Antifungal agents with enhanced activity in acidic pH

Abstract

Enfumafungin derivative triterpenoid antifungal compounds are used to treat or prevent fungal infections occurring in or under acidic conditions where the pH is lower than about 7, due to their unexpected, enhanced efficacy under such conditions. The enfumafungin derivative triterpenoids (or pharmaceutically acceptable salts or hydrates thereof) are inhibitors of (1,3)-β-D-glucan synthesis and are useful in the treatment or prevention of yeast or mold infections that occur in anatomic areas having a low pH, such as the vaginal cavity, or under acidic local environment conditions such of those seen in fungal abscesses, empyema, or upper gastrointestinal tract infections.

Claims

1. A method of treating vulvovaginal candidiasis (VVC) infection in a subject, the method comprising administering to the subject a compound of Formula (IIa): ##STR00007## which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[(2R)-2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazol-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenanthro[1,2-c]pyran-7-carboxylic acid, or a pharmaceutically acceptable salt or hydrate thereof, wherein the compound or the pharmaceutically acceptable salt thereof is administered at a total daily dose of 150 to 600 mg of the compound, and wherein the VVC infection occurs in a condition or an anatomic area in which the pH is lower than about 5.

2. The method according to claim 1, wherein the compound or the pharmaceutically acceptable salt thereof is administered at a total daily dose of 300 to 600 mg of the compound.

3. The method according to claim 1, wherein the compound or the pharmaceutically acceptable salt thereof is administered BID (twice daily) each time at a dose of 150 to 300 mg of the compound, for a total daily dose of 300 mg to 600 mg of the compound.

4. The method according to claim 1, wherein the compound or the pharmaceutically acceptable salt thereof is administered at a total daily dose of 150 mg, a total daily dose of 300 mg, or a total daily dose of 600 mg of the compound.

5. The method according to claim 1, wherein the compound or the pharmaceutically acceptable salt thereof is administered at a total daily dose of 600 mg of the compound.

6. The method according to claim 1, wherein the citrate salt of the compound of Formula (IIa) is administered.

7. The method according to claim 1, wherein the compound or the pharmaceutically acceptable salt thereof is administered orally.

8. The method according to claim 1, wherein the compound or the pharmaceutically acceptable salt thereof is administered orally in a tablet.

9. The method according to claim 1, wherein the compound or the pharmaceutically acceptable salt thereof is administered topically.

10. A method of preventing vulvovaginal candidiasis (VVC) infection in a subject, the method comprising administering to the subject a compound of Formula (IIa): ##STR00008## which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[(2R)-2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazol-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenanthro[1,2-c]pyran-7-carboxylic acid, or a pharmaceutically acceptable salt or hydrate thereof, wherein the compound or the pharmaceutically acceptable salt thereof is administered at a total daily dose of 150 to 600 mg of the compound, and wherein the VVC infection occurs in a condition or an anatomic area in which the pH is lower than about 5.

11. The method according to claim 10, wherein the citrate salt of the compound of Formula (IIa) is administered.

12. The method according to claim 10, wherein the compound or the pharmaceutically acceptable salt thereof is administered orally.

13. The method according to claim 10, wherein the VVC infection is a recurrent VVC infection.

14. A method of treating vulvovaginal candidiasis (VVC) infection in a subject, the method comprising orally administering to the subject a citrate salt of a compound of Formula (IIa): ##STR00009## which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[(2R)-2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazol-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenanthro[1,2-c]pyran-7-carboxylic acid, wherein the citrate salt of the compound is administered at a total daily dose of 150 to 600 mg of the compound.

15. The method according to claim 14, wherein the citrate salt of the compound is administered orally in a tablet.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) FIG. 1 is a table showing antifungal susceptibility at different pH conditions for vaginal Candida spp. isolates, adapted from Danby et al. (2012).

DETAILED DESCRIPTION OF THE INVENTION

(2) Previous reports have shown that the potency of most antifungal agents decreases at low pH. No antifungal to date has shown a significant increase in potency (for example, as shown by a >4-fold reduction in MIC) when tested against Candida glabrata and Candida albicans (the most common Candida species causing infections in humans) in acidic conditions. Unexpectedly, enfumafungin derivatives described herein show a significant enhancement in their antifungal potency when tested at low pH, providing the basis for an unexpected clinical benefit when using the compounds in the treatment or prevention of fungal infections under low pH conditions. Examples of a potential clinical benefit of the enhanced activity of enfumafungin derivatives under acidic conditions include but are not limited to: improved efficacy in treating or preventing fungal infections occurring under acidic conditions, enhanced likelihood to achieve tissue concentrations that are above the MIC of the causative fungal pathogen (providing a greater opportunity to kill or prevent the growth of the pathogen), and the opportunity to achieve successful outcomes while administering doses of the enfumafungin derivatives that are lower than the doses that would be required to treat or prevent an infection under neutral pH conditions.

(3) The present invention provides the use of a compound of Formula (I), or a pharmaceutically acceptable salt or hydrate thereof:

(4) ##STR00002##

(5) wherein:

(6) X is O or H, H;

(7) R.sup.e is C(O)NR.sup.fR.sup.g or a 6-membered ring heteroaryl group containing 1 or 2 nitrogen atoms wherein the heteroaryl group is optionally mono-substituted on a ring carbon with fluoro or chloro or on a ring nitrogen with oxygen;

(8) R.sup.f, R.sup.g, R.sup.6 and R.sup.7 are each independently hydrogen or C.sub.1-C.sub.3 alkyl;

(9) R.sup.8 is C.sub.1-C.sub.4 alkyl, C.sub.3-C.sub.4 cycloalkyl or C.sub.4-C.sub.5 cycloalkyl-alkyl;

(10) R.sup.9 is methyl or ethyl; and

(11) R.sup.8 and R.sup.9 are optionally taken together to form a 6-membered saturated ring containing 1 oxygen atom,

(12) in a subject for the treatment or prevention of a fungal infection that occurs under acidic pH conditions. The fungal infection may be a yeast or mold infection that occurs in conditions or anatomic areas that have a pH lower than about 7, such as, for example, a pH between about 4 to about 6.8. In some embodiments, the pH ranges from about 4 to about 6; and in certain embodiments, such as vaginal yeast infections, the pH is lower than about 5, and more specifically may be between about 4 to about 4.5. Infections treatable and/or preventable by the methods of the present invention include but are not limited to vaginal yeast infections, fungal abscess or empyema in any location, and infections in the upper gastrointestinal tract.

(13) The invention also provides methods of treating or preventing a fungal infection that occurs under acidic pH conditions in a subject by administering the compound of Formula (I) or a pharmaceutically acceptable salt or hydrate thereof. Further, the invention provides the use of a compound of Formula (I) or a pharmaceutically acceptable salt or hydrate thereof in the preparation of a medicament for treating a fungal infection that occurs under acidic pH conditions in a subject.

(14) The present invention also provides the use of a compound of Formula (Ia), or a pharmaceutically acceptable salt or hydrate thereof:

(15) ##STR00003##

(16) wherein the substituents are as provided for in Formula (I),

(17) in a subject for the treatment or prevention of a fungal infection that occurs under acidic pH conditions. The fungal infection may be a yeast or mold infection that occurs in conditions or anatomic areas that have a pH lower than about 7, such as, for example, a pH between about 4 to about 6.8. In some embodiments, the pH ranges from about 4 to about 6; and in certain embodiments, such as vaginal yeast infections, the pH is lower than about 5, and more specifically may be between about 4 to about 4.5. Infections treatable and/or preventable by the methods of the present invention include but are not limited to vaginal yeast infections, fungal abscess or empyema in any location, and infections in the upper gastrointestinal tract.

(18) The invention also provides methods of treating or preventing a fungal infection that occurs under acidic pH conditions in a subject by administering the compound of Formula (Ia) or a pharmaceutically acceptable salt or hydrate thereof. Further, the invention provides the use of a compound of Formula (Ia) or a pharmaceutically acceptable salt or hydrate thereof in the preparation of a medicament for treating a fungal infection that occurs under acidic pH conditions in a subject.

(19) In embodiment 1: X is H, H, and the other substituents are as provided in Formula (I).

(20) In embodiment 2: R.sup.e is either pyridyl or pyrimidinyl optionally mono-substituted on a ring carbon with fluoro or chloro or on a ring nitrogen with oxygen, and the other substituents are as provided in embodiment 1 or in Formula (I).

(21) In embodiment 3: R.sup.e is 4-pyridyl and the other substituents are as provided in embodiment 1 or in Formula (I).

(22) In embodiment 4: R.sup.e is C(O)NH.sub.2 or C(O)NH(C.sub.1-C.sub.3 alkyl) and the other substituents are as provided in embodiment 1 or in Formula (I).

(23) In embodiment 5: R.sup.8 is C.sub.1-C.sub.4 alkyl and R.sup.9 is methyl; and the other substituents are as provided in embodiment 1, 2, 3, or 4, or in Formula (I).

