A61K9/2054
HUMAN NECESSITIES
International classification
A61K31/444
HUMAN NECESSITIES
A61K9/00
HUMAN NECESSITIES
Abstract
The present invention relates to treatments of angioedema, and specifically bradykinin-mediated angioedema non-hereditary (BK-AEnH). In particular, the present invention provides on-demand treatments of bradykinin-mediated angioedema non-hereditary (BK-AEnH) by orally administering a plasma kallikrein inhibitor to a patient in need thereof on-demand. Regular (or continuous) treatments of BK-AEnH are also provided.
Claims
1. A method for treating bradykinin-mediated angioedema non-hereditary (BK-AEnH) on-demand comprising: orally administering the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) to a patient in need thereof on-demand, ##STR00002##
2-3. (canceled)
4. The method according to claim 1, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is for use in treating an acute attack of bradykinin-mediated angioedema non-hereditary (BK-AEnH) on-demand and is orally administered on-demand upon recognition of a symptom of an acute BK-AEnH attack.
5. The method according to claim 4, wherein the symptom of an acute BK-AEnH attack recognised is at least one of: swelling of tissues; fatigue; headache; muscle aches; skin tingling; abdominal pain; nausea; vomiting; diarrhoea; difficulty swallowing; hoarseness; shortness of breath; and/or mood changes.
6. The method according to claim 4, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered on-demand within 1 hour of the symptom of an acute BK-AEnH attack being recognised.
7. The method according to claim 4, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered on-demand within 30 minutes, within 20 minutes, within 10 minutes, or within 5 minutes of the symptom of an acute BK-AEnH attack being recognised.
8. The method according to claim 4, wherein the compound of Formula A (or a pharmaceutically acceptable salt or solvate thereof) is orally administered on-demand in the prodromal phase of an acute BK-AEnH attack.
9. The method according to claim 8, wherein the symptom recognised is at least one of: a slight swelling, abdominal pain or reddening of the skin.
10. The method according to claim 9, wherein the symptom recognised is erythema marginatum.
11. The method according to claim 1, wherein the treatment shortens the duration of the acute BK-AEnH attack.
12. The method according to claim 8, wherein the treatment prevents the acute BK-AEnH attack from progressing to the swelling stage of an acute BK-AEnH attack.
13. The method according to claim 1, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered on-demand to prophylactically reduce the likelihood of an acute BK-AEnH attack.
14. The method according to claim 13, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered on-demand when it is anticipated that an acute BK-AEnH attack will be induced.
15. The method according to claim 13, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered on-demand to prevent an acute BK-AEnH attack.
16. The method according to claim 14, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered on-demand when it is anticipated that an acute BK-AEnH attack will be induced by physical traumata and/or stress.
17. The method according to claim 16, wherein it is anticipated that an acute BK-AEnH attack will be induced by the physical traumata of a dental procedure and/or the mental stress associated with a dental procedure.
18. A method for treating bradykinin-mediated angioedema non-hereditary (BK-AEnH) comprising: orally administering the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) to a patient in need thereof, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered prophylactically to reduce the likelihood of an acute BK-AEnH attack, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is administered regularly to the patient, ##STR00003##
19-20. (canceled)
21. The method according to claim 18, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is administered to prevent an acute BK-AEnH attack.
22. The method according to claim 18, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered once daily.
23. The method according to claim 18, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered twice daily.
24. The method according to claim 18, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is orally administered three times daily.
25. The method according to claim 1, wherein the compound (or a pharmaceutically acceptable salt and/or solvate thereof) is administered as an oral dosage form comprising: (i) the compound (or a pharmaceutically acceptable salt and/or solvate thereof), and (ii) pharmaceutically acceptable excipients.
26. The method according to claim 25, wherein the oral dosage form is a tablet comprising microcrystalline cellulose as a diluent, croscarmellose sodium as a disintegrant, polyvinyl pyrrolidone as a binder, and optionally magnesium stearate as a lubricant.
27. The method according to claim 1, wherein the compound (or a pharmaceutically acceptable salt and/or solvate thereof) (i) inhibits plasma kallikrein, (ii) reduces cleavage of plasma prekallikrein, and/or (iii) reduces the generation of Factor XIIa from Factor XII.
28. The method according to claim 27, wherein the patient is administered a dose of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) such that the patient's plasma has a concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) of at least 500 ng/mL.
29. The method according to claim 28, wherein the patient is administered at least 60 mg of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof).
30. The method according to claim 1, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) blocks contact system activation for up to six hours.
31. The method according to claim 1, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is administered at a daily dosage amount of between 5 mg and 2000 mg.
32. The method according to claim 1, wherein the compound of Formula A is administered at a daily dosage amount of between 100 mg and 1500 mg, between 300 mg to 1800 mg, between 100 mg and 1400 mg per day, between 200 mg and 1200 mg, between 300 mg and 1200 mg, between 600 mg and 1200 mg, between 450 mg and 900 mg, between 500 mg and 1000 mg, between 450 mg and 600 mg, between 500 mg and 700 mg, between 800 mg and 1000 mg per day, between 900 mg and 1400 mg, or between 900 mg and 1200 mg.
33. The method according to claim 1, wherein the patient is administered the daily dosage amount in two dosage amounts within a 24 hour period starting from the time of taking the first dosage amount.
34. The method according to claim 33, wherein the two dosage amounts are administered simultaneously, separately or sequentially.
35. The method according to claim 33, wherein the second dosage amount is administered between 2 and 6 hours of the first, preferably between about 3 and 6 hours of the first dosage amount.
36. The method according to claim 33, wherein the second dosage amount can be administered at least about 6 hours after the first dosage amount.
37. The method according to claim 1, wherein the patient is administered the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) as three dosage amounts per day.
38. The method according to claim 37, wherein the three dosage amounts are administered simultaneously, separately or sequentially.
39. The method according to claim 37, wherein the second and third dosage amounts can be administered at least about 6 hours after the preceding dosage amount.
40. The method according to claim 30, wherein each dosage amount comprises about 600 mg of the compound of formula A.
41. The method according to claim 40, wherein each dosage amount is administered as two tablets each comprising about 300 mg of the compound of formula A.
42. The method according to claim 1, wherein the bradykinin-mediated angioedema non-hereditary (BK-AEnH) is not caused by an inherited genetic dysfunction, fault, or mutation.
43. The method according to claim 42, wherein the BK-AEnH is selected from: non-hereditary angioedema with normal C1 Inhibitor (AE-nC1 Inh), which can be environmental, hormonal, or drug-induced; acquired angioedema; anaphylaxis associated angioedema; angiotensin converting enzyme (ACE) inhibitor-induced angioedema; dipeptidyl peptidase-4 inhibitor-induced angioedema; and tPA-induced angioedema (tissue plasminogen activator-induced angioedema).
44. The method according to claim 42, wherein, the AE-nC1 Inh is environmentally-induced by air pollution and/or silver nanoparticles.
45. The method according to claim 13, wherein the BK-AEnH is tPA-induced angioedema, wherein the patient is also being administered a tissue plasminogen activator, wherein the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) is administered prior to, during, or after administration of the tissue plasminogen activator to the patient.
Description
FIGURES
[0122] In the Figures, the term “Compound” means the compound of Formula A.
[0123]
[0124]
[0125]
[0126]
[0127]
[0128]
[0129]
[0130]
[0131]
[0132]
[0133]
[0134]
[0135]
[0136]
[0137]
[0138]
[0139]
[0140]
[0141]
[0142]
[0143]
[0144]
[0145] Embodiments provided herein may be more fully understood by reference to the following examples. These examples are meant to be illustrative of treatments provided herein, but are not in any way limiting. Indeed, the scope of the invention is defined by the claims.
