Treatment of HCV infected patients with cirrhosis
11690860 · 2023-07-04
Assignee
Inventors
- Jean-Pierre Sommadossi (Boston, MA)
- Adel Moussa (Burlington, MA)
- Keith M. Pietropaolo (Boxford, MA, US)
- Xiao-Jian Zhou (Arlington, MA, US)
Cpc classification
A61K31/708
HUMAN NECESSITIES
A61K31/7076
HUMAN NECESSITIES
International classification
Abstract
A pharmaceutical composition that includes a compound of the structure: ##STR00001##
to treat an HCV infected patient with cirrhosis, and uses thereof.
Claims
1. A method to treat a hepatitis C-infected human with decompensated cirrhosis comprising providing an effective amount of a compound of the formula ##STR00009## optionally in a pharmaceutically acceptable carrier.
2. The method of claim 1, wherein the compound is administered orally.
3. The method of claim 1, wherein the compound is administered parentally.
4. The method of claim 1, wherein the compound is administered intravenously.
5. The method of claim 1, wherein the compound is administered via controlled release.
6. The method of claim 1, wherein at least 400 mg of the compound is administered.
7. The method of claim 1, wherein at least 500 mg of the compound is administered.
8. The method of claim 1, wherein at least 600 mg of the compound is administered.
9. The method of claim 1, wherein at least 700 mg of the compound is administered.
10. The method of claim 1, wherein the compound is administered for up to 12 weeks, for up to 8 weeks, or for up to 6 weeks.
11. The method of claim 1, wherein the compound is administered once a day.
12. The method of claim 1, wherein the compound is administered twice a day.
13. The method of claim 1, wherein the hepatitis C virus is Genotype 1a, 1b, 2a, 2b, 3a, 3b, 4a, 4d, 5a, or 6.
14. The method of claim 13, wherein the hepatitis C virus is Genotype 1a.
15. The method of claim 13, wherein the hepatitis C virus is Genotype 1b.
16. The method of claim 13, wherein the hepatitis C virus is Genotype 2a or 2b.
17. The method of claim 13, wherein the hepatitis C virus is Genotype 3a or 3b.
18. The method of claim 13, wherein the hepatitis C virus is Genotype 4a or 4d.
19. The method of claim 13, wherein the hepatitis C virus is Genotype 5a.
20. The method of claim 1, wherein the compound is of the formula: ##STR00010##
21. The method of claim 20, wherein the compound is administered orally.
22. The method of claim 20, wherein the compound is administered parentally.
23. The method of claim 20, wherein the compound is administered intravenously.
24. The method of claim 20, wherein the compound is administered via controlled release.
25. The method of claim 20, wherein at least 400 mg of the compound is administered.
26. The method of claim 20, wherein at least 500 mg of the compound is administered.
27. The method of claim 20, wherein at least 600 mg of the compound is administered.
28. The method of claim 20, wherein the compound is administered for up to 12 weeks, for up to 8 weeks, or for up to 6 weeks.
29. The method of claim 20, wherein the compound is administered once a day.
30. The method of claim 20, wherein the compound is administered twice a day.
31. The method of claim 20, wherein the hepatitis C virus is Genotype 1a, 1b, 2a, 2b, 3a, 3b, 4a, 4d, 5a, or 6.
32. The method of claim 31, wherein the hepatitis C virus is Genotype 1a.
33. The method of claim 31, wherein the hepatitis C virus is Genotype 1b.
34. The method of claim 31, wherein the hepatitis C virus is Genotype 2a or 2b.
35. The method of claim 31, wherein the hepatitis C virus is Genotype 3a or 3b.
36. The method of claim 31, wherein the hepatitis C virus is Genotype 4a or 4d.
37. The method of claim 31, wherein the hepatitis C virus is Genotype 5a.
Description
BRIEF DESCRIPTION OF THE FIGURES
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DETAILED DESCRIPTION OF THE INVENTION
(18) The invention disclosed herein is a compound, method, composition, and solid dosage form for the treatment of cirrhotic humans and other host animals infected with or exposed to the HCV virus that includes the administration of an effective amount of the hemi-sulfate salt of isopropyl((S)-(((2R,3R,4R,5R)-5-(2-amino-6-(methylamino)-9H-purin-9-yl)-4-fluoro-3-hydroxy-4-methyltetrahydrofuran-2-yl)methoxy)(phenoxy)phosphoryl)-L-alaninate (Compound 2) as described herein, optionally in a pharmaceutically acceptable carrier. In one embodiment, the cirrhotic host has compensated cirrhosis. In one embodiment, the host has decompensated cirrhosis. In one embodiment, the host has Child-Pugh A cirrhosis. In an alternative embodiment, the host has Child-Pugh B or Child-Pugh C cirrhosis.
(19) ##STR00005##
(20) The active compounds and compositions can also be used to treat the range of HCV genotypes in cirrhotic hosts. At least six distinct genotypes of HCV, each of which have multiple subtypes, have been identified globally. Genotypes 1-3 are prevalent worldwide, and Genotypes 4, 5, and 6 are more limited geographically. Genotype 4 is common in the Middle East and Africa. Genotype 5 is mostly found in South Africa. Genotype 6 predominately exists in Southeast Asia.
(21) Although the most common genotype in the United States is Genotype 1, defining the genotype and subtype can assist in treatment type and duration. For example, different genotypes respond differently to different medications and optimal treatment times vary depending on the genotype infection. Within genotypes, subtypes, such as Genotype 1a and Genotype 1b, respond differently to treatment as well. Infection with one type of genotype does not preclude a later infection with a different genotype.
(22) As described in Example 3, Compound 2 is active against GT1, GT2, and GT3 in cirrhotic patients. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver that are infected with HCV Genotype 1, HCV Genotype 2, HCV Genotype 3, HCV Genotype 4, HCV Genotype 5, or HCV Genotype 6. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver infected with HCV Genotype 1a or 1b. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver infected with HCV Genotype 2a or 2b. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver infected with HCV Genotype 3a. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver infected with HCV Genotype 3b. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver infected with HCV Genotype 4a, 4b, 4c, 4d, 4f, 4g/4k, or 4o. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver infected with HCV Genotype 5a or 6a. In one embodiment, Compound 2 is used to treat subjects with cirrhosis of the liver infected with HCV Genotype 6b, 6c, 6d, 6e, 6f, 6g, 6h, 6i, 6j, 6k, 6l, 6m, 6n, 6o, 6p, 6q, 6r, 6s, 6t, or 6u.
(23) In particular, it has been discovered that Compound 2 is active against HCV in subjects that are cirrhotic with GT1, GT2, or GT3 HCV infections.
(24) Compound 2 has S-stereochemistry at the phosphorus atom. In alternative embodiments, Compound 2 can be used in the form of any desired ratio of phosphorus R- and S-enantiomers, including up to pure enantiomers. In some embodiments, Compound 2 is used in a form that is at least 90% free of the opposite enantiomer, and can be at least 98%, 99%, or even 100% free of the opposite enantiomer. Unless described otherwise, an enantiomerically enriched Compound 2 is at least 90% free of the opposite enantiomer. In addition, in an alternative embodiment, the amino acid of the phosphoramidate can be in the D- or L-configuration, or a mixture thereof, including a racemic mixture.