(24) In embodiment 6: R.sup.8 is t-butyl, R.sup.9 is methyl; and the other substituents are as provided in embodiment 1, 2, 3, or 4, or in Formula (I).

(25) In embodiment 7: R.sup.6 and R.sup.7 are each independently hydrogen or methyl and the other substituents are as provided in embodiment 1, 2, 3, 4, 5, or 6, or in Formula (I).

(26) In embodiment 1′: X is H, H, and the other substituents are as provided for in Formula (Ia).

(27) In embodiment 2′: R.sup.e is either pyridyl or pyrimidinyl optionally mono-substituted on a ring carbon with fluoro or chloro or on a ring nitrogen with oxygen, and the other substituents are as provided in embodiment 1′ or in Formula (Ia).

(28) In embodiment 3′: R.sup.e is 4-pyridyl and the other substituents are as provided in embodiment 1′ or in Formula (Ia).

(29) In embodiment 4′: R.sup.e is C(O)NH.sub.2 or C(O)NH(C.sub.1-C.sub.3 alkyl) and the other substituents are as provided in embodiment 1′ or in Formula (Ia).

(30) In embodiment 5′: R.sup.8 is C.sub.1-C.sub.4 alkyl and R.sup.9 is methyl; and the other substituents are as provided in embodiment 1′, 2′, 3′, or 4′, or in Formula (Ia).

(31) In embodiment 6′: R.sup.8 is t-butyl, R.sup.9 is methyl; and the other substituents are as provided in embodiment 1′, 2′, 3′, or 4′, or in Formula (Ia).

(32) In embodiment 7′: R.sup.6 and R.sup.7 are each independently hydrogen or methyl and the other substituents are as provided in embodiment 1′, 2′, 3′, 4′, 5′, or 6′, or in Formula (Ia).

(33) In preferred embodiments, the present invention provides the use of a compound of Formula (II):

(34) ##STR00004##
which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazol-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenanthro[1,2-c]pyran-7-carboxylic acid,

(35) or a pharmaceutically acceptable salt or hydrate thereof,

(36) in a subject for the treatment or prevention of a fungal infection that occurs under acidic pH conditions. The fungal infection may be a yeast or mold infection that occurs in conditions or anatomic areas that have a pH lower than about 7, such as, for example, a pH between about 4 to about 6.8. In some embodiments, the pH ranges from about 4 to about 6; and in certain embodiments, such as vaginal yeast infections, the pH is lower than about 5, and more specifically may be between about 4 to about 4.5. Infections treatable and/or preventable by the methods of the present invention include but are not limited to vaginal yeast infections, fungal abscess or empyema in any location, and infections in the upper gastrointestinal tract.

(37) The invention also provides methods of treating or preventing a fungal infection that occurs under acidic pH conditions in a subject by administering the compound of Formula (II) or a pharmaceutically acceptable salt or hydrate thereof. Further, the invention provides the use of a compound of Formula (II) or a pharmaceutically acceptable salt or hydrate thereof in the preparation of a medicament for treating a fungal infection that occurs under acidic pH conditions in a subject.

(38) In other preferred embodiments, the present invention provides the use of a compound of Formula (IIa) (herein referred to as SCY-078):

(39) ##STR00005##
which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[(2R)-2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazol-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenanthro[1,2-c]pyran-7-carboxylic acid,

(40) or a pharmaceutically acceptable salt or hydrate thereof,

(41) in a subject for the treatment or prevention of a fungal infection that occurs under acidic pH conditions. The fungal infection may be a yeast or mold infection that occurs in conditions or anatomic areas that have a pH lower than about 7, such as, for example, a pH between about 4 to about 6.8. In some embodiments, the pH ranges from about 4 to about 6; and in certain embodiments, such as vaginal yeast infections, the pH is lower than about 5, and more specifically may be between about 4 to about 4.5. Infections treatable and/or preventable by the methods of the present invention include but are not limited to vaginal yeast infections, fungal abscess or empyema in any location, and infections in the upper gastrointestinal tract.

(42) The invention also provides methods of treating or preventing a fungal infection that occurs under acidic pH conditions in a subject by administering the compound of Formula (IIa) or a pharmaceutically acceptable salt or hydrate thereof. Further, the invention provides the use of a compound of Formula (IIa) or a pharmaceutically acceptable salt or hydrate thereof in the preparation of a medicament for treating a fungal infection that occurs under acidic pH conditions in a subject.

(43) In preferred embodiments, the phosphate salt of a compound of Formula (I), (Ia), (II), or (IIa) is used or administered as described herein.

(44) In preferred embodiments, the citrate salt of a compound of Formula (I), (Ia), (II), or (IIa) is used or administered as described herein.

(45) The present invention also provides the use of a pharmaceutical composition comprising a compound of Formula (I), (Ia), (II), or (IIa), or a pharmaceutically acceptable salt or hydrate thereof, and a pharmaceutically acceptable carrier, adjuvant, or vehicle, in a subject for the treatment or prevention of a fungal infection that occurs under acidic pH conditions. The fungal infection may be a yeast or mold infection that occurs in conditions or anatomic areas that have a pH lower than about 7, such as, for example, a pH ranging from about 4 to about 6, or more specifically a pH of about 5, about 4.5, or about 4. Such infections include but are not limited to vaginal yeast infections, fungal abscess or empyema in any location, and infections in the upper gastrointestinal tract. For example, the pH in the vaginal milieu is about 4-4.5, and the pH of abscesses can range from about 5.5 to about 6.8.

(46) The invention also provides methods of treating or preventing a fungal infection that occurs under acidic pH conditions in a subject by administering a pharmaceutical composition comprising the compound of Formula (I), (Ia), (II), or (IIa), or a pharmaceutically acceptable salt or hydrate thereof.

(47) In the description of compounds in the embodiments set forth above, indicated substitutions are included only to the extent that the substituents provide stable compounds consistent with the definition.

(48) The compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, have antimicrobial (e.g., antifungal) activities against yeasts and other fungi, including one or more of Acremonium, Absidia (e.g., Absidia corymbifera), Alternaria, Aspergillus (e.g., Aspergillus clavatus, Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, Aspergillus niger, Aspergillus terreus, and Aspergillus versicolor), Bipolaris, Blastomyces (e.g., Blastomyces dermatitidis), Blastoschizomyces (e.g., Blastoschizomyces capitatus), Candida (e.g., Candida albicans, Candida glabrata, Candida guilliermondii, Candida kefyr, Candida krusei, Candida lusitaniae, Candida parapsilosis, Candida pseudotropicalis, Candida stellatoidea, Candida tropicalis, Candida utilis, Candida lipolytica, Candida famata and Candida rugosa), Cladosporium (e.g., Cladosporium carrionii and Cladosporium trichloides), Coccidioides (e.g., Coccidioides immitis), Cryptococcus (e.g., Cryptococcus neoformans), Curvularia, Cunninghamella (e.g., Cunninghamella elegans), Dermatophyte, Exophiala (e.g., Exophiala dermatitidis and Exophiala spinifera), Epidermophyton (e.g., Epidermophyton floccosum), Fonsecaea (e.g., Fonsecaea pedrosoi), Fusarium (e.g., Fusarium solani), Geotrichum (e.g., Geotrichum candiddum and Geotrichum clavatum), Histoplasma (e.g., Histoplasma capsulatum var. capsulatum), Malassezia (e.g., Malassezia furfur), Microsporum (e.g., Microsporum canis and Microsporum gypseum), Mucor, Paracoccidioides (e.g., Paracoccidioides brasiliensis), Penicillium (e.g., Penicillium marneffei), Phialophora, Pityrosporum ovale, Pneumocystis (e.g., Pneumocystis carinii), Pseudallescheria (e.g., Pseudallescheria boydii), Rhizopus (e.g., Rhizopus microsporus var. rhizopodiformis and Rhizopus oryzae), Saccharomyces (e.g., Saccharomyces cerevisiae), Scedosporium (e.g., Scedosporium apiosperum), Scopulariopsis, Sporothrix (e.g., Sporothrix schenckii), Trichoderma, Trichophyton (e.g., Trichophyton mentagrophytes and Trichophyton rubrum), and Trichosporon (e.g., Trichosporon asahii, Trichosporon beigelii and Trichosporon cutaneum). The compounds are not only useful against organisms causing systemic human pathogenic fungal infections, but also are useful against organisms causing superficial fungal infections such as Trichoderma spp. and other Candida spp. The compounds are particularly effective against Candida species and Aspergillus species.

(49) In view of their antifungal activity, compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, are useful for the treatment and/or prevention of one or more of a variety of superficial, cutaneous, mucocutaneous, subcutaneous and systemic fungal infections in vulva, vagina, skin, eye, hair, nail, oral mucosa, gastrointestinal tract, bronchus, lung, pleura, peritoneum, endocardium, brain, meninges, urinary organ, vaginal portion, oral cavity, systemic, kidney, bronchus, heart, external auditory canal, bone, nasal cavity, paranasal cavity, spleen, liver, hypodermal tissue, lymph duct, gastrointestinal, articulation, muscle, tendon, interstitial plasma cell in lung, blood, and so on.