[0146] While examples of certain particular embodiments are provided herein, it will be apparent to those skilled in the art that various changes and modifications may be made. Such modifications are also intended to fall within the scope of the appended claims.
GENERAL EXPERIMENTAL DETAILS
[0147] In the following examples, the following abbreviations and definitions are used:
TABLE-US-00001 Aq Aqueous solution DCM Dichloromethane DMF N,N-Dimethylformamide DMSO Dimethyl sulfoxide DXS Dextran sulfate EtOAc Ethyl Acetate FXII Factor XII FXIIa Factor XIIa HK High molecular weight kininogen Hrs Hours HOBt Hydroxybenzotriazole IPA 2-Propanol/Propan-2-ol/Iso-propanol LCMS Liquid chromatography mass spectrometry Me Methyl MeCN Acetonitrile MeOH Methanol Min Minutes MS Mass spectrum NMR Nuclear magnetic resonance spectrum - NMR spectra were recorded at a frequency of 400 MHz unless otherwise indicated Pet. Ether Petroleum ether fraction boiling at 60-80° C. Ph Phenyl PKa Plasma kallikrein PPK Plasma prekallikrein SWFI Sterile water for injection Rt room temperature THF Tetrahydrofuran XRPD X-ray powder diffraction
[0148] All reactions were carried out under an atmosphere of nitrogen unless specified otherwise.
[0149] .sup.1H NMR spectra were recorded on a Bruker (400 MHz) or on a JEOL (400 MHz) spectrometer with reference to deuterium solvent and at rt.
[0150] Molecular ions were obtained using LCMS which was carried out using a Chromolith Speedrod RP-18e column, 50×4.6 mm, with a linear gradient 10% to 90% 0.1% HCO.sub.2H/MeCN into 0.1% HCO.sub.2H/H.sub.2O over 13 min, flow rate 1.5 mL/min, or using Agilent, X-Select, acidic, 5-95% MeCN/water over 4 min. Data was collected using a Thermofinnigan Surveyor MSQ mass spectrometer with electospray ionisation in conjunction with a Thermofinnigan Surveyor LC system.
[0151] Alternatively, molecular ions were obtained using LCMS which was carried out using an Agilent Poroshell 120 EC-C18 (2.7 μm, 3.0×50 mm) column with 0.1% v/v Formic acid in water [eluent A]; MeCN [eluent B]; Flow rate 0.8 mL/min and 1.5 minutes equilibration time between samples, gradient shown below. Mass detection was afforded with API 2000 mass spectrometer (electrospray).
[0152] Gradient:
TABLE-US-00002 Time (min) Eluent A (%) Eluent B (%) 0.00 95 5 0.20 95 5 2.00 5 95 3.00 5 95 3.25 95 5 3.50 95 5
[0153] Where products were purified by flash chromatography, ‘silica’ refers to silica gel for chromatography, 0.035 to 0.070 mm (220 to 440 mesh) (e.g. Merck silica gel 60), and an applied pressure of nitrogen up to 10 p.s.i accelerated column elution. Reverse phase preparative HPLC purifications were carried out using a Waters 2525 binary gradient pumping system at flow rates of typically 20 mL/min using a Waters 2996 photodiode array detector.
[0154] All solvents and commercial reagents were used as received.
[0155] Chemical names were generated using automated software such as the Autonom software provided as part of the ISIS Draw package from MDL Information Systems or the Chemaxon software provided as a component of MarvinSketch or as a component of the IDBS E-WorkBook.
[0156] X-Ray Powder Diffraction patterns were collected on a Philips X-Pert MPD diffractometer and analysed using the following experimental conditions (Method A), unless otherwise specified:
[0157] Tube anode: Cu
[0158] Generator tension: 40 kV
[0159] Tube current: 40 mA
[0160] Wavelength alpha1: 1.5406 Å
[0161] Wavelength alpha2: 1.5444 Å
[0162] Start angle [2θ]: 4
[0163] End angle [2θ]: 40
[0164] Continuous scan
[0165] Approximately 2 mg of sample under analysis was gently compressed on the XRPD zero back ground single obliquely cut silica sample holder. The sample was then loaded into the diffractometer for analysis.
Example 1—Preparation of the Compound of Formula A
A. 1-(4-Hydroxymethyl-benzyl)-1H-pyridin-2-one
[0166] 4-(Chloromethyl)benzylalcohol (5.0 g, 31.94 mmol) was dissolved in acetone (150 mL). 2-hydroxypyridine (3.64 g, 38.3 mmol) and potassium carbonate (13.24 g, 95.78 mmol) were added and the reaction mixture was stirred at 50° C. for 3 hrs after which time the solvent was removed in vacuo and the residue taken up in chloroform (100 mL). This solution was washed with water (30 mL), brine (30 mL), dried (Na.sub.2SO.sub.4) and evaporated in vacuo. The residue was purified by flash chromatography (silica), eluent 3% MeOH/97% CHCl.sub.3, to give a white solid identified as 1-(4-hydroxymethyl-benzyl)-1H-pyridin-2-one (5.30 g, 24.62 mmol, 77% yield).
[0167] [M+Na].sup.+=238
B. 1-(4-Chloromethyl-benzyl)-1H-pyridin-2-one
[0168] 1-(4-Hydroxymethyl-benzyl)-1H-pyridin-2-one (8.45 g, 39.3 mmol), dry DCM (80 mL) and triethylamine (7.66 ml, 55.0 mmol) were cooled in an ice bath. Methanesulfonyl chloride (3.95 ml, 51.0 mmol) was added and stirred in ice bath for 15 min. The ice bath was removed and stirring continued at rt temperature overnight. The reaction mixture was partitioned between DCM (100 mL) and saturated aqueous NH.sub.4Cl solution (100 mL). The aqueous layer was extracted with further DCM (2×50 mL) and the combined organics washed with brine (50 mL), dried over Na.sub.2SO.sub.4, filtered and concentrated to give 1-(4-chloromethyl-benzyl)-1H-pyridin-2-one (8.65 g, 36.6 mmol, 93% yield) as a pale yellow solid.
[0169] [MH].sup.+=234.1
C. Methyl 3-(methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylate
[0170] Potassium carbonate (519 mg, 3.76 mmol) was added to a solution of methyl 3-(methoxymethyl)-1H-pyrazole-4-carboxylate (320 mg, 1.88 mmol; CAS no. 318496-66-1 (synthesised according to the method described in WO 2012/009009)) and 1-(4-(chloromethyl)benzyl)pyridin-2(1H)-one (527 mg, 2.26 mmol) in DMF (5 mL) and heated at 60° C. overnight. The reaction mixture was diluted with EtOAc (50 mL) and washed with brine (2×100 mL), dried over magnesium sulfate, filtered and reduced in vacuo. The crude product was purified by flash chromatography (40 g column, 0-100% EtOAc in isohexanes) to afford two regioisomers. The second isomer off the column was collected to afford methyl 3-(methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylate (378 mg, 1.01 mmol, 53.7% yield) as a colourless gum.
[0171] [MH].sup.+=368.2
D. 3-(Methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylic acid
[0172] To methyl 3-(methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylate (3.77 g, 10.26 mmol) in THF (5 mL) and MeOH (5 mL) was added 2M NaOH solution (15.39 ml, 30.8 mmol) and stirred at rt overnight. 1M HCl (50 mL) was added and extracted with EtOAc (50 mL). The organic layer was washed with brine (50 mL), dried over magnesium sulfate, filtered and reduced in vacuo to give 3-methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylic acid (1.22 g, 3.45 mmol, 33.6% yield) as a white powder.