(25) Unless otherwise specified, the compounds described herein are provided in the β-D-configuration. In an alternative embodiment, the compounds can be provided in a β-L-configuration. Likewise, any substituent group that exhibits chirality can be provided in racemic, enantiomeric, diastereomeric form, or any mixture thereof. Where a phosphoramidate exhibits chirality, it can be provided as an R or S chiral phosphorus derivative or a mixture thereof, including a racemic mixture. All of the combinations of these stereo configurations are alternative embodiments in the invention described herein. In another embodiment, at least one of the hydrogens of Compound 2 (the nucleotide or the hemi-sulfate salt) can be replaced with deuterium.
(26) These alternative configurations include, but are not limited to,
(27) ##STR00006##
(28) In an alternative embodiment, Compound 2 is administered as an oxalate salt, a sulfate salt, or an HCl salt. Examples of additional alternative pharmaceutically acceptable salts are organic acid addition salts formed with acids, which form a physiological acceptable anion, for example, tosylate, methanesulfonate, acetate, citrate, malonate, tartrate, succinate, benzoate, ascorbate, α-ketoglutarate, and α-glycerophosphate. Suitable inorganic salts may also be formed, including sulfate, nitrate, bicarbonate, and carbonate salts. Alternative pharmaceutically acceptable salts may also be obtained using standard procedures well known in the art, for example by reacting a sufficiently basic compound such as an amine with a suitable acid affording a physiologically acceptable anion. Alkali metal (for example, sodium, potassium, or lithium) or alkaline earth metal (for example calcium) salts of carboxylic acids can also be made.
(29) In an alternative embodiment, Compound 2 is provided as the hemi-sulfate salt of a phosphoramidate of Compound 1 other than the specific phosphoramidate described in the compound illustration. A wide range of phosphoramidates are known to those skilled in the art that include various esters and phospho-esters, any combination of which can be used to provide an active compound as described herein in the form of a hemi-sulfate salt.
I. Hemi-sulfate salt of isopropyl((S)-(((2R,3R,4R,5R)-5-(2-amino-6-(methylamino)-9H-purin-9-yl)-4-fluoro-3-hydroxy-4-methyltetrahydrofuran-2-yl)methoxy)(phenoxy)phosphoryl)-L-alaninate (Compound 2
(30) The active compound of the invention is Compound 2, which can be provided in a pharmaceutically acceptable composition or solid dosage form thereof. In one embodiment, Compound 2 is an amorphous solid. In yet a further embodiment, Compound 2 is a crystalline solid as described in PCT Application WO 2018/144640.
II. Metabolism of Isopropyl((S)-(((2R,3R,4R,5R)-5-(2-amino-6-(methylamino)-9H-purin-9-yl)-4-fluoro-3-hydroxy-4-methyltetrahydrofuran-2-yl)methoxy)(phenoxy)phosphoryl)-L-alaninate (Compound 2)
(31) The metabolism of Compound 1 and Compound 2 involves the production of a 5′-monophosphate and the subsequent anabolism of the N.sup.6-methyl-2,6-diaminopurine base (1-3) to generate ((2R,3R,4R,5R)-5-(2-amino-6-oxo-1,6-dihydro-9H-purin-9-yl)-4-fluoro-3-hydroxy-4-methyltetrahydrofuran-2-yl)methyl dihydrogen phosphate (1-4) as the 5′-monophosphate. The monophosphate is then further anabolized to the active triphosphate species: the 5′-triphosphate (1-6). The 5′-triphosphate can be further metabolized to generate 2-amino-9-((2R,3R,4R,5R)-3-fluoro-4-hydroxy-5-(hydroxymethyl)-3-methyltetrahydrofuran-2-yl)-1,9-dihydro-6H-purin-6-one (1-7). Alternatively, 5′-monophophate 1-2 can be metabolized to generate the purine base 1-8. The metabolic pathway for isopropyl((S)-(((2R,3R,4R,5R)-5-(2-amino-6-(methylamino)-9H-purin-9-yl)-4-fluoro-3-hydroxy-4-methyltetrahydrofuran-2-yl)methoxy)(phenoxy)phosphoryl)-L-alaninate is illustrated in Scheme 1 (shown above in Scheme 1).
III. Definitions
(32) The term “D-configuration” as used in the context of the present invention refers to the principle configuration which mimics the natural configuration of sugar moieties as opposed to the unnatural occurring nucleosides or “L” configuration. The term “0” or “f3 anomer” is used with reference to nucleoside analogs in which the nucleoside base is configured (disposed) above the plane of the furanose moiety in the nucleoside analog.
(33) The terms “coadminister” and “coadministration” or combination therapy are used to describe the administration of Compound 2 according to the present invention in combination with at least one other active agent, for example where appropriate at least one additional anti-HCV agent. The timing of the coadministration is best determined by the medical specialist treating the patient. It is sometimes preferred that the agents be administered at the same time. Alternatively, the drugs selected for combination therapy may be administered at different times to the patient. Of course, when more than one viral or other infection or other condition is present, the present compounds may be combined with other agents to treat that other infection or condition as required.
(34) The term “host”, as used herein, refers to a unicellular or multicellular organism in which a HCV virus can replicate, including cell lines and animals, and typically a human. The term host specifically refers to infected cells, cells transfected with all or part of a HCV genome, and animals, in particular, primates (including chimpanzees) and humans. In most animal applications of the present invention, the host is a human patient. Veterinary applications, in certain indications, however, are clearly anticipated by the present invention (such as chimpanzees). The host can be for example, bovine, equine, avian, canine, feline, etc.
(35) The term “cirrhosis,” as used herein is the late stage, irreversible scarring (fibrosis) of the liver. Signs and symptoms include fatigue, easy bleeding or bruising, loss of appetite, nausea, swelling in the legs, feet or ankles (edema), weight loss, itchy skin, yellow discoloration in the skin and eyes (jaundice), fluid accumulation in the abdomen (ascites), spiderlike blood vessels on your skin, redness in the palms of the hands, confusion, drowsiness and slurred speech (hepatic encephalopathy).
(36) Cirrhosis can be classified as either compensated or decompensated. Patients with compensated cirrhosis do not necessarily have symptoms related to cirrhosis, but may have asymptomatic esophageal or gastric varices. Patients with decompensated cirrhosis have symptomatic complications related to cirrhosis, including jaundice.
(37) The Child-Turcotte-Pugh (CTP) score has been shown to accurately predict outcomes in patients with cirrhosis and portal hypertension. It consists of five parameters: serum bilirubin, serum albumin, prothrombin time, ascites, and grade of encephalopathy, and based on the sum of points from these parameters, patients are characterized as either A, B, or C. Patients that score an “A” on the CTP scoring system are considered to have mild hepatic impairment and compensated cirrhosis, while patients that score a “B” or “C” on the CTP scoring system are considered to have moderate or severe liver disease, respectively, and decompensated cirrhosis.
(38) Isotopic Substitutions
(39) The present invention includes compounds and the use of compound 2 with desired isotopic substitutions of atoms at amounts above the natural abundance of the isotope, i.e., enriched. Isotopes are atoms having the same atomic number but different mass numbers, i.e., the same number of protons but a different number of neutrons. By way of general example and without limitation, isotopes of hydrogen, for example, deuterium (.sup.2H) and tritium (.sup.3H) may be used anywhere in described structures. Alternatively or in addition, isotopes of carbon, e.g., .sup.13C and .sup.14C, may be used. A preferred isotopic substitution is deuterium for hydrogen at one or more locations on the molecule to improve the performance of the drug. The deuterium can be bound in a location of bond breakage during metabolism (an α-deuterium kinetic isotope effect) or next to or near the site of bond breakage (a β-deuterium kinetic isotope effect). Achillion Pharmaceuticals, Inc. (WO/2014/169278 and WO/2014/169280) describes deuteration of nucleotides to improve their pharmacokinetic or pharmacodynamic, including at the 5-position of the molecule.