(50) The compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, are useful for preventing and treating one or more of various infectious diseases, such as vulvovaginal candidiasis (VVC), dermatophytosis (e.g., trichophytosis, ringworm or tinea infections), paronychia, pityriasis versicolor, erythrasma, intertrigo, fungal diaper rash, candida vulvitis, candida balanitis, otitis externa, candidiasis (cutaneous and mucocutaneous), chronic mucocandidiasis (e.g., thrush and vaginal candidiasis), cryptococcosis, geotrichosis, trichosporosis, aspergillosis, penicilliosis, fusariosis, zygomycosis, sporotrichosis, chromomycosis, coccidioidomycosis, histoplasmosis, blastomycosis, paracoccidioidomycosis, pseudallescheriosis, mycetoma, fungal keratitis, otomycosis, pneumocystosis, fungal abscess, fungal pleural empyema, and fungemia. The compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, may also be used as prophylactic agents to prevent systemic and topical fungal infections.

(51) The compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, may be used to prevent recurrences of VVC in patients suffering from recurrent VVC. Use as prophylactic agents may, for example, be appropriate as part of a selective gut decontamination regimen in the prevention of infection in immuno-compromised patients (e.g., AIDS patients, patients receiving cancer therapy, or transplant patients). Prevention of fungal overgrowth during antibiotic treatment may also be desirable in some disease syndromes or iatrogenic states. Specifically, prevention of Candida spp. overgrowth in vagina in patients receiving antibiotic treatment or who have uncontrolled risk factors for Candida spp. overgrowth such as high glucose in blood, may be desirable.

(52) The compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, can be made according to the synthesis methods disclosed in U.S. Pat. No. 8,188,085, the contents of which are hereby incorporated by reference in their entirety.

(53) As used herein, the term “alkyl” refers to any linear or branched chain alkyl group having a number of carbon atoms in the specified range. Thus, for example, “C.sub.1-6 alkyl” (or “C.sub.1-C.sub.6 alkyl”) refers to all of the hexyl alkyl and pentyl alkyl isomers as well as n-, iso-, sec- and t-butyl, n- and isopropyl, ethyl and methyl. As another example, “C.sub.1-4 alkyl” refers to n-, iso-, sec- and t-butyl, n- and isopropyl, ethyl and methyl.

(54) The term “cycloalkyl” refers to any cyclic ring of an alkane having a number of carbon atoms in the specified range. Thus, for example, “C.sub.3-4 cycloalkyl” (or “C.sub.3-C.sub.4 cycloalkyl”) refers to cyclopropyl and cyclobutyl.

(55) The term “cycloalkyl-alkyl” (or equivalently “alkyl-cycloalkyl”) as used herein refers to a system that includes an alkyl portion as described above and also includes a cycloalkyl portion as described above. Attachment to a “cycloalkyl-alkyl” (or “alkyl-cycloalkyl”) may be through either the cycloalkyl or the alkyl portion. The specified number of carbon atoms in “cycloalkyl-alkyl” systems refers to the total number of carbon atoms in both the alkyl and the cycloalkyl parts. Examples of C.sub.4-C.sub.5 cycloalkyl-alkyl include but are not limited to methylcyclopropyl, dimethylcyclopropyl, methylcyclobutyl, ethylcyclopropyl, cyclopropylmethyl, cyclopropylethyl and cyclobutylmethyl.

(56) The term “halogen” (or “halo”) refers to fluorine, chlorine, bromine and iodine (alternatively referred to as fluoro, chloro, bromo, and iodo).

(57) The term “or” as used herein denotes alternatives that may, where appropriate, be combined.

(58) Unless expressly stated to the contrary, all ranges cited herein are inclusive. For example, a heterocyclic ring described as containing from “1 to 4 heteroatoms” means the ring can contain 1, 2, 3, or 4 heteroatoms. It is also to be understood that any range cited herein includes within its scope all of the sub-ranges within that range. Thus, for example, a heterocyclic ring described as containing from “1 to 4 heteroatoms” is intended to include as aspects thereof, heterocyclic rings containing 2 to 4 heteroatoms, 3 or 4 heteroatoms, 1 to 3 heteroatoms, 2 or 3 heteroatoms, 1 or 2 heteroatoms, 1 heteroatom, 2 heteroatoms, and so forth.

(59) Any of the various cycloalkyl and heterocyclic/heteroaryl rings and ring systems defined herein may be attached to the rest of the compound at any ring atom (i.e., any carbon atom or any heteroatom) provided that a stable compound results. Suitable 5- or 6-membered heteroaromatic rings include, but are not limited to, pyridyl, pyrazinyl, pyrimidinyl, pyridazinyl and triazolyl.

(60) A “stable” compound is a compound that can be prepared and isolated and whose structure and properties remain or can be caused to remain essentially unchanged for a period of time sufficient to allow use of the compound for the purposes described herein (e.g., therapeutic or prophylactic administration to a subject). Reference to a compound also includes stable complexes of the compound such as a stable hydrate.

(61) As a result of the selection of substituents and substituent patterns, certain of the compounds of Formula (I), (Ia), (II), and (IIa) can have asymmetric centers and can occur as mixtures of stereoisomers, or as individual diastereomers, or enantiomers. Unless otherwise indicated, all isomeric forms of these compounds (and pharmaceutically acceptable salts and/or hydrate forms thereof), whether isolated or in mixtures, are within the scope of the present invention. Also included within the scope of the present invention are tautomeric forms of the compounds as depicted (and pharmaceutically acceptable salts and/or hydrate forms thereof).

(62) When any variable occurs more than one time in any constituent or in Formula (I), (Ia), (II), or (IIa), its definition on each occurrence is independent of its definition at every other occurrence. Also, combinations of substituents and/or variables are permissible only if such combinations result in stable compounds.

(63) The term “substituted” includes mono- and poly-substitution by a named substituent to the extent such single and multiple substitution (including multiple substitution at the same site) is chemically allowed. Unless expressly stated to the contrary, substitution by a named substituent is permitted on any atom in a ring (e.g., an aryl, a cycloalkyl, a heteroaryl, or a heterocyclyl) provided such ring substitution is chemically allowed and results in a stable compound.

(64) A bond terminated by a wavy line is used herein to signify the point of attachment of a substituent group or partial structure. This usage is illustrated by the following example:

(65) ##STR00006##

(66) The compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, are also useful in the preparation and execution of screening assays for antifungal compounds. For example, the compounds are useful for isolating mutants, which are excellent screening tools for identifying further antifungal compounds.

(67) The compounds of Formula (I), (Ia), (II), and (IIa) may be administered in the form of “pharmaceutically acceptable salts” or hydrates as appropriate. Other salts may, however, be useful in the preparation of the compounds or of their pharmaceutically acceptable salts. For example, when the compounds contain a basic amine group, they may be conveniently isolated as trifluoroacetic acid salts (e.g., following HPLC purification). Conversion of the trifluoroacetic acid salts to other salts, including pharmaceutically acceptable salts, may be accomplished by a number of standard methods known in the art. For example, an appropriate ion exchange resin may be employed to generate the desired salt. Alternatively, conversion of a trifluoroacetic acid salt to the parent free amine may be accomplished by standard methods known in the art (e.g., neutralization with an appropriate inorganic base such as NaHCO.sub.3). Other desired amine salts may then be prepared in a conventional manner by reacting the free base with a suitable organic or inorganic acid. Representative pharmaceutically acceptable quaternary ammonium salts include the following: hydrochloride, sulfate, phosphate, carbonate, acetate, tartrate, citrate, malate, succinate, lactate, stearate, fumarate, hippurate, maleate, gluconate, ascorbate, adipate, gluceptate, glutamate, glucoronate, propionate, benzoate, mesylate, tosylate, oleate, lactobionate, laurylsulfate, besylate, caprylate, isetionate, gentisate, malonate, napsylate, edisylate, pamoate, xinafoate, napadisylate, hydrobromide, nitrate, oxalate, cinnamate, mandelate, undecylenate, and camsylate. Many of the compounds of Formula (I), (Ia), (II), and (IIa) carry an acidic carboxylic acid moiety, in which case suitable pharmaceutically acceptable salts thereof may include alkali metal salts, e.g., sodium or potassium salts; alkaline earth metal salts, e.g., calcium or magnesium salts; and salts formed with suitable organic ligands, e.g., quaternary ammonium salts.

(68) The present invention includes within its scope the use of prodrugs of Formula (I), (Ia), (II), and (IIa). In general, such prodrugs will be functional derivatives of the compounds, which are readily convertible in vivo into the required compound. Thus, in the methods of treatment of the present invention, the term “administering” shall encompass the treatment of the various conditions described with the compound specifically disclosed or with a compound that converts to the specified compound in vivo after administration to the patient. Conventional procedures for the selection and preparation of suitable prodrug derivatives are described, for example, in “Design of Prodrugs,” ed. H. Bundgaard, Elsevier, 1985, which is incorporated by reference herein in its entirety. Metabolites of the compounds of Formula (I), (Ia), (II), and (IIa) include active species produced upon introduction of the compounds into the biological milieu.