[0173] [MH].sup.+=354.2
E. 3-Fluoro-4-methoxy-pyridine-2-carbonitrile
[0174] To a large microwave vial, copper (I) cyanide (1.304 g, 14.56 mmol) was added to a solution of 2-bromo-3-fluoro-4-methoxypyridine (1 g, 4.85 mmol) in DMF (5 mL). The reaction vial was sealed and heated to 100° C. for 16 hrs. The reaction mixture was diluted with water (20 mL) and EtOAc (20 mL). The thick suspension was sonicated and required additional water (40 mL) and EtOAc (2×50 mL) with sonication to break-up the solid precipitated. The combined layers were filtered through a plug of celite and the organic layer isolated, washed with brine (50 mL), dried over magnesium sulfate, filtered and the solvent removed under reduced pressure to give a pale green solid identified as the desired compound 3-fluoro-4-methoxy-pyridine-2-carbonitrile (100 mg, 0.578 mmol, 12% yield)
F. (3-Fluoro-4-methoxy-pyridin-2-ylmethyl)-carbamic Acid Tert-Butyl Ester
[0175] 3-Fluoro-4-methoxy-pyridine-2-carbonitrile (100 mg, 0.578 mmol) was dissolved in anhydrous methanol (10 mL, 247 mmol) and nickel chloride hexahydrate (14 mg, 0.058 mmol) was added followed by di-tert-butyl dicarbonate (255 mg, 1.157 mmol). The resulting pale green solution was cooled in an ice-salt bath to −5° C. and then sodium borohydride (153 mg, 4.05 mmol) was added portionwise maintaining the reaction temperature ˜0° C. The deep brown solution was left to stir at 0° C. and slowly allowed to warm to rt and then left to stir at rt for 3 hrs. The reaction mixture was evaporated to dryness at 40° C. to afford a black residue which was diluted with DCM (10 mL) and washed with sodium hydrogen carbonate (10 mL). An emulsion formed so the organics were separated via a phase separating cartridge and concentrated. The crude liquid was purified by chromatography eluting with EtOAc/iso-Hexane to afford the title compound, (3-fluoro-4-methoxy-pyridin-2-ylmethyl)-carbamic acid tert-butyl ester as a clear yellow oil (108 mg, 62% yield)
[0176] [MH].sup.+=257
G. C-(3-Fluoro-4-methoxy-pyridin-2-yl)-methylamine Hydrochloride Salt
[0177] (3-Fluoro-4-methoxy-pyridin-2-ylmethyl)-carbamic acid tert-butyl ester (108 mg, 0.358 mmol) was taken up in iso-propyl alcohol (1 mL) and then HCl (6N in iso-propyl alcohol) (1 mL, 0.578 mmol) was added at rt and left to stir at 40° C. for 2 hrs. The reaction mixture was concentrated under reduced pressure and then triturated with ether, sonicated and then decanted to give a cream coloured solid (75 mg, 55% yield) identified as C-(3-fluoro-4-methoxy-pyridin-2-yl)-methylamine hydrochloride salt.
[0178] [MH].sup.+=157
Example 1a—N-[(3-Fluoro-4-methoxypyridin-2-yl)methyl]-3-(methoxymethyl)-1-({4-[(2-oxopyridin-1-yl)methyl]phenyl}methyl)pyrazole-4-carboxamide (Compound of Formula A)
[0179] 3-(Methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylic acid (825 mg, 2.34 mmol) and C-(3-fluoro-4-methoxy-pyridin-2-yl)-methylamine hydrochloride salt (450 mg, 2.34 mmol) were dissolved in DCM while cooling to 0° C. 1-Ethyl-3-(3-dimethylaminopropyl)carbodiimide hydrochloride (627.0 mg, 3.27 mmol), HOBt (378.8 mg, 2.80 mmol) and triethylamine (1.63 mL, 1182 mmol) were added while stirring, the mixture allowed to warm to rt and stirring continued for 20 hrs. Chloroform (50 mL) was added, the mixture was washed with saturated NaHCO.sub.3(aq) and reduced in vacuo. The crude material was purified by chromatography eluting with methanol/DCM. The solvent was removed in vacuo and the resulting solid triturated with diethyl ether. The resulting solids were collected by filtration to afford the compound of Formula A.
[0180] [MH].sup.+=492.0
[0181] NMR (CD.sub.3OD) 67 : 3.41 (3H, s), 4.03 (3H, s), 4.65 (2H, s), 4.72 (2H, d,J=2.3 Hz) 5.24 (2H, s), 5,37 (2H, s), 6.44 (1H, td, J=1,4, 6.8 Hz), 6.62 (1H, d, J=9.0 Hz), 7.18-7.22 (1H, m), 7.31-7.38 (4H, m), 7.56-7.60 (1H, m), 7.75 (1H, dd, J=1.9, 7.1 Hz), 8.18 (1H, s), 8.27 (1H, d, J=5.6 Hz) ppm.
[0182] An XRPD diffractogram of the compound of Formula A resultant from the above procedure is shown in
[0183] Peak position table:
TABLE-US-00003 No. Pos. [°2Th.] Rel. Int. [%] 1 4.436 32.36 2 5.0471 58.74 3 10.2255 43.07 4 11.2061 48.44 5 12.0101 16.4 6 12.5494 37.17 7 13.165 67.26 8 14.4984 38.94 9 15.8919 23.54 10 16.2983 34.56 11 17.4492 36.63 12 17.8564 71.49 13 18.6888 21.9 14 20.285 26.12 15 21.1598 100 16 22.04 87.76 17 22.5857 36.38 18 23.4408 14.33 19 24.3045 31.11 20 25.1655 78.97 21 25.3728 93.91 22 26.4946 56.79 23 27.991 76.91 24 28.7495 22.99 25 30.7611 13.4 26 32.413 17.2 27 37.2144 14.13 28 38.1171 14.14
Example 2—Preparation of a Dosage Form Comprising the Compound of Formula A
Blending and Roller Compaction
[0184] Equipment: Freund Vector TFC Lab Micro Roller Compactor and Granulator (the roller compactor and granulator are separate entities). The equipment parameters are below:
TABLE-US-00004 Parameter Range Used Screw Speed (rpm) 10.0-20.0 Roll Speed (rpm) 1.0-2.0 Roll Force (kN) 0.50-12.00 Granulator Screen Size (mm) 1
Method
[0185] Two tablet formulations (Tablets A and B) were prepared according to the following method at 30 g blend scale to produce tablets having components in the amounts shown below.
TABLE-US-00005 wt % (compared to the total mass of the tablet) Component Tablet A Tablet B Intragranular The compound of 42.5 47.5 Formula A Microcrystalline 34.5 29.5 Cellulose (Avicel PH101) Croscarmellose 4 4 Sodium (Ac-di-sol) Polyvinyl Pyrrolidone 3 3 (Kollidon 30) Extragranular Microcrystalline 15 15 Cellulose (Avicel PH102) Magnesium Stearate 1 1
[0186] For each of the tablets, blends were prepared by passing the intragranular components through a 355 μm sieve at a suitable scale for the scope of the roller compactor in a glass vessel using a Turbula Blender at 34 rpm. The blend was then run through the roller compactor using the parameters described above. The ribbons produced were collected into a suitably sized container. The collected ribbons were then subjected to the granulator fixed with a 1 mm screen and the resultant granules were collected for further downstream processing.