(40) Substitution with isotopes such as deuterium can afford certain therapeutic advantages resulting from greater metabolic stability, such as, for example, increased in vivo half-life or reduced dosage requirements. Substitution of deuterium for hydrogen at a site of metabolic break-down can reduce the rate of or eliminate the metabolism at that bond. At any position of the compound that a hydrogen atom may be present, the hydrogen atom can be any isotope of hydrogen, including protium (.sup.1H), deuterium (.sup.2H) and tritium (.sup.3H). Thus, reference herein to a compound encompasses all potential isotopic forms unless the context clearly dictates otherwise.
(41) The term “isotopically-labeled” analog refers to an analog that is a “deuterated analog”, a “.sup.13C-labeled analog,” or a “deuterated/.sup.13C-labeled analog.” The term “deuterated analog” means a compound described herein, whereby a H-isotope, i.e., hydrogen/protium (.sup.1H), is substituted by a H-isotope, i.e., deuterium (.sup.2H). Deuterium substitution can be partial or complete. Partial deuterium substitution means that at least one hydrogen is substituted by at least one deuterium. In certain embodiments, the isotope is 90, 95 or 99% or more enriched in an isotope at any location of interest. In some embodiments it is deuterium that is 90, 95 or 99% enriched at a desired location. Unless indicated to the contrary, the deuteration is at least 80% at the selected location. Deuteration of the nucleoside can occur at any replaceable hydrogen that provides the desired results.
IV. Method of Treatment or Prophylaxis
(42) Treatment, as used herein, refers to the administration of Compound 2 to a host that is infected with HCV, for example a human, wherein the host has cirrhosis of the liver caused by HCV. In one embodiment, the cirrhotic host has compensated cirrhosis. In an alternative embodiment, the cirrhotic host has decompensated cirrhosis. In one embodiment, the host has Child-Pugh A cirrhosis. In an alternative embodiment, the host has Child-Pugh B or Child-Pugh C cirrhosis.
(43) The invention is directed to a method of treatment or prophylaxis of a hepatitis C virus, including drug resistant and multi-drug resistant forms of HCV and related disease states, conditions, or complications of a cirrhotic HCV infection, including related hepatotoxicities, as well as other conditions that are secondary to a cirrhotic HCV infection, such as weakness, loss of appetite, weight loss, breast enlargement (especially in men), rash (especially on the palms), difficulty with clotting of blood, spider-like blood vessels on the skin, confusion, coma (encephalopathy), buildup of fluid in the abdominal cavity (ascites), esophageal varices, portal hypertension, variceal hemorrhage, kidney failure, enlarged spleen, decrease in blood cells, anemia, thrombocytopenia, jaundice, and hepatocellular cancer, among others. The method comprises administering to a host in need thereof, typically a human, with an effective amount of Compound 2 as described herein, optionally in combination with at least one additional bioactive agent, for example, an additional anti-HCV agent, further in combination with a pharmaceutically acceptable carrier additive and/or excipient.
(44) In yet another aspect, the present invention is a method for prevention or prophylaxis of a cirrhotic HCV infection or a disease state or related or follow-on disease state, condition or complication of a cirrhotic HCV infection, including related hepatotoxicities, weakness, loss of appetite, weight loss, breast enlargement (especially in men), rash (especially on the palms), difficulty with clotting of blood, spider-like blood vessels on the skin, confusion, coma (encephalopathy), buildup of fluid in the abdominal cavity (ascites), esophageal varices, portal hypertension, variceal hemorrhage, kidney failure, enlarged spleen, decrease in blood cells, anemia, thrombocytopenia, jaundice, and hepatocellular (liver) cancer, among others, said method comprising administering to a patient at risk with an effective amount Compound 2 as described above in combination with a pharmaceutically acceptable carrier, additive, or excipient, optionally in combination with another anti-HCV agent. In another embodiment, the active compounds of the invention can be administered to a patient after a hepatitis-related liver transplantation to protect the new organ.
V. Pharmaceutical Compositions and Dosage Forms
(45) In an aspect of the invention, pharmaceutical compositions according to the present invention comprise an anti-HCV virus effective amount of Compound 2 as described herein to treat a cirrhotic HCV infection, optionally in combination with a pharmaceutically acceptable carrier, additive, or excipient, further optionally in combination or alternation with at least one other active compound. In one embodiment, the invention includes a solid dosage form of Compound 2 in a pharmaceutically acceptable carrier.
(46) In an aspect of the invention, pharmaceutical compositions according to the present invention comprise an anti-HCV effective amount of Compound 2 described herein to treat a cirrhotic HCV infection, optionally in combination with a pharmaceutically acceptable carrier, additive, or excipient, further optionally in combination with at least one other antiviral agent, such as an anti-HCV agent.
(47) The invention includes pharmaceutical compositions that include an effective amount to treat a cirrhotic hepatitis C virus infection of Compound 2 of the present invention or prodrug, in a pharmaceutically acceptable carrier or excipient.
(48) One of ordinary skill in the art will recognize that a therapeutically effective amount will vary with the infection or condition to be treated, its severity, the treatment regimen to be employed, the pharmacokinetic of the agent used, as well as the patient or subject (animal or human) to be treated, and such therapeutic amount can be determined by the attending physician or specialist.
(49) Compound 2 according to the present invention can be formulated in a mixture with a pharmaceutically acceptable carrier. In general, it is preferable to administer the pharmaceutical composition in orally-administrable form, an in particular, a solid dosage form such as a pill or tablet. Certain formulations may be administered via a parenteral, intravenous, intramuscular, topical, transdermal, buccal, subcutaneous, suppository, or other route, including intranasal spray. Intravenous and intramuscular formulations are often administered in sterile saline. One of ordinary skill in the art may modify the formulations to render them more soluble in water or another vehicle, for example, this can be easily accomplished by minor modifications (salt formulation, esterification, etc.) that are well within the ordinary skill in the art. It is also well within the routineers' skill to modify the route of administration and dosage regimen of Compound 2 in order to manage the pharmacokinetics of the present compounds for maximum beneficial effect in patients, as described in more detail herein.
(50) The amount of Compound 2 included within the therapeutically active formulation according to the present invention is an effective amount to achieve the desired outcome according to the present invention, for example, for treating the cirrhotic HCV infection, reducing the likelihood of a cirrhotic HCV infection or the inhibition, reduction, and/or abolition of cirrhotic HCV or its secondary effects, including disease states, conditions, and/or complications which occur secondary to cirrhotic HCV. In general, a therapeutically effective amount of the present compound in a pharmaceutical dosage form may range from about 0.001 mg/kg to about 100 mg/kg per day or more, more often, slightly less than about 0.1 mg/kg to more than about 25 mg/kg per day of the patient or considerably more, depending upon the compound used, the condition or infection treated and the route of administration. Compound 2 is often administered in amounts ranging from about 0.1 mg/kg to about 15 mg/kg per day of the patient, depending upon the pharmacokinetic of the agent in the patient. This dosage range generally produces effective blood level concentrations of active compound which may range from about 0.001 to about 100, about 0.05 to about 100 micrograms/cc of blood in the patient.