(69) The term “administration” and variants thereof (e.g., “administering” a compound) mean providing a compound (optionally in the form of a salt or hydrate thereof) or a prodrug of the compound to the subject in need of treatment. When a compound of Formula (I), (Ia), (II), and (IIa) or pharmaceutically acceptable salt thereof or a hydrate or prodrug thereof is provided in combination with a second active agent (e.g., other antifungal and/or antibacterial agents useful for treating fungal and/or bacterial infections), “administration” and its variants are each understood to include concurrent and sequential provision of the compound (or the salt, hydrate, or prodrug thereof) and of the other active agent.

(70) As used herein, the term “composition” is intended to encompass a product comprising the specified ingredients, as well as any product that results, directly or indirectly, from combining the specified ingredients.

(71) By “pharmaceutically acceptable” is meant that the ingredients of the pharmaceutical composition must be compatible with each other and not deleterious to the recipient thereof.

(72) The term “subject” (alternatively referred to herein as “patient”) as used herein refers to an animal, preferably a mammal, most preferably a human, who has been the object of treatment, observation, or experiment.

(73) The term “enhanced antifungal activity” refers to the effect of a compound of Formula (I), (Ia), (II), or (IIa) or a pharmaceutically acceptable salt thereof or a hydrate or prodrug thereof having a greater than 4-fold reduction of the in vitro minimum inhibitory concentration (MIC.sub.50) when tested in clinically relevant acidic conditions, such as, for example, conditions where the pH is about 4-4.5 (which is clinically relevant for vaginal infections), in comparison with the MIC.sub.50 observed when tested at a neutral pH of about 7.

(74) The term “effective amount” as used herein means an amount of active ingredient or pharmaceutical agent that elicits the biological or medicinal response in a tissue, system, animal, or human that is being sought by a researcher, veterinarian, medical doctor, or other clinician. In one embodiment, the “effective amount” can be a therapeutically effective amount that alleviates the symptoms of the disease or condition being treated. In another embodiment, the “effective amount” can be a prophylactically effective amount for prophylaxis of the symptoms of the disease or condition being prevented or for reducing the likelihood of occurrence. The term can also refer to an inhibition effective amount of the enfumafungin derivative sufficient to inhibit (1,3)-β-D-glucan synthase and thereby elicit the response being sought.

(75) References to “treat,” “treating,” “treatment,” and variants thereof, generally refer to a treatment that, after it is administered, results in resolution or improvement of one or more signs or symptoms associated with a fungal infection, or that results in eradication of the fungi responsible for an infection, or any combination of these outcomes.

(76) For the purpose of preventing or treating a fungal infection, the compound of Formula (I), (Ia), (II), or (IIa) (optionally in the form of a salt or a hydrate) can be administered in conventional ways available for use in conjunction with pharmaceuticals.

(77) For the purpose of preventing or treating fungal infections that occur in conditions or anatomic areas that have acidic pH, the compound of Formula (I), (Ia), (II), or (IIa) (optionally in the form of a salt or a hydrate) can be administered alone as an individual therapeutic agent or with one or more other antifungal agents (sequentially or concurrently) as a combination of therapeutic agents.

(78) For the purpose of preventing or treating a fungal infection, the compound of Formula (I), (Ia), (II), or (IIa) (optionally in the form of a salt or a hydrate) can be administered with a pharmaceutical carrier selected on the basis of the chosen route of administration and standard pharmaceutical practice.

(79) For example, the compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically salts and/or hydrate forms thereof, can be administered by one or more of the following routes: orally, parenterally (including subcutaneous injections, intravenous, intramuscular, intra-lesion injection or infusion techniques), by inhalation (e.g., nasal or buccal inhalation spray, aerosols from metered dose inhalator, and dry powder inhalator), by nebulizer, ocularly, topically, transdermally, or rectally, in the form of a unit dosage of a pharmaceutical composition containing an effective amount of the compound and conventional non-toxic pharmaceutically-acceptable carriers, adjuvants and vehicles. Liquid preparations suitable for oral administration (e.g., suspensions, syrups, elixirs and the like) can be prepared according to techniques known in the art and can employ the usual media such as water, glycols, oils, alcohols and the like. Solid preparations suitable for oral administration (e.g., powders, pills, capsules and tablets) can be prepared according to techniques known in the art and can employ such solid excipients as starches, sugars, kaolin, lubricants, binders, disintegrating agents and the like. Parenteral compositions can be prepared according to techniques known in the art and typically employ sterile water as a carrier and optionally other ingredients, such as a solubility aid. Injectable solutions can be prepared according to methods known in the art wherein the carrier comprises a saline solution, a glucose solution or a solution containing a mixture of saline and glucose.

(80) Further description of methods suitable for use in preparing pharmaceutical compositions and of ingredients suitable for use in said compositions is provided in Remington's Pharmaceutical Sciences, 20.sup.th edition, edited by A. R. Gennaro, Mack Publishing Co., 2000.

(81) The compounds of Formula (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salts and/or hydrate forms thereof, can be administered, e.g., orally or intravenously, in a dosage range of, for example, 0.001 to 1000 mg/kg of mammal (e.g., human) body weight per day in a single dose or in divided doses. An example of a dosage range is 0.01 to 500 mg/kg body weight per day orally or intravenously in a single dose or in divided doses. Another example of a dosage range is 0.1 to 50 mg/kg body weight per day orally or intravenously in single or divided doses. For oral administration, the compositions can be provided in the form of tablets or capsules containing, for example, 1.0 to 1000 milligrams of the active ingredient, particularly 1, 5, 10, 15, 20, 25, 50, 75, 100, 150, 200, 250, 300, 400, 500, 600, 750, and 1000 milligrams of the active ingredient for the symptomatic adjustment of the dosage to the patient to be treated. The specific dose level and frequency of dosage for any particular patient may be varied and will depend upon a variety of factors including the activity of the specific compound employed, the metabolic stability and length of action of that compound, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the severity of the particular condition, and the host undergoing therapy. For example, in embodiments, a pharmaceutically acceptable salt of the compound of Formula (IIa) is administered to a subject to provide a total daily dose of 150 to 600 mg of the compound of Formula (IIa). In certain embodiments, a total daily dose of 150 mg, a total daily dose of 300 mg, or a total daily dose of 600 mg of the compound of Formula (IIa) is administered; the total daily dose may be administered on a once-daily basis or it may be divided such as for BID (twice daily) dosing or TID (thrice daily) dosing. In embodiments, a pharmaceutically acceptable salt of the compound of Formula (IIa) is administered BID to provide 150 to 300 mg of the compound of Formula (IIa) twice daily, for a total daily dose of 300 mg to 600 mg of the compound of Formula (IIa). In an embodiment, two tablets containing a pharmaceutically acceptable salt of the compound of Formula (IIa), each tablet providing 150 mg of the compound of Formula (IIa), are administered to a subject, and then two more such tablets are administered to the subject 12 hours later, for a total daily dose of 600 mg. In another embodiment, a tablet containing a pharmaceutically acceptable salt of the compound of Formula (IIa), providing 150 mg of the compound of Formula (IIa), is administered to a subject, and then another such tablet is administered to the subject 12 hours later, for a total daily dose of 300 mg.

(82) The present invention provides methods for treating or preventing a fungal infection that occurs in low pH environments (e.g., where the pH is lower than about 5), comprising administering an effective amount of a compound of Formula (I), (Ia), (II), or (IIa) (or a pharmaceutically acceptable salt or hydrate thereof), wherein the effective amount is less than the amount of the compound that would be required to treat or prevent a fungal infection occurring where the pH is about 7.

(83) For example, the amount of a compound of Formula (I), (Ia), (II), or (IIa) effective to treat or prevent a fungal infection under pH conditions where the pH is, for example, about 4-4.5, may be about 90%, about 80%, about 70%, about 60%, or about 50% lower than the amount of the compound required to treat or prevent a fungal infection under conditions where the pH is, for example, about 7. As shown herein, in an exemplary embodiment of the methods of the present invention, the compound of Formula (I), (Ia), (II), or (IIa) or a pharmaceutically acceptable salt of hydrate thereof exhibited increased potency in low pH environments, including in environments where the pH is 4.5. In addition, good absorption and delivery to tissues (including vaginal tissues) following oral administration was exhibited in mice. The present invention therefore provides the ability to use reduced dosage amounts of a compound of Formula (I), (Ia), (II), or (IIa) (or a pharmaceutically acceptable salt or hydrate thereof) to achieve an effective amount of the compound at the site of infection.