Tabletting
[0187] Equipment: RIVA Mini single station Tablet Press. The equipment parameters are shown below:
TABLE-US-00006 Parameter Range Used Tooling Diameter 8 mm round Force (kN) 6-10 Fill Weight (mg) 178-300
[0188] The granules were subsequently blended with their extragranular excipients, respectively. The extragranular excipients were prepared by screening through a 355 μm sieve in a glass vessel using a Turbula Blender at 34 rpm. The target tablet weight was then dispensed and manually compressed into tablets. Tablet A was compressed at 7.2 to 8.8 kN compression force. Tablet B was compressed at 6.9 to 7.7 kN compression force.
[0189] The tablets were found to be robust. Tablets A and B were subsequently submitted for long-term stability testing.
[0190] The production of tablets per the method described above has been scaled to 180 g with a roller compaction time of approximately 60 minutes.
Example 3—Comparison of the Compound of Formula A with a C1 Inhibitor (C1-INH)
[0191] Aim: To identify the biochemical and biophysical properties of the compound of Formula A that contribute to its optimal efficacy in controlling the Kallikrein Kinin System in plasma. These properties are then compared to C1-INH.
Methods
[0192] Plasma kallikrein inhibitory activity in vitro was determined using standard published methods (see e.g. Johansen et al., Int. J. Tiss. Reac. 1986, 8, 185; Shori et al., Biochem. Pharmacol., 1992, 43, 1209; Stürzebecher et al., Biol. Chem. Hoppe-Seyler, 1992, 373, 1025). Human plasma kallikrein (Protogen) was incubated at 25° C. with the fluorogenic substrate H-DPro-Phe-Arg-AFC and various concentrations of the test compound. Residual enzyme activity (initial rate of reaction) was determined by measuring the change in optical absorbance at 410 nm and the IC.sub.50 value for the test compound was determined.
[0193] The rate of formation of the enzyme-inhibitor complex (K.sub.on) was determined using purified PKa rapidly mixed with a solution containing fluorogenic substrate and a concentration range of inhibitor. The time-dependent establishment of inhibition was then used to calculate the rate of formation of the enzyme-inhibitor complex for each concentration of inhibitor. The K.sub.on was calculated by plotting the rate of inhibition versus the inhibitor concentration. Data in Table 1 are presented in μM.sup.−1 sec.sup.−1.
[0194] Catalytic activity of PKa in dextran sulfate-activated (DXS, Sigma; 10 μg/ml) plasma (1:4 diluted or undiluted, VisuCon-F control plasma, Affinity Biologicals Inc) was determined by the time-dependent hydrolysis of fluorogenic substrate. For IC.sub.50 and efficacy determination, the compound of Formula A or C1-INH (Sigma Cat #E0518) were added either before (
[0195] DXS-activated cleavage of HK in undiluted plasma was performed in the absence or presence of 300 nM PKa inhibitor and quantified by SDS-PAGE gel electrophoresis, using 7.5% Criterion TGX Precast gels (Biorad). Transfer was made onto Immunobilon-FL PVDF membrane. Image analysis was done using the LICOR imaging system. Mouse monoclonal anti-HK antibody (MAB15692, R&D systems) was used for traditional immunoblotting. Data presented as % of HK remaining after 20 min incubation with DXS compared to HK levels in unactivated plasma (Table 1).
[0196] Plasma free fraction was determined using “Rapid Equilibrium Dialysis” system (Thermo Scientific), test compounds were prepared at 5 μM in neat human plasma and dialysed against phosphate buffer for 5 hrs at 37° C. Quantification of the compound partitioned in two chambers of the dialysis device was performed via LCMS/MS. Fraction of compound unbound to plasma proteins presented as % of total.
[0197] The ability of the compound to inhibit the enzyme activity of pre-activated plasma was assessed by addition of the compound after DXS stimulation. Aliquots of plasma (20 μL) were mixed with a 2.5 μL solution containing 1,300 mM fluorogenic substrate (H-DPro-Phe-Arg-AFC) and a 2.5 μL solution of dextran sulphate (DXS; 100 μg/mL) which acted as an activator of the plasma kallikrein-kinin pathway. Enzyme activity was immediately measured by monitoring the accumulation of fluorescence liberated from the substrate by substrate cleavage over 16 minutes. At 3.5 minutes post DXS addition 5 μl of inhibitors or water control are were added into each well. The compound was tested at concentrations of 300, 1000 and 3000 nM. C1-INH at a concentration of 3000 nM and vehicle controls were also included. Data are presented in
Results
[0198] As shown in
[0199] Table 1 showing the biochemical profile of the therapies tested in this example.
TABLE-US-00007 IC.sub.50 IC.sub.50 Plasma purified plasma K.sub.on Free HK enzyme enzyme (μM.sup.−1 Fraction protection nM nM sec.sup.−1) % % C1-INH 50 1700 0.04 Compound of 6 71 11 25 85 Formula A
[0200]
[0201]
[0202] Table 2 shows the potency and selectivity of the compound of Formula A against human isolated enzymes using literature methods as for the above-described in vitro plasma kallikrein assay.
TABLE-US-00008 The compound Ki (nM) Plasma Kallikrein 3.02 Selectivity vs PKa Fold Tissue Kallikrein (KLK1) >6000 Factor XIa >6000 Factor XIIa >6000 Thrombin >6000 Trypsin >6000
Example 4—Phase 1 Single Ascending Dose Study in Healthy Males and Food Effect of the Compound
[0203] Aim: To evaluate the pharmacodynamic (PD) effects of the compound of Formula A when orally administered using ex vivo whole plasma assays for plasma kallikrein catalytic activity and HK cleavage, in samples from a Phase 1 Single Ascending Dose Study in healthy adult males. Also, an aim was to investigate safety, tolerability and pharmacokinetic (PK) effects of the compound of Formula A when orally administered.
Methods
[0204] This study was a randomized, double-blind, placebo-controlled single ascending dose (SAD) and crossover studies for food effect and capsule/tablet formulations.
[0205] 64 healthy male participants (n=6 active, 2 placebo per cohort, 8 SAD cohorts) were administered single ascending doses of the compound of Formula A: 5, 10, 20, 40, 80, 160, 300 or 600 mg in a capsule.
[0206] 8 participants were administered 100 mg the compound of Formula A in a crossover study of the capsule and a tablet formulation.
[0207] 12 participants were administered 600 mg the compound of Formula A in a food effect crossover study.
[0208] Samples for pharmacokinetic (PK) and PD assessment were taken at repeated intervals over 48 hours.
[0209] Plasma samples used for PK assessment were analysed using a validated liquid chromatography tandem mass spectrometry (LC MS/MS) method.
[0210] PD measurements were determined in dextran sulfate (DXS) stimulated undiluted plasma using a fluorogenic enzyme assay and capillary based HK cleavage immunoassay.
[0211] Catalytic activity of PKa in DXS-stimulated (Sigma; 10 μg/mL) plasma samples from the compound of Formula A phase 1 study was determined by the time-dependent hydrolysis of fluorogenic substrate in all samples from all parts of the study.
[0212] The time until appearance of detectable amidolytic enzyme activity in DXS-stimulated plasma (lag time) was calculated from the catalytic activity assay. The detection sensitivity of the rate of catalytic activity in plasma based on using a Spark (Tecan) fluorimeter is a fluorescence increase to reach 1ΔF unit/sec.