(51) Often, to treat, prevent or delay the onset of these infections and/or to reduce the likelihood of a cirrhotic HCV virus infection, or a secondary disease state, condition or complication of HCV, Compound 2 will be administered in a solid dosage form in an amount ranging from about 250 micrograms up to about 800 milligrams or more at least once a day, for example, at least about 5, 10, 20, 25, 50, 75, 100, 150, 200, 250, 300, 350, 400, 450, 500, 550, 600, 650, 700, 750, 800, 850, 900, 950, or 1000 milligrams or more, once, twice, three, or up to four times a day according to the direction of the healthcare provider. Compound 2 is often administered orally, but may be administered parenterally, topically, or in suppository form, as well as intranasally, as a nasal spray or as otherwise described herein. More generally, Compound 2 can be administered in a tablet, capsule, injection, intravenous formulation, suspension, liquid, emulsion, implant, particle, sphere, cream, ointment, suppository, inhalable form, transdermal form, buccal, sublingual, topical, gel, mucosal, and the like.
(52) When a dosage form herein refers to a milligram weight dose, it refers to the amount of Compound 2 (i.e., the weight of the hemi-sulfate salt) unless otherwise specified to the contrary.
(53) In certain embodiments, the pharmaceutical composition is in a dosage form that contains from about 1 mg to about 2000 mg, from about 10 mg to about 1000 mg, from about 100 mg to about 800 mg, from about 200 mg to about 600 mg, from about 300 mg to about 500 mg, or from about 400 mg to about 450 mg of Compound 2 in a unit dosage form. In certain embodiments, the pharmaceutical composition is in a dosage form, for example in a solid dosage form, that contains up to about 10, about 50, about 100, about 125, about 150, about 175, about 200, about 225, about 250, about 275, about 300, about 325, about 350, about 375, about 400, about 425, about 450, about 475, about 500, about 525, about 550, about 575, about 600, about 625, about 650, about 675, about 700, about 725, about 750, about 775, about 800, about 825, about 850, about 875, about 900, about 925, about 950, about 975, or about 1000 mg or more of Compound 2 in a unit dosage form. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 300 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 400 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 450 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 500 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 550 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 600 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 650 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 700 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 750 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 800 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 850 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 900 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 950 mg. In one embodiment, Compound 2 is administered in a dosage form that delivers at least about 1000 mg. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for up to 12 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for up to 10 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for up to 8 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for up to 4 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for at least 4 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for at least 6 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for at least 8 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for at least 10 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for at least 12 weeks. In certain embodiments, Compound 2 is administered at least once, twice, or three times a day for up to 12 weeks, up to 10 weeks, up to 8 weeks, up to 6 weeks, or up to 4 weeks. In certain embodiments, Compound 2 is administered at least every other day for at least 4 weeks, at least 6 weeks, at least 8 weeks, at least 10 weeks, or at least 12 weeks. In one embodiment, at least about 1000 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 900 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 800 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 700 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 600 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 550 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 500 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 450 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 400 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least about 350 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least 300 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least 200 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks. In one embodiment, at least 100 mg of Compound 2 is administered at least once, twice, or three times a day for up to 6 weeks.
(54) In certain embodiments, a dose of approximately 600 mg of Compound 2 administered to a cirrhotic GT1 HCV infected patient results in at least a 3 log, 4 log, or 5 log HCV RNA reduction.
(55) In certain embodiments, a dose of approximately 600 mg of Compound 2 administered to a cirrhotic GT2 HCV infected patient results in at least a 3 log, 4 log, or 5 log HCV RNA reduction. In certain embodiments, a dose of approximately 600 mg of Compound 2 administered to a cirrhotic GT3 HCV infected patient results in at least a 3 log, 4 log, or 5 log HCV RNA reduction.
(56) In the case of the co-administration of Compound 2 in combination with another anti-HCV compound as otherwise described herein, the amount of Compound 2 according to the present invention to be administered in ranges from about 0.01 mg/kg of the patient to about 800 mg/kg or more of the patient or considerably more, depending upon the second agent to be co-administered and its potency against the virus, the condition of the patient and severity of the disease or infection to be treated and the route of administration. The other anti-HCV agent may for example be administered in amounts ranging from about 0.01 mg/kg to about 800 mg/kg. Examples of dosage amounts of the second active agent are amounts ranging from about 250 micrograms up to about 750 mg or more at least once a day, for example, at least about 5, 10, 20, 25, 50, 75, 100, 150, 200, 250, 300, 350, 400, 450, 500, 600, 700, 800, 850, 900, 9050, or 1000 milligrams or more, up to four times a day. In certain preferred embodiments, Compound 2 may be often administered in an amount ranging from about 0.5 mg/kg to about 50 mg/kg or more (usually up to about 100 mg/kg), generally depending upon the pharmacokinetic of the two agents in the patient. These dosage ranges generally produce effective blood level concentrations of active compound in the patient.
(57) For purposes of the present invention, a prophylactically or preventive effective amount of the compositions according to the present invention falls within the same concentration range as set forth above for therapeutically effective amount and is usually the same as a therapeutically effective amount.
(58) Administration of Compound 2 may range from continuous (intravenous drip) to several oral or intranasal administrations per day (for example, Q.I.D.) or transdermal administration and may include oral, topical, parenteral, intramuscular, intravenous, sub-cutaneous, transdermal (which may include a penetration enhancement agent), buccal, and suppository administration, among other routes of administration. Enteric coated oral tablets may also be used to enhance bioavailability of the compounds for an oral route of administration. The most effective dosage form will depend upon the bioavailability/pharmacokinetic of the particular agent chosen as well as the severity of disease in the patient. Oral dosage forms are particularly preferred, because of ease of administration and prospective favorable patient compliance.
(59) To prepare the pharmaceutical compositions according to the present invention, a therapeutically effective amount of Compound 2 according to the present invention is often intimately admixed with a pharmaceutically acceptable carrier according to conventional pharmaceutical compounding techniques to produce a dose. A carrier may take a wide variety of forms depending on the form of preparation desired for administration, e.g., oral or parenteral. In preparing pharmaceutical compositions in oral dosage form, any of the usual pharmaceutical media may be used. Thus, for liquid oral preparations such as suspensions, elixirs, and solutions, suitable carriers and additives including water, glycols, oils, alcohols, flavoring agents, preservatives, coloring agents, and the like may be used. For solid oral preparations such as powders, tablets, capsules, and for solid preparations such as suppositories, suitable carriers and additives including starches, sugar carriers, such as dextrose, manifold, lactose, and related carriers, diluents, granulating agents, lubricants, binders, disintegrating agents, and the like may be used. If desired, the tablets or capsules may be enteric-coated or sustained release by standard techniques. The use of these dosage forms may significantly enhance the bioavailability of the compounds in the patient.
(60) For parenteral formulations, the carrier will usually comprise sterile water or aqueous sodium chloride solution, though other ingredients, including those which aid dispersion, also may be included. Of course, where sterile water is to be used and maintained as sterile, the compositions and carriers must also be sterilized. Injectable suspensions may also be prepared, in which case appropriate liquid carriers, suspending agents, and the like may be employed.
(61) Liposomal suspensions (including liposomes targeted to viral antigens) may also be prepared by conventional methods to produce pharmaceutically acceptable carriers. This may be appropriate for the delivery of free nucleosides, acyl/alkyl nucleosides or phosphate ester pro-drug forms of the nucleoside compounds according to the present invention.