(84) Antifungal activity of compounds can be demonstrated by various assays known in the art, for example, by their minimum inhibitory concentration (MIC) against yeasts and minimum effective concentration (MEC) against filamentous molds and dermatophytes in a broth microdilution assay, or in vivo evaluation of the anti-Candida and anti Aspergillus activity in mouse or rabbit models. The compounds of Formula (I) provided in the Examples of U.S. Pat. No. 8,188,085 were generally found to inhibit the growth of Candida spp. in the range of <0.03-32 μg/mL or to give an MEC against Aspergillus fumigatus in the range of <0.03-32 μg/mL.

EXAMPLES

(85) The following examples serve only to illustrate the invention and its practice. The examples are not to be construed as limitations on the scope or spirit of the invention.

Example 1

Evaluation of the Effect of pH on the Susceptibility of Clinical Vaginal Candida Glabrata and Candida Albicans Isolates

(86) The purpose of this study was to determine whether changes in test medium pH had an effect on the in vitro susceptibility of Candida glabrata and Candida albicans vaginal isolates to a representative compound of the enfumafungin derivatives (for example, the citrate salt of SCY-078), using fluconazole and micafungin as comparators.

Materials and Methods

(87) Clinical Isolates and Antifungals

(88) Ten strains each of C. glabrata and C. albicans vaginal isolates were tested. The strains were obtained from recent clinical trial patients with vulvovaginal candidiasis (VVC) prior to treatment. Candida strains were obtained from the Mycology Reference Library (MRL) at Case Western Reserve University School of Medicine, Ohio, United States.

(89) Antifungal Susceptibility Testing

(90) Susceptibility testing was performed using a broth microdilution method, according to CLSI M27-A3 guidelines (CLSI. 2008. Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Approved Standard—Third Edition. Clinical and Laboratory Standards Institute, CLSI document M27-A3). Antifungals and concentrations tested were SCY-078 and micafungin (both at concentrations within the range of 0.015 to 8 μg/ml) and fluconazole (at concentrations within the range of 0.125 to 64 μg/ml). A 0.1-ml C. albicans and C. glabrata inoculum of 0.5-2.5×10.sup.3 blastospores/ml in RPMI 1640 medium was added to each microdilution well. ATCC strains of Candida parapsilosis and Candida krusei QC isolates were also included concurrently to ensure quality control. Antifungal susceptibility testing was carried out for each isolate in RPMI 1640 at pH 7 (to mimic RPMI medium used in testing the susceptibility of yeast by the CLSI M-27A3 document), pH 5.7, and pH 4.5 (to mimic the pH of the vaginal cavity) by adjusting the pH of the media using NaOH or HCl. Buffering of the media was achieved with morpholinepropanesulfonic acid (MOPS; 0.165 M) as described by Marr et al., The trailing end point phenotype in antifungal susceptibility testing is PH dependent, Antimicrob. Agents Chemother., 43: 1383-1386 (1999).

(91) Inhibition endpoints were read as a 50% reduction in growth, as determined by optical density, compared to the growth of the control after 24 hours incubation at 35° C. SCY-078 powder was manufactured by Avista, Laboratories, NC. Micafungin and fluconazole were sourced from LGM Pharma.

Results

(92) Activity of SCY-078 Against C. Glabrata

(93) Tables 1a-1c show the MIC ranges and MIC.sub.50 and MIC.sub.90 for the test compounds against C. glabrata. The MIC ranges for SCY-078 at pH 7.0, pH 5.72 and pH 4.5 against the C. glabrata isolates were 0.5-1 μg/mL, 0.5 μg/mL, and 0.031-0.063 μg/mL, respectively. The MIC.sub.50 and MIC.sub.90 for SCY-078 at a pH of 7.0 were 1 μg/mL. The MIC.sub.50 and MIC.sub.90 for SCY-078 at a pH of 5.72 were 0.5 μg/mL. The MIC.sub.50 and MIC.sub.90 for SCY-078 at a pH of 4.5 were 0.063 μg/mL. These results showed a significant, 16-fold reduction in MIC.sub.50 at pH 4.5 compared to the MIC.sub.50 at pH 7.0, indicating a significant increase in antifungal potency at pH 4.5 against Candida glabrata.

(94) Activity of SCY-078 Against C. Albicans

(95) Tables 2a-2c show the MIC ranges and MIC.sub.50 and MIC.sub.90 for the test compounds against C. albicans. The MIC ranges for SCY-078 at pH 7.0, pH 5.72 and pH 4.5 against the C. albicans isolates were 0.125-0.5 μg/mL, 0.125-0.25 μg/mL, and <0.016-0.031 μg/mL, respectively. The MIC.sub.50 for SCY-078 at pH of 7.0 and pH of 5.72 were 0.25 μg/mL, and the MIC90s were 0.5 and 0.25 μg/mL, respectively. The MIC.sub.50 and MIC.sub.90 for SCY-078 at pH 4.5 were <0.016 μg/mL. These results showed a significant, 16-fold reduction in MIC.sub.50 at pH 4.5 compared to the MIC.sub.50 at pH 7.0, indicating a significant increase in antifungal potency at pH 4.5 against Candida albicans.

(96) For both C. glabrata and C. albicans, lowering the pH to 4.5 resulted in significantly lower MIC values compared to neutral pH conditions (pH 7.0). This result indicated that pH had an impact on the antifungal activity of SCY-078. This trend continued at 48 hours.

(97) Micafungin Against C. Glabrata

(98) The MIC ranges for micafungin at pH 7.0, pH 5.72 and pH 4.5 against the C. glabrata isolates tested were 0.25-0.5 μg/mL, 0.25 μg/mL and 0.25 μg/mL, respectively. The MIC50s of C. glabrata of all three pH, and the MIC90s of pH 5.72 and pH 4.5 were the same (0.25 μg/mL), while the MIC.sub.90 of micafungin at a pH of 7.0 was 0.5 μg/mL.

(99) Micafungin Against C. Albicans

(100) The MIC ranges for micafungin at pH 7.0, pH 5.72 and pH 4.5 against the C. albicans isolates tested were 0.25 μg/mL, 0.063-1 μg/mL and 0.25-0.5 μg/mL, respectively. The MIC50s and MIC90s of micafungin against C. albicans did not differ for each pH and did not differ significantly between the pH conditions (pH 7.0 MIC.sub.50 and MIC.sub.90=0.25 μg/mL, pH 5.72 MIC.sub.50 and MIC.sub.90=1 μg/mL, pH 4.5 MIC.sub.50 and MIC.sub.90=0.5 μg/mL).

(101) There were no significant differences between the minimum inhibitory concentrations (MICs) for micafungin at the three different pHs for either C. albicans or C. glabrata.

(102) Fluconazole Against C. Glabrata

(103) The MIC ranges for fluconazole at pH 7.0, pH 5.72 and pH 4.5 against the C. glabrata isolates tested were 0.5-2 μg/mL, 2-16 μg/mL and 1-16 μg/mL, respectively. The MIC.sub.50 of fluconazole at 7.0, 5.72 and 4.5 pHs were 1 μg/mL, 8 μg/mL and 8 μg/mL, respectively. The MIC.sub.90 of fluconazole at 7.0, 5.72 and 4.5 pHs were 2 μg/mL, 16 μg/mL and 16 μg/mL, respectively. These results showed a significant, 8-fold increase in MIC.sub.50 when the activity of fluconazole at pH 7 was compared to its activity at pH 4.5, indicating a significant decrease in antifungal potency at pH 4.5 against Candida glabrata.

(104) Fluconazole Against C. Albicans

(105) The MIC ranges for fluconazole at pH 7.0, pH 5.72 and pH 4.5 against the C. albicans isolates tested were <0.125-1 μg/mL, <0.125-1 μg/mL, and 0.25-8 μg/mL, respectively. The MIC.sub.50 and MIC.sub.90 of fluconazole at pH 7.0, pH 5.72 and pH 4.5 were 0.25 μg/mL and 0.25 μg/mL, <0.125 and 0.25 μg/mL, and 0.25 and 1 μg/mL, respectively. The MICs of fluconazole against C. albicans tended to increase as the pH decreased. However, the differences were not significant.