[0213] DXS-stimulated cleavage of HK, in undiluted plasma was quantified by capillary-based immunoassay on the Wes System (ProteinSimple) using monoclonal anti-HK antibody and chemiluminescence-based detection. Plasma kallikrein mediated HK cleavage in undiluted citrated human plasma was induced by contact system activation with DXS (6.25 μg/ml) at 4° C. in selected samples from the SAD phase.
[0214] DXS-stimulated cleavage of plasma prekallikrein and Factor XII (FXII) were quantified by capillary-based immunoassay on the Wes System (ProteinSimple) analogously.
Results
[0215]
[0216]
[0217] The kinetic fluorescent measurements from the undiluted plasma enzyme assay can be plotted as assay progression curves (
[0218]
[0219] In
[0220] In
[0221] To assess whether the compound of Formula A also reduced the generation of plasma kallikrein and Factor XIIa, immunoassays were used to quantify levels of contact system proteins in DXS-activated plasma at pre-dose and up to 12 hrs post-dose of 600 mg orally administered in capsules. The results from these assays are shown in
[0222]
[0223] No serious adverse events were reported in the phase I trial. There were also no tolerability signals. No subjects withdrew from the trial.
[0224] These data demonstrate that the compound of Formula A has an inhibitory effect on the bradykinin and contact activation systems. As discussed above, these pharmacodynamic effects are implicated in disorders such as BK-AEnH. These data also show that the compound of Formula A has a pharmacokinetic profile suitable for oral administration.
Example 5—Immunoassays Investigating the Compound of Formula A in the Protection of High Molecular Weight Kininogen (HK) from PKa-Mediated Cleavage in HAE and Control Plasma
Method
[0225] High molecular weight kininogen (HK) cleavage in undiluted citrated human plasma was induced by contact system activation with dextran sulfate (DXS, Sigma #31395-10G; 6.25 μg/ml) on wet ice. Pooled normal (CONTROL) human plasma (VisuCon-F Frozen Normal Control plasma) was purchased from Affinity Biologicals Inc. A working stock of 10 mM of the compound of formula A (“the compound”) in DMSO was prepared and diluted in 1X PBS to the respective final concentrations described. HAE plasma was obtained from HAE subjects (n=6) and C1-inhibitor deficiency was confirmed by western blotting. Protection of HK from PKa mediated cleavage in DXS-stimulated whole undiluted plasma was then determined by two methods; traditional western blotting and a semi-automated capillary-based immunoassay.
[0226] Western blotting: SDS-PAGE gel electrophoresis was done using 7.5% Criterion TGX Precast gels (Bio-rad). Transfer was made onto Immobilon-FL PVDF membrane. Image analysis was performed using the LICOR imaging system. Mouse monoclonal anti-human HK antibody (MAB15692, R&D systems) was used for traditional immunoblotting.
[0227] Capillary-based immunoassay on the WES System (ProteinSimple):
[0228] Preparation of samples: Combine one part 5× fluorescent master mix with four parts of the 1:200 plasma sample. Vortex to mix. Heat the samples+fluorescent master mix and the biotinylated ladder at 95° C. for 5 minutes, vortex, and load onto the WES plate. Monoclonal anti-human HK antibody was used for this chemiluminescence-based detection method using the Wes System (ProteinSimple).
[0229] Analysis: Collect the peak area measurement obtained in the Compass software (cbz file) for the full-length HK molecular weight of the respective time-point sample with DXS-induced activation. The peak area is defined as the area calculated for the spectral peak profile for HK. To measure the plasma kallikrein inhibition by the compound, the percent full-length HK detected was calculated.
Results
[0230]
[0231]
Example 6—Phase 2 Study of the Compound of Formula A
[0232] Aim: To evaluate the efficacy and safety of the compound of Formula A in the on-demand treatment of angioedema attacks in adult subjects with hereditary angioedema type I or II.
Methods
[0233] The study is a randomized, double-blind, placebo-controlled, phase 2, cross-over clinical trial evaluating the efficacy and safety of the compound of formula A (“the compound”), an oral plasma kallikrein inhibitor, in the on-demand treatment of angioedema attacks in adult subjects with hereditary angioedema type I or II (EudraCT number: 2018-004489-32).
Objectives
[0234] Primary Objective: [0235] To investigate the efficacy of the compound compared to placebo in halting the progression of a peripheral or abdominal attack of hereditary angioedema (HAE).
[0236] Secondary Objectives: [0237] To investigate the safety and tolerability of the compound. [0238] To investigate the pharmacokinetic (PK) profile of the compound when taken during the intercritical period between HAE attacks. [0239] To investigate the pharmacodynamic (PD) profile of the compound in reducing the concentration of residual cleaved high molecular weight kininogen (HK) during the intercritical period between HAE attacks. [0240] To investigate the PD profile of the compound in reducing activated plasma enzyme activity during the intercritical period between HAE attacks.
Setup
[0241] This is a phase 2, two-part, two-sequence, two-period (2×2) cross-over clinical trial. Subjects with HAE type I or II will be recruited through HAE treatment centres in Europe and US.
[0242] In Part 1, subjects will receive a single oral dose of 600 mg of the compound to investigate the safety, PK and PD of the compound during the intercritical period between HAE attacks.
[0243] Eligible adult subjects ≥18 years old will undergo a screening assessment for study inclusion, receive study drug, followed by a 4 h, in-clinic, safety and PK/PD assessment.
[0244] In Part 2, the subjects will be randomized 1:1 to 2 treatment sequences. This part of the study will be conducted away from the clinic or hospital. In Sequence 1 (study arm 1) subjects will receive a single dose of 600 mg of the compound to treat the first eligible HAE attack. Following resolution of this attack, subjects will receive a second single dose of placebo to treat the second eligible HAE attack.
[0245] In Sequence 2 (study arm 2) subjects will receive a single dose of placebo to treat the first eligible HAE attack. Following resolution of this attack, subjects will receive a second single dose of 600 mg of the compound to treat the second eligible HAE attack.
[0246] A minimum of 48-hour washout period is required between each dose of study drug.
[0247] Laryngeal or facial attacks are not eligible for treatment. HAE attacks must be treated within the first hour of onset and before reaching severe on the global attack severity scale. Subjects must also be able to identify the start of a HAE attack. Upon onset of the eligible HAE attack, subjects will notify the dedicated study physician or qualified designee with a description of the HAE attack. The dedicated study physician or qualified designee will confirm eligibility of the HAE attack and agree to study drug being administered. HAE attacks require documentation, on the Subject Diary, of attack location, attack symptoms, time of onset, attack severity, and time of last substantial meal prior to dosing. Subjects will take study drug, as instructed, and will complete timed assessments of their HAE attack symptoms for a 48 h period as documented below in Table 3. The dedicated study physician or qualified designee will contact the subject within 24 h of the eligible HAE attack to confirm the subject's safety and wellbeing. Subjects will be instructed to contact the dedicated study physician or qualified designee in case of any safety concerns. In the case of hypersensitivity, subjects are to contact the dedicated study physician or qualified designee or contact the nearest emergency service. The dedicated study physician or qualified designee will be available 24 h/day and 7 days/week to receive subject calls.
TABLE-US-00009 TABLE 3 Frequency of Subject Assessment Time Period Frequency Allowed Time following Study of Subject Window for Drug Administration Assessment* Assessment 0 h-4 h Every 30 min None 4 h-12 h Every 1 h +/−15 min 12 h-24 h Every 3 h +/−30 min 36 h Once +/−60 min 48 h Once +/−60 min *in the event that conventional attack treatment is used, the subject should perform assessments every 30 min for 4 h following first administration of conventional attack treatment. After this, the subject should revert back to original frequency of assessments based on time of study drug administration.