(62) In typical embodiments according to the present invention, Compound 2 and the compositions described are used to treat, prevent or delay a cirrhotic HCV infection or a secondary disease state, condition or complication of cirrhotic HCV.
VI. Combination and Alternation Therapy
(63) It is well recognized that drug-resistant variants of viruses can emerge after prolonged treatment with an antiviral agent. Drug resistance sometimes occurs by mutation of a gene that encodes for an enzyme used in viral replication. The efficacy of a drug against a cirrhotic HCV infection may be prolonged, augmented, or restored by administering the compound in combination or alternation with another, and perhaps even two or three other, antiviral compounds that induce a different mutation or act through a different pathway from that of the principle drug. Alternatively, the pharmacokinetic, biodistribution, half-life, or other parameter of the drug may be altered by such combination therapy (which may include alternation therapy if considered concerted). Since the disclosed Compound 2 is an NSSB polymerase inhibitor, it may be useful to administer the compound to a host in combination with, for example a (1) Protease inhibitor, such as an NS3/4A protease inhibitor; (2) NSSA inhibitor; (3) Another NSSB polymerase inhibitor; (4) NSSB non-substrate inhibitor; (5) Interferon alfa-2a, which may be pegylated or otherwise modified, and/or ribavirin; (6) Non-substrate-based inhibitor; (7) Helicase inhibitor; (8) Antisense oligodeoxynucleotide (S-ODN); (9) Aptamer; (10) Nuclease-resistant ribozyme; (11) iRNA, including microRNA and SiRNA; (12) Antibody, partial antibody or domain antibody to the virus, or (13) Viral antigen or partial antigen that induces a host antibody response.
(64) Non limiting examples of anti-HCV agents that can be administered in combination with Compound 2 of the invention, alone or with multiple drugs from this lists, are (i) protease inhibitors such as telaprevir (Incivek®), boceprevir (Victrelis™), simeprevir (Olysio™), paritaprevir (ABT-450), glecaprevir (ABT-493), ritonavir (Norvir), ACH-2684, AZD-7295, BMS-791325, danoprevir, Filibuvir, GS-9256, GS-9451, MK-5172, Setrobuvir, Sovaprevir, Tegobuvir, VX-135, VX-222, and, ALS-220; (ii) NS5A inhibitor such as ACH-2928, ACH-3102, IDX-719, daclatasvir, ledispasvir, velpatasvir (Epclusa), elbasvir (MK-8742), grazoprevir (MK-5172), Ombitasvir (ABT-267), ruzasvir (MK-8408), ravidasvir, pibrentasvir, and coblopasvir (KW-136); (iii) NS5B inhibitors such as AZD-7295, Clemizole, dasabuvir (Exviera), ITX-5061, PPI-461, PPI-688, sofosbuvir (Sovaldi®, MK-3682, and mericitabine; (iv) NS5B inhibitors such as ABT-333, and MBX-700; (v) Antibody such as GS-6624; (vi) Combination drugs such as Harvoni (ledipasvir/sofosbuvir); Viekira Pak (ombitasvir/paritaprevir/ritonavir/dasabuvir); Viekirax (ombitasvir/paritaprevir/ritonavir); G/P (paritaprevir and glecaprevir); Technivie (ombitasvir/paritaprevir/ritonavir), Epclusa (sofosbuvir/velpatasvir), Zepatier (elbasvir and grazoprevir), and Mavyret (glecaprevir/pibrentasvir).
(65) If Compound 2 is administered to treat advanced hepatitis C virus leading to liver cancer, in one embodiment, the compound can be administered in combination or alternation with another drug that is typically used to treat hepatocellular carcinoma (HCC), for example, as described by Andrew Zhu in “New Agents on the Horizon in Hepatocellular Carcinoma” Therapeutic Advances in Medical Oncology, V 5(1), January 2013, 41-50. Examples of suitable compounds for combination therapy where the host has or is at risk of HCC include anti-angiogenic agents, sunitinib, brivanib, linifanib, ramucirumab, bevacizumab, cediranib, pazopanib, TSU-68, lenvatinib, antibodies against EGFR, mTor inhibitors, MEK inhibitors, and histone decetylace inhibitors.
EXAMPLES
(66) General Methods
(67) .sup.1H, .sup.19F and .sup.31P NMR spectra were recorded on a 400 MHz Fourier transform Brucker spectrometer. Spectra were obtained DMSO-d.sub.6 unless stated otherwise. The spin multiplicities are indicated by the symbols s (singlet), d (doublet), t (triplet), m (multiplet) and, br (broad). Coupling constants (J) are reported in Hz. The reactions were generally carried out under a dry nitrogen atmosphere using Sigma-Aldrich anhydrous solvents. All common chemicals were purchased from commercial sources.
(68) The following abbreviations are used in the Examples: AUC: Area under the Curve C.sub.max: Maximum concentration of the drug achieved in plasma DCM: Dichloromethane EtOAc: Ethyl acetate EtOH: Ethanol HPLC: High pressure liquid chromatography NaOH: Sodium hydroxide Na.sub.2SO.sub.4: Sodium sulphate (anhydrous) MeCN: Acetonitrile MeNH.sub.2: Methylamine MeOH: Methanol Na.sub.2SO.sub.4: Sodium sulfate NaHCO.sub.3: Sodium bicarbonate NH.sub.4Cl: Ammonium chloride NH.sub.4OH: Ammonium hydroxide PE: Petroleum ether Ph.sub.3P: Triphenylphosphine QD: once daily RH: relative humidity Silica gel (230 to 400 mesh, Sorbent) t-BuMgCl: t-Butyl magnesium chloride T.sub.max: Time at which C.sub.max is achieved THF: Tetrahydrofuran (THF), anhydrous TP: Triphosphate
Example 1. Synthesis of Compound 1
(69) ##STR00007##
Step 1: Synthesis of (2R,3R,4R,5R)-5-(2-Amino-6-(methylamino)-9H-purin-9-yl)-4-fluoro-2-(hydroxymethyl)-4-methyltetrahydrofuran-3-ol (2-2)
(70) A 50 L flask was charged with methanol (30 L) and stirred at 10±5° C. NH.sub.2CH.sub.3 (3.95 Kg) was slowly ventilated into the reactor at 10±5° C. Compound 2-1 (3.77 kg) was added in batches at 20±5° C. and stirred for 1 hour to obtain a clear solution. The reaction was stirred for an additional 6-8 hours, at which point HPLC indicated that the intermediate was less than 0.1% of the solution. The reactor was charged with solid NaOH (254 g), stirred for 30 minutes and concentrated at 50±5° C. (vacuum degree: −0.095). The resulting residue was charged with EtOH (40 L) and re-slurried for 1 hour at 60° C. The mixture was then filtered through celite and the filter cake was re-slurried with EtOH (15 L) for 1 hour at 60° C. The filtrate was filtered once more, combined with the filtrate from the previous filtration, and then concentrated at 50±5° C. (vacuum degree: −0.095). A large amount of solid was precipitated. EtOAc (6 L) was added to the solid residue and the mixture was concentrated at 50±5° C. (vacuum degree: −0.095). DCM was then added to the residue and the mixture was re-slurried at reflux for 1 hour, cooled to room temperature, filtered, and dried at 50±5° C. in a vacuum oven to afford compound 2-2 as an off-white solid (1.89 Kg, 95.3%, purity of 99.2%).