(106) TABLE-US-00002 TABLE 1a MIC data (in μg/ml) for SCY-078 and comparators against C. glabrata isolates at a pH of 7.0 SCY-078 Micafungin Fluconazole Range 0.5-1 0.25-0.5 0.5-2 MIC.sub.50 1 0.25 1 MIC.sub.90 1 0.5 2

(107) TABLE-US-00003 TABLE 1b MIC data (in μg/ml) for SCY-078 and comparators against C. glabrata isolates at a pH of 5.72 SCY-078 Micafungin Fluconazole Range 0.5 0.25 2-16 MIC.sub.50 0.5 0.25 8 MIC.sub.90 0.5 0.25 16

(108) TABLE-US-00004 TABLE 1c MIC data (in μg/ml) for SCY-078 and comparators against C. glabrata isolates at a pH of 4.5 SCY-078 Micafungin Fluconazole Range 0.031-0.063 0.25 1-16 MIC.sub.50 0.063 0.25 8 MIC.sub.90 0.063 0.25 16

(109) TABLE-US-00005 TABLE 2a MIC data (in μg/ml) for SCY-078 and comparators against C. albicans isolates at a pH of 7.0 SCY-078 Micafungin Fluconazole Range 0.125-0.5 0.25 <0.125-1 MIC.sub.50 0.25 0.25 0.25 MIC.sub.90 0.5 0.25 0.25

(110) TABLE-US-00006 TABLE 2b MIC data (in μg/ml) for SCY-078 and comparators against C. albicans isolates at a pH of 5.72 SCY-078 Micafungin Fluconazole Range 0.125-0.25 0.063-1 <0.125-1 MIC.sub.50 0.25 1 <0.125 MIC.sub.90 0.25 1 0.25

(111) TABLE-US-00007 TABLE 2c MIC data (in μg/ml) for SCY-078 and comparators against C. albicans isolates at a pH of 4.5 SCY-078 Micafungin Fluconazole Range <0.016-0.031 0.25-0.5 0.25-8 MIC.sub.50 <0.016 0.5 0.25 MIC.sub.90 <0.016 0.5 1

(112) TABLE-US-00008 TABLE 3a-d Individual data for Candida isolates (all units in μg/mL) Table 3a. MIC results for SCY-078 against the C. glabrata isolates tested at all pHs at 24 hours MRL SCY-078 50% 100% pH Organism 7.0 5.72 4.5 7.0 5.72 4.5 C. glabrata 32075 0.5 0.5 0.063 1 1 0.125 C. glabrata 32232 1 0.5 0.063 1 1 0.125 C. glabrata 32626 0.5 0.5 0.063 1 1 0.125 C. glabrata 32993 0.5 0.5 0.031 1 1 0.063 C. glabrata 33204 1 0.5 0.031 1 1 0.063 C. glabrata 33960 0.5 0.5 0.031 1 1 0.063 C. glabrata 33961 1 0.5 0.063 1 1 0.063 C. glabrata 34339 1 0.5 0.063 1 1 0.125 C. glabrata 34407 1 0.5 0.063 2 1 0.125 C. glabrata 34576 1 0.5 0.063 2 1 0.125 RANGE 0.5-1 0.5 0.031-0.063 1-2 1 0.063-0.125 MIC.sub.50 1 0.5 0.063 1 1 0.125 MIC.sub.90 1 0.5 0.063 2 1 0.125

(113) TABLE-US-00009 TABLE 3b MIC results for comparators against the C. glabrata isolates tested at all pHs at 24 hours MRL Micafungin Fluconazole 50% 50% pH Organism 7.0 5.72 4.5 7.0 5.72 4.5 C. glabrata 32075 0.25 0.25 0.25 2 8 8 C. glabrata 32232 0.5 0.25 0.25 2 8 8 C. glabrata 32626 0.5 0.25 0.25 1 8 8 C. glabrata 32993 0.25 0.25 0.25 2 16 16 C. glabrata 33204 0.25 0.25 0.25 2 8 8 C. glabrata 33960 0.5 0.25 0.25 1 16 16 C. glabrata 33961 0.25 0.25 0.25 1 2 1 C. glabrata 34339 0.25 0.25 0.25 0.5 2 8 C. glabrata 34407 0.25 0.25 0.25 1 8 8 C. glabrata 34576 0.25 0.25 0.25 1 8 16 RANGE 0.25-0.5 0.25 0.25 0.5-2 2-16 1-16 MIC.sub.50 0.25 0.25 0.25 1 8 8 MIC.sub.90 0.5 0.25 0.25 2 16 16

(114) TABLE-US-00010 TABLE 3c MIC results for SCY-078 against the C. albicans isolates tested at all pHs at 24 hours MRL SCY-078 50% 100%* pH Organism 7.0 5.72 4.5 7.0 5.72 4.5 C. albicans 34366 0.5 0.25 0.031 0.5 0.5 0.031 C. albicans 34367 0.125 0.125 <0.016 0.5 0.5 0.031 C. albicans 34372 0.25 0.25 <0.016 0.25 0.25 <0.016 C. albicans 34373 0.25 0.25 <0.016 0.25 0.25 <0.016 C. albicans 34374 0.25 0.125 <0.016 0.25 0.25 <0.016 C. albicans 34385 0.25 0.25 <0.016 0.5 0.5 0.031 C. albicans 34389 0.125 0.25 <0.016 0.25 0.25 0.031 C. albicans 34399 0.25 0.25 <0.016 0.25 0.25 0.031 C. albicans 34408 0.5 0.25 <0.016 4 2 4 C. albicans 34449 0.25 0.25 <0.016 0.5 0.25 0.031 RANGE 0.125-0.5 0.125-.25 <0.016-0.031 0.25-4 0.25-2 <0.016-4 MIC.sub.50 0.25 0.25 <0.016 0.25 0.25 0.031 MIC.sub.90 0.5 0.25 <0.016 0.5 0.5 0.031

(115) TABLE-US-00011 TABLE 3d MIC results for comparators against the C. albicans isolates tested at all pHs at 24 hours MRL Micafungin Fluconazole 50% 50% pH Organism 7.0 5.72 4.5 7.0 5.72 4.5 C. albicans 34366 0.25 0.5 0.5 <0.125 <0.125 0.25 C. albicans 34367 0.25 0.5 0.5 0.25 0.25 1 C. albicans 34372 0.25 1 0.5 <0.125 <0.125 0.25 C. albicans 34373 0.25 1 0.5 0.25 <0.125 0.5 C. albicans 34374 0.25 1 0.5 0.25 <0.125 0.25 C. albicans 34385 0.25 1 0.5 <0.125 <0.125 0.25 C. albicans 34389 0.25 1 0.5 <0.125 <0.125 0.5 C. albicans 34399 0.25 1 0.5 1 1 8 C. albicans 34408 0.25 0.063  0.25 0.25 0.25 0.25 C. albicans 34449 0.25 0.25 0.5 0.25 <0.125 0.5 RANGE 0.25 0.063-1 0.25-0.5 <0.125-1 <0.125-1 0.25-8 MIC.sub.50 0.25 1 0.5 0.25 <0.125 0.25 MIC.sub.90 0.25 1 0.5 0.25 0.25 1

(116) These data showed that the MIC of SCY-078 against C. glabrata and C. albicans decreased as the pH decreased. The MIC values for the comparators, consistent with previous reports, seemed to be unaffected by pH in the case of micafungin, or seemed to be significantly affected by the pH in the case of fluconazole, which showed an increase in MIC values as the pH decreased, especially for C. glabrata.

(117) Quality control strains C. parapsilosis ATCC 22019 and C. krusei ATCC 6258 were within their ranges for fluconazole and micafungin.

(118) The pH ranges tested in this experiment covered the most common clinical conditions in which acidic pH is associated with a fungal infection.

Example 2

Vaginal Concentrations of SCY-078 Following Oral Administration in Mice

(119) The objective of this study was to determine the exposure of SCY-078 in vaginal tissue and secretions, and the relationship of this exposure to concentrations of SCY-078 in plasma, following oral administration of SCY-078 to mice, a recognized model for Candida infections.

Methods

(120) Female CD-1 mice (n=3/time point/dose group) were given SCY-078 via oral gavage for either one, two, or eight total doses ranging from 10 to 80 mg/kg, consisting of QD (once per day) and BID (twice per day) dose regimens, with and without loading doses, as follows: QD (Day 1): 10, 20, 40, 80 mg/kg BID (Day 1): 10/5, 20/10, 40/20, 80/40 mg/kg BID repeat dose (Days 1-4): 10/5, 20/10 40/20, 80/40 mg/kg on Day 1; 5, 20, 20, 40 mg/kg BID on Days 2 to 4

(121) Blood, vulvo-vaginal tissue and vaginal secretions were collected pre-dose, and at 1, 2, 4, 6, 8, 12, 18 and 24 hours post-dose, following the final dose administered per group. Samples were then processed, extracted via protein precipitation and analyzed for SCY-078 via LC MS/MS.

Results

(122) Following oral administration, high concentrations of SCY-078 were achieved in both vaginal tissue and vaginal secretions, relative to plasma concentration.

(123) In vaginal tissues, SCY-078 exposure was greater than dose proportional, with the AUC.sub.0-24 (area under the curve, measured from 0 to 24 hrs) for each dosing regimen ranging from 26.7 to 171, 24.6 to 337, and 24.4 to 1798 μg*hr/g, respectively. In the repeated-dose regimen, the accumulation potential of SCY-078 in vaginal tissue increased with increasing dose, as the ratio of the concentration in vaginal tissue following the last dose, to the concentration in vaginal tissue following the first dose, ranged from 1 to 10.5-fold.