[0248] Subjects will return to the clinic following the first HAE attack, prior to the second HAE attack, to undergo safety checks including adverse event (AE) reporting, vital sign recording, and Subject Diary review.
[0249] Once two HAE attacks have been treated in Part 2, the subject will return to the clinic to undergo final safety checks including AE reporting, vital sign recording and blood sampling for laboratory safety measurements.
[0250] Conventional attack treatment is permitted after 4 h, or earlier as warranted, following study drug intake, provided HAE attack symptoms are judged severe enough by the subject to require treatment as per the subject's usual treatment regimen, or are deemed ineligible for study drug treatment, or are associated with laryngeal or facial symptoms. Prior to use of conventional attack treatment, subjects will notify the dedicated study physician or qualified designee who will confirm conventional treatment is appropriate per protocol and subject report of symptom severity. Subjects are permitted to treat their HAE attacks with their conventional attack treatment (pdC1INH or rhC1INH intravenous [iv] or icatibant).
Investigational Medicinal Product
[0251] The compound of formula A—100 mg film-coated tablet. These contain the following excipients: microcrystalline cellulose, croscarmellose sodium, povidone, magnesium stearate; the aesthetic coating contains hypromellose, lactose monohydrate, titanium dioxide and triacetin.
[0252] Placebo to the compound 100 mg film-coated tablet. These contain microcrystalline cellulose, colloidal silicon dioxide, sodium starch glycolate, and sodium stearyl fumarate and are film-coated; the aesthetic coating contains hypromellose, lactose monohydrate, titanium dioxide and triacetin.
[0253] No study drug dose modifications are allowed in this study.
Number of Subjects
[0254] Approximately 60 subjects will be enrolled into the study to ensure 50 subjects complete the study.
Population
[0255] The study population will include male and female subjects 18 years of age or older with HAE type I or II.
[0256] Inclusion Criteria: [0257] 1. Male or female adult subjects 18 years of age and older. [0258] 2. Confirmed diagnosis of HAE type I or II at anytime in the medical history: [0259] a. Documented clinical history consistent with HAE (subcutaneous or mucosal, nonpruritic swelling episodes without accompanying urticaria) AND [0260] b. C1-esterase inhibitor (C1-INH) antigen or functional level <40% of the normal level. Subjects with antigen or functional C1-INH level 40-50% of the normal level may be enrolled if they also have a C4 level below the normal range and a family history consistent with HAE type I or II. [0261] 3. At least 3 documented HAE attacks in the past 93 days, as supported by medical history. [0262] 4. Access to and ability to use conventional attack treatment for attacks of HAE. [0263] 5. Adequate organ functions as defined below: [0264] a. Hemoglobin within normal range; [0265] b. International normalized ratio (INR)<1.2; [0266] c. Activated partial thromboplastin time (aPTT) ≤upper limit of normal (ULN); [0267] d. Creatinine<1× ULN; [0268] e. Creatinine clearance (CrCl)≥60 mL/min; [0269] f. Alanine aminotransferase (ALT)≤2× ULN; [0270] g. Aspartate aminotransferase (AST)≤2× ULN; [0271] h. Total bilirubin≤1.5× ULN; [0272] i. Leucocytes≤1.5× ULN; [0273] j. Thrombocytes≤1.5× ULN. [0274] 6. Female of childbearing potential must agree to use highly effective birth control from the Screening visit until the end of the trial follow-up procedures. Highly effective methods of birth control include: [0275] a. Progestogen-only hormonal contraception associated with inhibition of ovulation: oral/injectable/implantable. [0276] (Hormonal contraception that contains estrogen is excluded per exclusion criterion 3). [0277] b. Intrauterine device (IUD). [0278] c. Intrauterine hormone-releasing system (IUS). [0279] d. Bilateral tubal occlusion. [0280] e. Vasectomised partner (provided that the partner is the sole sexual partner of the female subject of childbearing potential and that the vasectomised partner has received medical assessment of the surgical success). [0281] f. Sexual abstinence (this method is not acceptable in Switzerland). [0282] Note: Sexual abstinence will only be considered a highly effective method if it is defined as refraining from heterosexual intercourse. The reliability of sexual abstinence needs to be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the subject. [0283] 7. Females of non-childbearing potential, defined as surgically sterile (status post hysterectomy, bilateral oophorectomy, or bilateral tubal ligation) or post-menopausal for at least 12 months, do not require contraception during the study. [0284] 8. Males with female partners of childbearing potential must agree to be abstinent or else use a highly effective method of birth control as defined in inclusion criterion 6 from the Screening visit until the end of the trial follow-up procedures. [0285] 9. Provide signed informed consent and are willing and capable of complying with study requirements and procedures.
[0286] Exclusion criteria: [0287] 1. Any concomitant diagnosis of another form of chronic angioedema, such as acquired C1 inhibitor deficiency, HAE with normal C1-INH (also known as HAE type III), idiopathic angioedema, or angioedema associated with urticaria. [0288] 2. Current use of C1INH, androgens, lanadelumab or tranexamic acid for HAE prophylaxis. [0289] 3. Use of angiotensin-converting enzyme (ACE) inhibitors or any estrogen-containing medications with systemic absorption (such as oral contraceptives or hormonal replacement therapy) within 93 days prior to initial study treatment. [0290] 4. Use of androgens (e.g. stanozolol, danazol, oxandrolone, methyltestosterones, testosterone) or antifibrinolytics within 30 days prior to initial study treatment. [0291] 5. Use of lanadelumab within 10 weeks prior to initial study treatment. [0292] 6. Use of strong CYP3A4/CYP2C9 inhibitors and inducers during participation in the trial. [0293] Note: These medications include but are not limited to the following: cobicistat, conivaptan, itraconazole, ketoconazole, posaconazole, voriconazole, ritonavir, boceprevir, telaprevir, troleandomycin, clarithromycin, carbamazepine, enzalutamide, mitotane, phenytoin, phenobarbital, fluconazole, isoniazid, metronidazole, paroxetine, sulfamethoxazole, rifampicin, St. John's Wort, diltiazem, idelalisib, nefazodone and nelfinavir. [0294] 7. Clinically significant abnormal electrocardiogram (ECG) at Visit 1 and pre-dose at Visit 2. This includes, but is not limited to, a QTcF>470 msec (for women) or >450 msec (for men), a PR>220 msec or ventricular and/or atrial premature contractions that are more frequent than occasional and/or occur as couplets or higher in grouping. [0295] 8. Any clinically significant history of angina, myocardial infarction, syncope, clinically significant cardiac arrhythmias, left ventricular hypertrophy, cardiomyopathy, or any other cardiovascular abnormality. [0296] 9. Any other systemic dysfunction (e.g., gastrointestinal, renal, respiratory, cardiovascular) or significant disease or disorder which, in the opinion of the Investigator, would jeopardize the safety of the subject by taking part in the trial. [0297] 10. History of substance abuse or dependence that would interefere with the completion of the study, as determined by the Investigator. [0298] 11. Known lactose allergy or intolerance. [0299] 12. Known hypersensitivity to the compound or placebo or to any of the excipients. [0300] 13. Participation in an interventional investigational clinical study within 93 days or within 5 half-lives of the last dosing of investigational drug (whichever is longer) prior to initial study treatment. [0301] 14. Any pregnant or breast-feeding subject.