(71) Analytic Method for Compound 2-2: The purity of compound 2-2 (15 mg) was obtained using an Agilent 1100 HPLC system with a Agilent Poroshell 120 EC-C18 4.6*150 mm 4-Micron column with the following conditions: 1 mL/min flow rate, read at 254 nm, 30° C. column temperature, 15 μL injection volume, and a 31 minute run time. The sample was dissolved in acetonitrile-water (20:80) (v/v). The gradient method is shown below.
(72) TABLE-US-00001 Time (min) A % (0.05 TFA in water) B % (Acetonitrile) 0 95 5 8 80 20 13 50 50 23 5 95 26 5 95 26.1 95 5 31 95 5
Step 2: Synthesis of isopropyl((S)-(((2R,3R,4R,5R)-5-(2-Amino-6-(methylamino)-9H-purin-9-yl)-4-fluoro-3-hydroxy-4-methyltetrahydrofuran-2-yl)methoxy)(phenoxy)phosphoryl)-L-alaninate (Compound 1)
(73) Compound 2-2 and compound 2-3 (isopropyl ((perfluorophenoxy)(phenoxy)phosphoryl)-L-alaninate) were dissolved in THF (1 L) and stirred under nitrogen. The suspension was then cooled to a temperature below −5° C. and a 1.7 M solution of t-BuMgCl solution (384 mL) was slowly added over 1.5 hours while a temperature of 5-10° C. was maintained. A solution of NH.sub.4Cl (2 L) and water (8 L) was added to the suspension at room temperature followed by DCM. The mixture was stirred for 5 minutes before a 5% aqueous solution of K.sub.2CO.sub.3 (10 L) was added and the mixture was stirred for 5 additional minutes before filtering through diatomite (500 g). The diatomite was washed with DCM and the filtrate was separated. The organic phase was washed with a 5% aqueous K.sub.2CO.sub.3 solution (10 L×2), brine (10 L×3), and dried over Na.sub.2SO.sub.4 (500 g) for approximately 1 hour. Meanwhile, this entire process was repeated 7 times in parallel and the 8 batches were combined. The organic phases were filtered and concentrated at 45±5° C. (vacuum degree of 0.09 Mpa). EtOAc was added and the mixture was stirred for 1 hour at 60° C. and then at room temperature for 18 hours. The mixture was then filtered and washed with EtOAc (2 L) to afford crude Compound 1. The crude material was dissolved in DCM (12 L), heptane (18 L) was added at 10-20° C., and the mixture was allowed to stir for 30 minutes at this temperature. The mixture was filtered, washed with heptane (5 L), and dried at 50±5° C. to afford pure Compound 1 (1650 g, 60%).
(74) Analytic Method for Compound 1: The purity of Compound 1 (25 mg) was obtained using an Agilent 1100 HPLC system with a Waters XTerra Phenyl 5 μm 4.6*250 mm column with the following conditions: 1 mL/min flow rate, read at 254 nm, 30° C. column temperature, 15 μL injection volume, and a 25 minute run time. The sample was dissolved in acetonitrile-water (50:50) (v/v). The gradient method is shown below.
(75) TABLE-US-00002 Time (min) A % (0.1% H.sub.3PO.sub.4 in water) B % (Acetonitrile) 0 90 10 20 20 80 20.1 90 10 25 90 10
Example 2. Synthesis of Amorphous Compound 2
(76) ##STR00008##
(77) A 250 mL flask was charged with MeOH (151 mL) and the solution was cooled to 0-5° C. A concentrated solution of H.sub.2SO.sub.4 was added dropwise over 10 minutes. A separate flask was charged with Compound 1 (151 g) and acetone (910 mL), and the H.sub.2SO.sub.4/MeOH solution was added dropwise at 25-30° C. over 2.5 hours. A large amount of solid was precipitated. After the solution was stirred for 12-15 hours at 25-30° C., the mixture was filtered, washed with MeOH/acetone (25 mL/150 mL), and dried at 55-60° C. in vacuum to afford Compound 2 (121 g, 74%).
(78) Analytic Method for Compound 2: The purity of Compound 2 was obtained using an Agilent 1100 HPLC system with a Waters XTerra Phenyl 5 μm 4.6*250 mm column with the following conditions: 1 mL/min flow rate, read at 254 nm, 30° C. column temperature, 10 μL injection volume, and a 30 minute run time. The sample was dissolved in ACN:water (90:10, v/v). The Gradient method for separation is shown below. R.sub.t (min) of Compound 2 was approximately 12.0 minutes.
(79) TABLE-US-00003 Time (min) 0.1% H.sub.3PO.sub.4 in Water (A) % Acetonitrile (B) % 0 90 10 20 20 80 20.1 90 10 30 90 10
(80) .sup.1HNMR: (400 MHz, DMSO-d.sub.6): δ 8.41 (br, 1H), 7.97 (s, 1H), 7.36 (t, J=8.0 Hz, 2H), 7.22 (d, J=8.0 Hz, 2H), 7.17 (t, J=8.0 Hz, 1H), 6.73 (s, 2H), 6.07 (d, J=8.0 Hz, 1H), 6.00 (dd, J=12.0, 8.0 Hz, 1H), 5.81 (br, 1H), 4.84-4.73 (m, 1H), 4.44-4.28 (m, 3H), 4.10 (t, J=8.0 Hz, 2H), 3.85-3.74 (m, 1H), 2.95 (s, 3H), 1.21 (s, J=4.0 Hz, 3H), 1.15-1.10 (m, 9H).
(81) Compound 2 was further characterized by eye, .sup.1HNMR, .sup.13CNMR, .sup.19FNMR, MS, HPLC, and XRPD as described in PCT Application WO 2018/144640.
Example 3. Three-Part Study to Evaluate Safety/Tolerability, Pharmacokinetics (PK), and Anti-Viral Activity of Compound 2
(82) A three-part study was conducted with Compound 2 to evaluate safety/tolerability, pharmacokinetics (PK), and anti-viral activity. The three parts included: 1) the administration of multiple doses of up to 600 mg of Compound 2 (equivalent to 550 mg of Compound 1) once daily (QD) for 7 days in NC (non-cirrhotic) GT1 HCV-infected patients (Part C); 2) the administration of 600 mg of Compound 2 (equivalent to 550 mg of Compound 1) QD for 7 days in NC GT3 HCV-infected patients (Part D); and, 3) the administration of 600 mg of Compound 2 (equivalent to 550 mg of Compound 1) QD for 7 days in a cohort of Child-Pugh A (CPA) cirrhotic patients with either GT1, GT2, or GT3 HCV infections (Part E). Doses were administered as the Compound 2 salt base. The free base Compound 1 equivalent is often given in parenthesis.
(83) Part C was a randomized, double-blind, placebo-controlled MAD study divided into three cohorts. Subjects were given 150 mg, 300 mg, or 600 mg of Compound 2 or placebo for 7 days in the fasting state. The dose escalation only proceeded following satisfactory review of the data. Part D and Part E were open-labeled studies where patients received a dose of 600 mg of Compound 2 (equivalent to 550 mg of Compound 1) for 7 days in the fasting state.