(124) In vaginal secretions, the AUC.sub.0-24 for each dosing regimen ranged from 1.32 to 12.3, 1.55 to 17.8, and 4.32 to 120 μg*hr/ml, respectively. In plasma, the AUC.sub.0-24 for each dosing regimen ranged from 8.33 to 75.5, 7.47 to 101, and 7.47 to 101 μg*hr/ml, respectively. Table 4 summarizes the exposures (AUC.sub.0-24) per dose group.

(125) TABLE-US-00012 TABLE 4 Dose Plasma Vaginal Secretion Vaginal Tissue (mg/kg) (μg*hr/ml) (μg*hr/ml) (μg*hr/g) QD 10 8.33 1.32 26.7 20 19.7 1.87 53.6 40 42.3 4.41 187 80 75.5 12.3 171 BID 10/5 7.47 1.55 24.6 20/10 16.6 4.21 72.9 40/20 46.5 10.6 204 80/40 101 17.8 337 BID repeat- dose 10/5 5.12 4.32 24.4 20/10 14.6 8.63 71.6 40/20 53.0 38.8 275 80/40 143 120 1798

(126) Following oral administration to mice, SCY-078 exposure was demonstrated in vaginal tissues, vaginal secretions, and plasma. High concentrations of SCY-078 were achieved in vaginal tissues following oral administration and, with repeat-dosing, a potential to accumulate in vaginal tissue to more than 10-fold relative to plasma was demonstrated.

Example 3

SCY-078 Phase 2 Study in Moderate and Severe Vulvovaginal Candidiasis (VVC)

(127) This study was a proof-of-concept study conducted to evaluate the safety and efficacy of two dosing regimens of oral SCY-078 (administered as the phosphate salt) in subjects presenting with moderate to severe VVC.

(128) Methods

(129) Key criteria for inclusion included: 1. Subjects with moderate to severe VVC, confirmed by positive potassium hydroxide (KOH) test from a vaginal secretion sample 2. Three vaginitis episodes in the past year that were either confirmed to be caused by Candida spp. or that responded to antifungal therapy

(130) Subjects were randomized in a 1:1:1 ratio to one of the three treatment arms: Oral SCY-078 loading dose of 1250 mg SCY-078, followed by 750 mg SCY-078 QD for 2 days or for 4 days, or Oral Fluconazole 150 mg for 1 day.

(131) Subjects were evaluated on Day 24 (Test-of-Cure visit), Day 60, Day 90, and 120 days (end of study).

(132) The analyses included clinical cure (all signs and symptoms present at baseline improved by at least two points (e.g., from moderate to absent or from severe to mild); after the study started, the FDA proposed that clinical cure is achieved if all signs and symptoms present at baseline are absent), mycological eradication (a negative culture for the baseline yeast pathogen), and therapeutic cure (both clinical cure and mycological eradication). Clinical cure has been proposed by the FDA as the primary endpoint for assessment of efficacy in VVC.

(133) Ninety-six subjects were enrolled (intent-to-treat (ITT) population), and 70 subjects had cultured-confirmed Candida spp. infection (per protocol (PP) population).

(134) Table 5 summarizes the results.

(135) TABLE-US-00013 TABLE 5 N Rates % SCY-078 SCY-078 SCY-078 % Δ SCY-078 (3-Days) (5-Days) (Combined) Fluconazole (combined) vs. (n = 24) (n = 26) (n = 50) (n = 20) Fluconazole Efficacy Evaluation at Day 24 (per Protocol Population) Clinical 19 19 38 13 11% Cure 79.2% 73.1% 76% 65% Clinical 17 18 35 11 15% Cure 70.8% 69.2% 70% 55% (Updated FDA Definition) Efficacy Evauation at Month 4 Recurrences 1 1  2  3 −11%  Requiring 4.2% 3.8%  4% 15% Antifungal Therapy Clinical 21 23 44 13 23% Cure 87.5% 88.46% 88% 65% ‘0’ Signs 19 21 40 13 15% and 79.1% 80.7% 80% 65% Symptoms

(136) The rate of mycological eradication at Day 24 and Month 4 was 70% and 74% for the SCY-078 combined arms, versus 65% and 60% for the fluconazole arm. Therapeutic cure (defined as both clinical cure and mycological eradication) at the Day 24 Test-of-Cure visit was 56.3% for the SCY-078 combined arms and the fluconazole arm. There were no severe or serious adverse events in any treatment groups. A higher rate of GI adverse events (e.g., nausea, diarrhea), which events were mild to moderate in severity and transient in nature, was reported in the SCY-078 treatment arms.

(137) The results from the per protocol (PP) population were consistent with the results from the intent-to-treat (ITT) population (patients who received at least one dose of the study medication), as shown in Table 6.

(138) TABLE-US-00014 TABLE 6 Intent-to-Treat (ITT) Population Combined SCY-078 Fluconazole (n = 64) (n = 32) Clinical cure* 78.1% 65.6% Mycological 70.3% 68.8% eradication Therapeutic cure 56.3% 56.3% *In this analysis, clinical cure was defined as resolution of signs and symptoms of infection (signs and symptoms that had a score of 2 or 1 at baseline should be 0, and signs and symptoms with a score of 3 at baseline should be 0 or 1, at the Test-of-Cure visit).

(139) The high clinical cure rates and the reduction of recurrence rates observed in this study provided evidence of the potent anti-Candida effect of SCY-078 in VVC.

Example 4

(140) An experiment is conducted to demonstrate that the enhanced activity of SCY-078 under acidic conditions allows for a reduction of the doses needed to achieve efficacy in VVC. This is a randomized, double-blind, double-dummy, active-controlled or placebo-controlled study to evaluate the efficacy of oral SCY-078 in adult female subjects 18 years and older with moderate to severe VVC. The study evaluates doses lower than doses that have been shown to elicit a response in other studies, considering the surprising finding of enhanced activity of SCY-078 under low pH conditions. The following dose regimens are evaluated:

(141) Treatment Group 1: oral SCY-078 750 mg QD on Day 1 only

(142) Treatment Group 2: oral SCY-078 300 mg BID on Day 1 only

(143) Treatment Group 3: oral SCY-078 450 mg BID on Day 1 only

(144) Treatment Group 4: oral SCY-078 150 mg BID on Days 1 to 3

(145) Treatment Group 5: oral SCY-078 300 mg BID on Days 1 to 3

(146) SCY-078 is administered orally in a suitable oral dosage form containing 50 mg or 100 mg or 150 mg or 200 mg or 250 mg or 300 mg or 500 mg or 750 mg of the active ingredient. Suitable oral dosage forms include, for example, tablets, capsules, suspensions, powders, granules and the like.

(147) Having approximately 30 subjects per treatment group provides an indication of the magnitude of the effect of each dose regimen. A control arm, receiving oral fluconazole at its approved dose regimen, is included.

(148) The patients in this study are evaluated at a Baseline visit on Day 1 and at Day 10 to evaluate efficacy. Pharmacokinetic assessments are conducted to evaluate the exposure of SCY-078 achieved in vaginal tissue and in plasma at each dosing regimen.

(149) The subjects in this study are required to meet the following inclusion criteria: 1. Subject is a female subject 18 years or older and is in good general health. 2. Subject has a diagnosis of symptomatic VVC that meets the following criteria: a. Moderate to severe disease, defined as a minimum composite vulvovaginal signs and symptoms score of ≥7 with at least 2 signs or symptoms having a score of 2 (moderate) or greater in the VSS Scale at Baseline. b. Positive microscopic examination with 10% Potassium Hydroxide (KOH) in a vaginal sample revealing yeast forms (hyphae/pseudohyphae) or budding yeasts with subsequent confirmation of positive culture for yeast. c. Vaginal pH≤4.5

(150) Efficacy is determined primarily by the percentage of subjects with clinical cure (resolution of signs and symptoms) as well as mycological eradication (negative culture) at Day 10. The data is analyzed using standard statistical software such SAS® version 9.3 or later. Statistical tests are two-sided and interpreted at a 5% significance level. The study does not need to be powered for formal statistical comparisons; rather, it provides a directional indication of the efficacy of lower doses or of shorter dose regimens of SCY-078 relative to, for example, the doses and dose regimens used in Example 3. Descriptive statistics (mean, standard deviation, median, minimum, maximum, etc.) is provided for all continuous variables; frequencies and percentages are tabulated for incidence and categorical variables. All analyses are presented by treatment group.

Example 5

(151) An experiment is conducted to demonstrate that the enhanced activity of SCY-078 under acidic conditions allows for improved efficacy in treating VVC with a topical formulation of SCY-078. The enhanced activity of SCY-078 under low pH facilitates the development of a topical formulation that is applied in the vaginal cavity and results in improved efficacy by readily achieving local concentrations higher than the MIC required to treat or prevent the yeast causing the infection. Examples of suitable topical formulations include cream, ointment, gel, suppository, vaginal tablets or foam, and the like.

(152) The study is a randomized, double-blind, active-controlled or placebo-controlled study to evaluate the efficacy of a topical formulation of SCY-078 in adult female subjects 18 years and older with moderate to severe VVC. This study includes 2 to 5 different dose regimens of SCY-078 and a placebo or an active comparator such as topical nystatin or topical clotrimazole or topical miconazole.