Assessments
[0302] Part 1: Blood samples for PK and PD measurements will be collected at the following timepoints: Pre-dose (0 h), 15 min, 30 min, 45 min, 1 h, 1.5 h, 2 h, 3 h, and 4 h post-dose. Vital signs (systolic blood pressure [SBP], diastolic blood pressure [DBP], pulse rate [PR], respiratory rate [RR] and body temperature) will be measured at pre-dose (0 h), 1 h, and 4 h post-dose. Samples for post-treatment safety laboratory assessments will be taken with the 4 h PK/PD samples.
[0303] Part 2: Following study drug intake, subject assessments of overall HAE attack severity and change in HAE attack severity will take place for a 48 h period as documented in Table 3 above.
Efficacy Variables
[0304] Time to use of conventional attack treatment will be assessed. The subject diary will capture the efficacy endpoints including time to use of conventional attack treatment and HAE attack severity.
[0305] Overall HAE attack severity will be assessed on a 5-point Likert scale (5LS) scored as none, mild, moderate, severe and very severe.
[0306] Change in HAE attack severity will be assessed using a 7-point transition question (7TQ), scored as Much better/Better/A little better/No change/A little worse/Worse/Much worse.
[0307] The type of HAE attack symptoms (abdominal pain, skin pain and skin swelling) will each be assessed on a 100 mm visual analogue scale (VAS) anchored at 0 (none) and 100 (very severe).
[0308] Safety Variables: [0309] AEs, including serious adverse events (SAEs). [0310] Laboratory test results (clinical chemistry, hematology, coagulation, and urinalysis). [0311] Vital signs (SBP, DBP, PR, RR, body temperature). [0312] Physical examination findings. [0313] ECG results. [0314] Pregnancy test (female subjects of child-bearing potential).
Criteria for Evaluation of Efficacy
[0315] Primary Efficacy Endpoints: [0316] Time to use of conventional attack treatment.
[0317] Secondary Efficacy Endpoints: [0318] Proportion of HAE attacks that progress by one level or more on the 5LS or that require conventional attack treatment within 12 h of study drug. [0319] Time between treatment and (1) progression of global attack severity on the 5LS by one level or more, or (2) use of conventional attack treatment, whichever comes first within 12 h.
[0320] Exploratory Endpoints: [0321] Cumulative global attack severity on the 5LC following study drug expressed as area under the curve (AUC) for the compound 600 mg vs. placebo. [0322] Proportion of HAE attacks that require conventional attack treatment. [0323] Proportion of HAE attacks that are rated “worse” or “much worse” on the TQ. [0324] Proportion of HAE attacks that are rated “better” or “much better” on the TQ. [0325] Time from study drug administration to complete HAE attack resolution (rating of none) on global attack severity scale (5LS). [0326] Time to HAE attack being rated worse or much worse on the TQ. [0327] Time to HAE attack being rated better or much better on the TQ.
General Statistical Methods and Types of Analyses
[0328] Analysis Sets: [0329] Safety set (SAF): Subjects who have taken at least one dose of study drug (including the study drug dose in Part 1). [0330] Full analysis set (for efficacy) (FAS): All randomized subjects who received both doses of study drug in Part 2. [0331] Per protocol set (for efficacy) (PPS): Randomized subjects in Part 2. who received the compound both doses of study drug in Part 2 and have no major protocol deviations. [0332] PK/PD analysis set: All subjects for whom PK/PD samples were taken in Part 1.
Sample Size
[0333] A sample size of 50 subjects (25 per sequence) is proposed to provide 90% power for testing at the 5% alpha level (2-sided) for the primary endpoint of time to use of conventional attack treatment. This sample size has been derived based upon an assumption that 40% of subjects will use conventional attack treatment while on the control arm while 10% will use conventional attack treatment on the experimental arm and that within subject data has minimal correlation. The assumption of minimal correlation should be a conservative assumption with respect to sample size. Approximately 60 subjects will be enrolled to ensure that 50 subjects complete the study.
[0334] An oversampling by 20% (10 subjects) is proposed to account for subjects that may not complete both treatment periods due to infrequent or ineligible NAE attacks or for subjects who discontinue the trial early, for whatever reason. Thus, study enrolment will be considered sufficient to address the primary efficacy hypothesis after 50 subjects have completed both treatment periods. Since further exposure is not required and could be considered unnecessary, ongoing subjects who have not completed both periods will be asked to return to the study site and complete Visit 4 (Early Discontinuation visit). Data from all subjects, complete and incomplete, will be analyzed in the safety set.
General Considerations
[0335] Individual subject data will be presented in subject data listings. Appropriate descriptive statistics will be calculated for continuous and categorical data and summarized in tabular format.
Sample Analyses
[0336] AEs will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) dictionary (v21.0 or higher) and classified by preferred term and system organ class (SOC). Listings of treatment-emergent adverse events (TEAEs), serious TEAEs, and TEAEs causing premature discontinuation will be provided by sequence group, and further classified by TEAE severity and relationship to study drug.
Efficacy Analyses
Primary Endpoint
[0337] The primary endpoint, time to use of conventional attack treatment, will be analyzed using a generalization of Gehan's test proposed by Feingold and Gillespie (1996) (Crossover trials with censored data. Statistics in Medicine 1996; 15(10): 953-967) to reflect the repeat measures on each subject. Subjects will be treated as censored if no worsening occurs within 12 h of study drug.
Secondary Endpoints
[0338] The proportion of HAE attacks that worsen by one level or more on the 5LS or that require conventional attack treatment within 12 h of study drug will be analyzed using Prescott's test (1981) (The comparison of success rates in cross-over trials in the presence of an order effect. Applied Statistics 1981; 30: 9-15) to compare the treatment arms.
[0339] A similar approach to that used for the primary endpoint will be followed for the analysis of the time between study drug and HAE attack worsening by one level or more on the 5LS or use of conventional attack treatment, whichever comes first within 12 h. In addition to the tests described above, descriptive statistics will be presented for the primary, secondary and exploratory endpoints, in each case comparing the compound to placebo, such as: [0340] Cumulative global attack severity on the 5LS following study drug expressed as AUC for the compound 600 mg vs. placebo. [0341] Proportion of HAE attacks that require conventional attack treatment. [0342] Proportion of HAE attacks that are rated “worse” or “much worse” on the TQ. [0343] Proportion of HAE attacks that are rated “better” or “much better” on the TQ. [0344] Time from study drug administration to complete HAE attack resolution (rating of none) on global attack severity scale (5LS). [0345] Time to HAE attack being rated worse or much worse on the TQ. [0346] Time to HAE attack being rated better or much better on the TQ.
PK Analysis
[0347] Non-compartmental PK parameters will include maximum concentration in plasma (Cmax), time to reach Cmax in plasma (tmax), and area under the curve from time 0 to last sample (AUC0-t). Compartmental PK modelling will describe the PK of the compound and generate underlying Cmax, tmax, AUC, apparent clearance (CL/F), apparent volume of distribution (Vd/F) and estimated terminal elimination half-life (t½).
[0348] The PK parameters of the compound will be determined from the individual concentration versus time data using Phoenix WinNonlin. In case of a deviation from the theoretical time, the actual time of blood sample will be used in the calculation of the derived PK parameters. Individual concentrations and derived PK parameters of the compound in plasma will be listed and summarized for each treatment. Individual and geometric mean concentration-time data will be plotted on linear and semi-logarithmic scales.