(84) HCV-infected patients were treatment-naïve with HCV RNA ≥5 log 10 IU/mL. HCV RNA was quantified using COBAS® AmpliPrep TaqMAN® v2.0 with LLQ of 15 IU/mL. Plasma drug levels were measured using LC-MS/MS. Baseline HCV RNA averaged >6 logs in all cohorts of patients administered 500 mg of Compound 2. Cirrhosis was confirmed by prior liver biopsy or Fibroscan >12.5 kPa. The mean baseline Fibroscan was 6.3, 6.8, and 17.6 kPa in patients administered 600 mg equivalent of Compound 2 in Part C, Part D, and Part E, respectively. Mean ages of enrolled subjects were 44, 39, and 56 years in the non-cirrhotic GT1b 600 mg dose cohort, non-cirrhotic GT3 cohort, and the cirrhotic cohort, respectively.
(85) Part A and Part B were previously conducted and described in WO 2018/144640. Part A and Part B were single ascending dose (SAD) studies. In Part A, healthy subjects were given up to 400 mg of Compound 2 (equivalent to 367 mg of Compound 1) and in Part B, GT1 NC HCV-infected subjects were given single doses of up to 600 mg of Compound 2 (equivalent to 550 mg of Compound 1).
Example 4. Results of Study of Compound 2
(86) No serious adverse events (AEs), dose-limiting toxicities, or premature discontinuations were reported. Compound 2 was well tolerated up to the highest doses tested (600 mg salt form) for seven days. The only pattern observed was a higher incidence of mostly low-grade lipid abnormalities (cholesterol and triglyceride increase) in subjects receiving Compound 2 compared to placebo. However, this observation is consistent with previously published data showing rapid increase in lipids with HCV clearance upon initiation of DAA therapy in HCV-infected subjects. In addition, there were no findings suggestive of liver injury. ALT/AST values decreased over time during the treatment period in subjects receiving Compound 2. Finally, there were no other clinically relevant, dose-related patterns upon analysis of AEs, laboratory parameters, ECGs and vital signs.
(87) In part B, a single dose of the Compound 2 equivalent of 92 mg, 275 mg, 368 mg, or 550 mg of Compound 1 was administered to non-cirrhotic GT1b HCV-infected subjects separated into dosing cohorts (n=3 for each cohort) to determine the mean maximum reduction of HCV RNA, the results of which are shown in
(88) TABLE-US-00004 TABLE 1 HCV RNA Change from Baseline in GT1b HCV Patients after a Single Dose of Compound 2 Dosing Cohort (Compound 2 Mean (Individual) Max Equivalent of Compound 1) Reduction (log.sub.10 IU/ml) 92 mg 0.8 (0.6, 0.8, 0.9) 275 mg 1.7 (1.1, 1.8, 2.2) 368 mg 2.2 (1.8, 2.2, 2.6) 550 mg 2.3 (2.1, 2.3, 2.6)
(89) In Part C, dose-related antiviral activity was observed 7 days after dosing with a mean maximum HCV RNA reduction up to 4.4 log.sub.10 IU/mL in non-cirrhotic GT1b HCV-infected subjects (n=6). 50% of subjects achieved HCV RNA <LOQ.
(90) In Part D, potent antiviral activity was observed in non-cirrhotic GT3 HCV-infected subjects (n=6) with a mean maximum HCV RNA reduction of 4.5 log.sub.10 IU/mL. The mean HCV RNA reduction was 2.4 log.sub.10 IU/mL after the first dose of 600 mg of Compound 2 (equivalent to 550 mg of Compound 1) and one subject achieved HCV RNA <LOQ within four days after the first dose.
(91) Antiviral activity in the CPA cirrhotic HCV-infected subjects of Part E was similar to non-cirrhotic GT1b and GT3 cohorts. In Part E, the mean maximum HCV RNA reduction of cirrhotic HCV infected patients was 4.6 log.sub.10 IU/mL. Mean HCV RNA changes from baseline in these populations are presented in
(92) The mean maximum HCV RNA change for Part C, Part D, and Part E is shown in Table 2.
(93) TABLE-US-00005 TABLE 2 Maximum HCV RNA Change in Part B, Part C, Part D, and Part E Part C Part D Part E 150 mg/day 300 mg/day 600 mg/day 600 mg/day 600 mg/day Endpoint, log.sub.10 Placebo Compd 2 Compd 2 Compd 2 Compd 2 Compd 2 IU/mL N = 6 N = 6 N = 6 N = 6 N = 6 N = 6 Mean ± SD 0.0 ± 0.2 1.2 ± 0.3 1.9 ± 0.2 2.1 ± 0.2 2.3 ± 0.3 2.4 ± 0.2 HCV RNA change from baseline to 24 h Mean ± SD 0.4 ± 0.1 2.6 ± 1.1 4.0 ± 0.4 4.4 ± 0.7 4.5 ± 0.3 4.6 ± 0.5 HCV RNA (0.2 − 0.5)* (1.5 − 3.7)* (3.5 − 4.4)* (3.7 − 5.1)* (4.1 − 5.0)* maximum change from baseline Individual HCV 0.3, 0.3, 1.7, 1.8, 1.8, 3.4, 3.7, 3.9 3.5, 4.0, 4.1 4.2, 4.4, 4.4, GT1b: 4.0, RNA 0.4, 0.4, 2.7, 3.0, 4.5 4.2, 4.2, 4.5 4.3, 5.2, 5.3 4.5, 4.5, 5.0 4.1, 4.5 maximum 0.5, 0.6 GT2: 4.8 change from GT3: 5.1, 5.2 baseline *95% C.I.
(94) TABLE-US-00006 TABLE 3 Summary of Antiviral Activity of Compound 2 in Part C, Part D, and Part E for 600 mg of Compound 2 Mean Reduction Mean (Individual) HCV RNA < After 24 hours Max Reduction LOQ Dosing Cohort (log.sub.10 IU/mL) (log.sub.10 IU/mL) (15 IU/mL) GT1, non- 2.1 4.4 3/6 cirrhotic (3.5, 4.0. 4.1, (n = 6) 4.3, 5.2, 5.3) GT3, non- 2.4 4.5 1/6 cirrhotic (4.2, 4.4, 4.5, 4.5, 5.0) (n = 6) GT1, Child- 2.4 4.2 1/3 Pugh A (4.0, 4.1, 4.5) (n = 3) GT3, Child- 2.2 4.8 0/1 Pugh A (n = 1) (n = 1)
(95) Compound 1, the free base of Compound 2, was rapidly and well-absorbed with estimated fraction absorbed approximating 50% based on urine recovery. After repeated QD administrations for seven days in a fasted state, Compound 1 was quickly absorbed followed by rapid metabolic activation.
(96) Following daily dosing for 7 days in Part C, Compound 1 exhibited a short half-life and did not accumulate over time. Plasma exposure of Compound 1 was slightly more than dose proportional from 150 mg to 300 mg and mostly dose proportional thereafter. While plasma peak and total exposure of metabolite 1-7 was dose proportional from 150 to 300 mg and less than dose proportional from 300 mg to 600 mg, trough levels of metabolite 1-7 were mostly dose proportional in the studied dose range. Based on metabolite 1-7 trough levels, steady state PK was essentially reached after the third or fourth dose. The formation of metabolite 1-7 peaked at approximately 6 hours after dosing and metabolite 1-7 exhibited a long half-life (-13-30 h) which supports once a day (QD) dosing. The long half-life resulted in the desired higher metabolite 1-7 trough (50%-60%) upon reaching steady state. (Active triphosphate 1-6 is not measurable in plasma since it does not leave the cell, and therefore 1-7, which is measurable is plasma, acts as a surrogate for triphosphate 1-6 and reflects intracellular active triphosphate).