(153) SCY-078 is administered topically in a suitable formulation containing 5 mg or 10 mg or 20 mg or 25 mg or 50 mg or 75 mg or 100 mg or 150 mg of the active ingredient. The active comparator is administered at the doses approved for this intended use.

(154) Having approximately 30 subjects per treatment group provides an indication of the magnitude of the effect of each dose regimen.

(155) The patients in this study are evaluated at a Baseline visit on Day 1 and at Day 10 to evaluate efficacy.

(156) The subjects in this study are required to meet the following inclusion criteria: 1. Subject is a female subject 18 years or older and is in good general health. 2. Subject has a diagnosis of symptomatic VVC that meets the following criteria: a. Positive microscopic examination with 10% Potassium Hydroxide (KOH) in a vaginal sample revealing yeast forms (hyphae/pseudohyphae) or budding yeasts with subsequent confirmation of positive culture for yeast. b. Vaginal pH≤4.5

(157) Efficacy is determined primarily by the percentage of subjects with clinical cure (resolution of signs and symptoms) as well as mycological eradication (negative culture) at Day 10. The data is analyzed using standard statistical software such SAS® version 9.3 or later. Statistical tests are two-sided and interpreted at a 5% significance level. The study does not need to be powered for formal statistical comparisons; rather, it provides a directional indication of the efficacy of different doses or of different dose regimens of SCY-078. Descriptive statistics (mean, standard deviation, median, minimum, maximum, etc.) are provided for all continuous variables; frequencies and percentages are tabulated for incidence and categorical variables. All analyses are presented by treatment group.

Example 6

(158) An experiment is conducted to demonstrate that the enhanced activity of SCY-078 under acidic conditions allows for efficacy in the prevention of VVC episodes in patients suffering from recurrent VVC (rVVC). There are no current therapies approved for the prevention of VVC in patients suffering from rVVC, and an antifungal agent with enhanced activity in the vaginal milieu would have the potential to be efficacious in preventing recurrent episodes of this disease by allowing more effective killing of the yeast causing the infection and preventing re-growth.

(159) This experiment is a randomized, double-blind, placebo-controlled study to evaluate the efficacy of an oral formulation of SCY-078 in adult female subjects 18 years and older with moderate to severe VVC. This study includes 1 to 4 different dose regimens of SCY-078. The dose regimens tested include administering 1 to 3 doses of oral SCY-078 once a month for 3 or 6 months, or once a week for 3 or 6 months, to mention some.

(160) SCY-078 is administered orally as tablets containing 50 mg or 100 mg or 150 mg or 200 mg or 250 mg or 300 mg or 500 mg or 750 mg of the active ingredient.

(161) The subjects in this study are required to meet the following inclusion criteria: 1. Subject is a female subject 18 years or older and is in good general health. 2. Subject has a diagnosis of symptomatic recurrent VVC, defined as at least 3 episodes of VVC in the past year, that meets the following criteria: a. Positive microscopic examination with 10% Potassium Hydroxide (KOH) in a vaginal sample revealing yeast forms (hyphae/pseudohyphae) or budding yeasts with subsequent confirmation of positive culture for yeast. b. Vaginal pH≤4.5

(162) Efficacy is determined primarily by the percentage of subjects without recurrence during the observation period. The observation period is 6 or 9 or 12 months.

Example 7

A Phase 2, Multicenter, Randomized, Double-Blind, Double-Dummy, Active-Controlled Study to Compare the Safety and Efficacy of Oral SCY-078 to Oral Fluconazole in Subjects with Acute VVC

(163) A Phase 2 study was conducted to evaluate the safety, efficacy, tolerability, and pharmacokinetics of five dose regimens of oral SCY-078 (administered as the citrate salt) compared to oral fluconazole in adult, female patients with moderate-to-severe acute VVC (defined as having a signs and symptoms (S&S) score of 7 or greater). A total of 186 intent-to-treat (ITT) patients were randomized into six different treatment arms as follows: five different dosing regimens of oral SCY-078 and one oral fluconazole treatment arm. The modified intent-to-treat (mITT) population was used for efficacy analysis and included 153 patients with culture-confirmed Candida spp. vaginal infection (positive microscopic examination of vaginal secretions showing yeast, vaginal pH≤4.5) at baseline. The doses of SCY-078 tested ranged from 600 mg to 1800 mg total dose administered over the duration of treatment, and the durations of treatment were 1 or 3 days:

(164) TABLE-US-00015 TABLE 7 Number of patients, Total Dose (mg) Dosing Regimen ITT/mITT 600 mg SCY-078 300 mg BID for 1 day 30/27 750 mg SCY-078 750 mg QD for 1 day 32/26 900 mg SCY-078 450 mg BID for 1 day 28/21 900 mg SCY-078 150 mg BID for 3 days 32/29 1800 mg SCY-078 300 mg BID for 3 days 32/26 150 mg Fluconazole 150 mg QD for 1 day 32/24

(165) The primary efficacy endpoint was clinical cure, which according to current FDA guidance is defined as complete resolution (score=0) of all signs and symptoms at the Day 10 Test-of-Cure visit without the need of additional antifungal therapy. Secondary endpoints included mycological eradication (negative culture) and a composite endpoint including both clinical cure and mycological eradication. Response was also evaluated based on the percent of patients achieving a noticeable improvement in their signs and symptoms, either by achieving an S&S score of 0 or 1 or an absolute change (reduction) in mean composite S&S score from baseline. An S&S score is based on a patient's reported symptoms (burning, itching, and irritation) and investigator-assessed signs (swelling, redness, and excoriations); each sign and symptom can be absent, mild, moderate, or severe, with a corresponding score from 0 to 3; the total composite scale is 0 to 18 points. Response was further evaluated by assessing the number of patients who received rescue antifungal therapy. Patients were assessed at the Day 10 Test-of-Cure visit and also at a Day 25 Follow-Up visit. The study was not designed to achieve statistically significant differences in any of the evaluated endpoints.

(166) All dosage regimens of SCY-078 that were tested achieved meaningful clinical cure and mycological eradication rates. In particular, administration of a total dose of 600 mg SCY-078, given on a BID schedule (300 mg administered twice daily) for 1 day, provided optimal clinical and mycological activity and favorable tolerability. Estimated exposure with this 300 mg BID for 1 day dosing regimen is AUC.sub.0-24 in a range from about 3 to about 8 μM*hr, and C.sub.max in a range of about 200 to about 500 nM.

(167) At the Day 10 Test-of-Cure visit, patients receiving the 300 mg BID for 1 day dosing regimen (600 mg total dose) for SCY-078 showed clinical and mycological response rates in-line with the response rates of subjects in the reference fluconazole arm. Specifically, clinical cure was reported in 14 of 27 patients (52%) in the 600 mg SCY-078 dose arm, and in 14 of 24 of patients (58%) in the fluconazole arm. The percentage of patients showing an S&S score of 0 or 1 was also comparable, with 70% and 71% patients reporting this improvement in the 600 mg SCY-078 dose and fluconazole arms, respectively. The mean S&S score at this timepoint was 1.0 in the SCY-078 600 mg dose arm, versus 1.8 in the fluconazole arm. The mycological eradication at this timepoint was 63% for both arms.

(168) At the Day 25 Follow-Up visit, the 600 mg SCY-078 dose arm showed a trend toward improved clinical and mycological outcomes when compared with the fluconazole arm. If patients continued to have signs and symptoms of VVC at the Test-of-Cure visit or later, rescue antifungal medication could be prescribed. Seven of the 24 patients treated with fluconazole (29%) received rescue antifungal medication, whereas only one of the 27 patients treated with 600 mg SCY-078 (4%) received rescue antifungal medication. In addition, the percentage of patients with clinical cure (complete resolution of signs and symptoms) at the Follow-Up visit was 70% for the SCY-078 600 mg dose arm, versus 50% for the fluconazole arm. A similar difference was observed with the 0-or-1 S&S score analysis, with 81% of patients who received 600 mg SCY-078 achieving this improvement, versus 58% of patients in the fluconazole arm. Further, the mean S&S score at Day 25 was 0.4 in the 600 mg SCY-078 dose arm, versus 2.6 in the fluconazole arm, and for this endpoint the two treatments resulted in a statistically significant difference (p=0.1). Moreover, at Day 25, mycological eradication was achieved in 48% of patients in the SCY-078 600 mg dose arm, compared to 38% of patients in the fluconazole arm.

(169) The oral SCY-078 600 mg dose was generally well-tolerated, with self-limiting (generally one-day duration), mild-to-moderate gastrointestinal adverse events being the most commonly reported.

(170) While this invention has been particularly shown and described with references to preferred embodiments thereof, it will be understood in light of the present disclosure by those skilled in the art that various changes in form and details may be made therein without departing from the scope of the invention encompassed by the appended claims.