PD Analysis
[0349] The compound's effect on plasma kallikrein (PKa) activity will be analyzed using two exploratory measures of PKa enzyme activity in plasma: [0350] An assay to determine inhibition of exogenously activated plasma kallikrein enzyme activity from plasma samples obtained before and after receiving the compound. [0351] An assay to measure the level of protection of cleavage of high molecular weight kininogen (HK) substrate (contained in whole plasma) from plasma kallikrein enzyme activity.
[0352] The PD will be summarized for each treatment. Individual and mean data will be provided as a report addendum located in the appendix of the final Clinical Study Report.
Preliminary PK Data from Part 1 of the Study
[0353] At the time of filing this application, preliminary PK data from 27 HAE patients have been collated and analysed, and are shown in Table 4 and
TABLE-US-00010 TABLE 4 Cmax (ng/mL) Mean (95% CI) Dose n = 27 600 mg 5907 (4913, 6901)
[0354] Thus, these preliminary results show that the compound of Formula A demonstrates a pharmacokinetic profile that is suitable for on-demand oral administration in HAE patients. The study is ongoing at the time of filing.
Example 7—Phase 1 Multiple Dose Study in Healthy Adult Subjects
[0355] Aim: To evaluate the safety, tolerability, pharmacokinetics, and the change from baseline in QTc following administration of the compound formulated as 100 mg film coated tablets in healthy adult subjects.
[0356] Primary Objective: [0357] To investigate the safety and tolerability of multiple doses of the compound.
[0358] Secondary Objectives: [0359] To investigate the pharmacokinetics (PK) of multiple doses of the compound. [0360] To evaluate the effects of the compound on ECG parameters, including concentration-QTc relationship, following administration of the compound 100 mg Film Coated Tablets (KalVista Pharmaceuticals) to healthy adult subjects.
[0361] Exploratory Objectives: [0362] To investigate the pharmacodynamics (PD) of multiple doses of the compound.
Methods
[0363] This is a phase 1, double-blind, placebo-controlled, multiple-dose, multiple-cohort study to evaluate safety and tolerability of the compound as well as of the ECG effects of the compound formulated as 100 mg Film Coated Tablets in healthy adult male and female subjects.
[0364] Four (4) cohorts are planned for evaluation. Cohorts 1, 2 and 3 will include 8 subjects each. Cohort 4 will include 18 subjects. Every attempt will be made to include an equal number of male and female subjects in each cohort.
[0365] During the study, oral doses of 600 mg of the compound as Film Coated Tablets (six 100 mg tablets) or 6 matching placebo tablets will be administered once every 8 hours (Cohort 1) every 4 hours (Cohort 2), or every 2 hours (Cohort 3 and 4) to healthy adult male and female subjects up to a total dose of 1800 mg. In Cohorts 1, 2 and 3, 6 subjects will receive the compound as 100 mg Film Coated Tablets and 2 subjects will receive the placebo for a total of 8 subjects per cohort. In Cohort 4, 12 subjects will receive the compound as 100 mg Film Coated Tablets and 6 subjects will receive the placebo for a total of 18 subjects.
[0366] Progression from Cohort 1 to Cohort 2 and Cohort 2 to Cohort 3 will occur after review of the safety data (labs, vital signs, safety ECGs, and adverse events) captured during the conduct of Cohort 1 and Cohort 2. Progression to Cohort 4 will occur after review of the safety data and pharmacokinetic data from Cohort 3. The pharmacokinetic data from Cohort 3 will be reviewed to ensure that the Cmax of the 3rd dose is high enough to support the evaluation of the change in the Cgic interval from baseline.
[0367] A Holter monitor will be attached to each subject in order to continuously record ECGs. The monitor will be attached 1 hour before the first dose and will remain attached until after the final blood sample collection. The electrodes for the Holter monitor will be checked by a member of the clinic staff at appropriate intervals to ensure they are attached.
[0368] Blood samples will be collected at pre-dose, at intervals after the first dose, and at intervals over 24 hours after the final (third) dose (40 hours from the initial dose in Cohort 1, 32 hours from the initial dose in Cohort 2, 28 hours from the initial dose in Cohorts 3 and 4) in each cohort. Subjects will be confined to the clinical facility from at least 10 hours before dosing until after the final blood sample collection in each study cohort and will return to the clinic 5 to 7 days after the final dose for safety evaluations.
[0369] The pharmacokinetics of the compound will be measured by a fully validated analytical procedure and the pharmacodynamic effect on plasma kallikrein inhibition enzyme activity will be evaluated by an exploratory pharmacodynamic assessment.
[0370] Statistical analysis will be performed to evaluate the relationship between plasma drug concentrations and the change from baseline in ECG effects of the test formulation.
Treatment Administration
Cohort 1
[0371] The subjects will receive the test or placebo treatment every 8 hours over a 16-hour period (3 administrations of: 6×100 mg of the compound as 100 mg Film Coated Tablets or placebo dose administrations at 0, 8, and 16 hours, total dose of 1800 mg of the compound or placebo) according to a two-treatment randomization schedule under direct observation. Each dose will be administered with 240 mL of room temperature water. Subjects will be instructed to swallow the tablets whole without chewing or biting. Any subject who bites or chews the tablets will be dropped from the study. Immediately after dosing a mouth check will be performed
Cohort 2
[0372] The subjects will receive the test or placebo treatment every 4 hours over an 8-hour period (3 administrations of: 6×100 mg of the compound as 100 mg Film Coated Tablets or placebo dose administrations at 0, 4, and 8 hours, total dose of 1800 mg of the compound or placebo) according to a two-treatment randomization schedule under direct observation. Each dose will be administered with 240 mL of room temperature water. Subjects will be instructed to swallow the tablets whole without chewing or biting. Any subject who bites or chews the tablets will be dropped from the study. Immediately after dosing a mouth check will be performed to ensure that the tablets were swallowed whole without chewing or biting.
Cohort 3 and 4
[0373] The subjects will receive the test or placebo treatment every 2 hours over a 4- hour period (3 administrations of: 6×100 mg of the compound as 100 mg Film Coated Tablets or placebo dose administrations at 0, 2, and 4 hours, total dose of 1800 mg of the compound or placebo) according to a two-treatment randomization schedule under direct observation. Each dose will be administered with 240 mL of room temperature water. Subjects will be instructed to swallow the tablets whole without chewing or biting. Any subject who bites or chews the tablets will be dropped from the study. Immediately after dosing a mouth check will be performed to ensure that the tablets were swallowed whole without chewing or biting.
[0374] All subjects will fast (except water) for at least 8 hours before the first dosing. After initial dosing, subjects will continue to fast until at least 6 hours after the first dose.
Method of Assigning Subjects to Treatment Groups
Cohort 1, 2 and 3
[0375] Subjects will be randomized such that 6 subjects will receive the test product and 2 subjects will receive the placebo. As a safety measure, a sentinel dosing scheme will be incorporated for each cohort, in which one subject will receive the test product and one subject will receive the placebo product followed by the remainder of the cohort.
Cohort 4
[0376] Subjects will be randomized such that 12 subjects receive the test product and 6 subjects receive the placebo.
[0377] The randomization schedule will be generated prior to the first dosing cohort using SAS®, Version 9.4 or higher.
Results
[0378] No serious adverse events were reported during the study and no subjects were discontinued because of an AE. All reported adverse events were considered “mild” in severity and had an outcome of “recovered/resolved” at the end of the study.
[0379] No clinically relevant effects on the studied ECG parameters were identified.
[0380]
[0381]
[0382] These data demonstrate that the compound of Formula A has a pharmacokinetic profile suitable for oral administration when administered in multiple dosage amounts. The results further suggest that the compound of Formula A can be dosed safely at regular intervals.