(97) Steady state of metabolite 1-7 concentrations was reached by day 3 or 4 in NC subjects and by day 5 in the subjects with cirrhosis. Overall, mild hepatic impairment did not significantly impact the PK of Compound 2 based on plasma exposures. No food effect on total and trough exposure of metabolite 1-7 was observed.
(98)
(99) Tables 4A, 4B, and 4C shows the mean PK results of subjects enrolled in the study. As shown in Tables 4A-4C and
(100) TABLE-US-00007 TABLE 4A C.sub.max and T.sub.max for Compound 1 and Metabolite 1-7 at Day 1 and Steady State (SS) Dose (n) C.sub.max (ng/mL) T.sub.max (h) Analyte Part (mg/d) Day 1 SS Day 1 SS Compd 1 C 150 (6) 573 ± 280 462 ± 409 0.5 (0.5-1.0) 1.0 (0.5-1.0) 300 (6) 2277 ± 893 1834 ± 1313 0.5 (0.5-0.9) 0.5 (0.4-1.0) 600 (6) 4211 ± 2302 3604 ± 1742 0.5 (0.5-0.5) 0.5 (0.5-1.0) D 600 (6) 3971 ± 1943 4144 ± 2280 0.5 (0.5-0.5) 0.5 (0.5-1.0) E 600 (6) 3412 ± 2175 3192 ± 2085 0.5 (0.5-1.0) 0.5 (0.5-1.0) Metabolite C 150 (6) 75.6 ± 15.4 81.1 ± 33.9 4.0 (4.0-6.0) 4.0 (4.0-8.0) 1-7 300 (6) 123 ± 16.6 220 ± 203 4.0 (2.9-6.0) 4.0 (2.0-5.9) 600 (6) 197 ± 57.1 233 ± 42.9 5.0 (4.0-6.0) 4.0 (4.0-6.0) D 600 (6) 195 ± 42.9 263 ± 104 5.0 (3.0-6.0) 4.0 (4.0-6.0) E 600 (6) 201 ± 68.1 255 ± 95.4 5.0 (3.0-6.0) 6.0 (4.0-6.0)
(101) TABLE-US-00008 TABLE 4B AUC and T.sub.1/2 for Compound 1 and Metabolite 1-7 at Day 1 and Steady State (SS) Dose (n) AUC.sup.# (ng/mLxh) T.sub.1/2 (h) Analyte Part (mg/d) Day 1 SS Day 1 SS Compd 1 C 150 (6) 492 ± 141 475 ± 301 0.62 ± 0.64 ± 0.11 0.20 300 (6) 1947 ± 1120 1510 ± 976 0.80 ± 0.73 ± 0.18 0.15 600 (6) 3335 ± 1502 4036 ± 2093 0.86 ± 0.85 ± 0.11 0.12 D 600 (6) 3333 ± 1241 3754 ± 2275 0.73 ± 0.83 ± 0.12 0.06 E 600 (6) 3323 ± 1467 3527 ± 1605 0.86 ± 0.81 ± 0.18 0.12 Metabolite C 150 (6) 800 ± 213 962 ± 409 12.5 ± 1-7 6.33 300 (6) 1414 ± 220 1828 ± 453 24.5 ± 15.3 600 (6) 2204 ± 486 2839 ± 572 28.9 ± 14.4 D 600 (6) 2253 ± 595 3117 ± 1048 27.9 ± 18.3 E 600 (6) 2625 ± 873 3569 ± 1214 24.4 ± 9.81 .sup.#AUC.sub.inf for Compound 1 and AUC, for Metabolite 1-7
(102) TABLE-US-00009 TABLE 4C C.sub.24 h for Compound 1 and Metabolite 1-7 at Day 1 and Steady State (SS) Dose (n) C.sub.24 h* (ng/mL) Analyte Part (mg/d) Day 1 SS* Compd 1 C 150 (6) 300 (6) 600 (6) D 600 (6) E 600 (6) Metabolite C 150 (6) 8.08 ± 3.48 12.8 ± 4.45 1-7 300 (6) 18.0 ± 8.83 26.1 ± 7.56 600 (6) 27.5 ± 5.21 46.9 ± 15.5 D 600 (6) 30.1 ± 10.9 37.8 ± 11.4 E 600 (6) 41.6 ± 12.9 69.9 ± 18.5 *C.sub.24 only reported for Metabolite 1-7; C.sub.24 at steady state was the mean of C.sub.24 at 72, 96, 120, 144 and 168 h.
(103)
(104) An E.sub.max model, generated by plotting the AUC of metabolite 1-7 against the HCV RNA reduction, was used to predict that metabolite 1-7 exposures of ≥2000 ng/mL×h will result in a maximal viral load reduction of at least 4 log units after 7 days of QD dosing with Compound 2 (
(105) Mean plasma concentration-time profiles for ascending Compound 2 doses in subjects without cirrhosis enrolled in Part C of the study are shown in
(106) Based on the known metabolism of Compound 2, metabolite 1-7 is regarded as the most important metabolite in circulation as it reflects liver conversion of Compound 2 to the active metabolite 1-7. Therefore metabolite 1-7 plasma levels may be a correlate of Compound 2 dose-associated antiviral activity in subjects' livers. For rapidly-replicating viruses such as HCV, maintenance of antiviral activity throughout inter-dose time intervals optimizes efficacy by reducing chances for recrudescent viral replication during inter-dose trough periods. Compound 2 exhibited early and potent viral suppression which correlated well with the plasma PK of metabolite 1-7 regardless of genotype or mild hepatic impairment. After the first 600 mg dose, mean metabolite 1-7 trough concentration (27.5 ng/mL in NC GT1b infected subjects; 30.1 ng/mL in NC GT3 infected subjects; 41.6 ng/mL in subjects with cirrhosis) already exceeded the EC.sub.95 of Compound 1 in inhibiting replicons containing HCV constructs of clinical isolates (GT1b EC.sub.95 of ˜22 ng/mL metabolite 1-7 equivalent; GT2 EC.sub.95 of ˜12 ng/mL; GT3 EC.sub.95 of ˜18 ng/mL), resulting in very rapid plasma HCV RNA decreases of up to 2.4 log.sub.10 IU/mL within the first 24 h of dosing. Upon reaching steady state, metabolite 1-7 troughs were 2- to 6-fold the EC.sub.95 values (depending on genotype), exerting sustained suppressive pressure on viral replication, leading to −4.5 log.sub.10 IU/mL reductions in plasma HCV RNA regardless of genotype or cirrhosis status. In those cohorts receiving 600 mg QD, ˜30% of subjects achieved HCV RNA below the lower limit of quantitation with only seven days of therapy. Further modeling demonstrated that E.sub.max was achieved with metabolite 1-7 AUCτ greater than 2000 ng/mL×h and only the 600 mg QD dose produced exposure values that were consistently above this threshold. Overall, Compound 2 monotherapy exhibited very rapid and equally potent antiviral activity regardless of genotype or cirrhosis status. Compound 2 at the highest doses evaluated for seven days was well tolerated in HCV-infected subjects. Compound 2 demonstrated rapid, potent, dose/exposure-related and pan-genotypic antiviral activity with similar responses in those subjects with and without cirrhosis.
(107) This specification has been described with reference to embodiments of the invention. However, one of ordinary skill in the art appreciates that various modifications and changes can be made without departing from the scope of the invention as set forth in the claims below. Accordingly, the specification is to be regarded in an illustrative rather than a restrictive sense, and all such modifications are intended to be included within the scope of invention.