Formulations for treatment of osteoarthritis

Abstract

The present disclosure relates to formulations for the treatment of osteoarthritis. Disclosed are formulations for treating osteoarthritis by altering a change in shape of articular subchondral bone. The use includes assessing the bone shape of the patient's joint, injecting the patient with a peptide of SEQ ID NO: 1 or applying other therapeutic interventions that reduce changes in the shape of the articular subchondral bone, and thereby assessing the bone shape of the patient's joint.

Description

[0001] This application is a divisional application of Chinese patent application No. 201980079767.9. Technical Field

[0002] The present invention generally relates to a method for treating osteoarthritis by altering the shape changes of joint bones, which is the pathological basis for the occurrence and development of osteoarthritis. Background Art

[0003] Osteoarthritis

[0004] Osteoarthritis is the most common joint disease and one of the most widespread of all chronic diseases. In the United States, osteoarthritis (OA) is the second leading cause of work disability in men over 50 years old, after heart disease. Globally, OA is the sixth leading cause of disability (Woolf 2003).

[0005] Approximately 80% of patients with OA require knee treatment. The most common radiographic findings within the knee of symptomatic individuals are loss of articular (hyaline) cartilage and remodeling of adjacent bone, often with osteophyte formation at the joint margin. Both the tibiofemoral and patellofemoral joint spaces are commonly affected by degenerative changes. Patellofemoral arthritis, which is caused by loss of cartilage in the patella and trochlear groove, is common in patients with knee OA and is often accompanied by loss of cartilage in other joint spaces (Davies 2002).

[0006] Pain is a common symptom in patients with knee OA. Pain is often treated with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). However, following the initial boxed warning and warnings and precautions section of the NSAID prescription label in 2005, the FDA strengthened the existing label warning in 2015 that non-aspirin NSAIDs, including their over-the-counter products, can increase the chance of heart attack or stroke (https: / / www.fda.gov / drugs / drug-safety-and-availability / fda-drug-safety-communication-fda-strengthens-warning-non-aspirin-nonsteroidal-anti-inflammatory). Intra-articular treatment with corticosteroids or hyaluronic acid products has also been used to relieve pain. Corticosteroid injections have been associated with further knee cartilage degeneration (McAlindon 2017), limiting clinicians’ willingness to use this treatment modality. The American Academy of Orthopaedic Surgeons / American Association of Orthopaedic Surgeons does not recommend corticosteroid injections for the treatment of knee OA.

[0007] Hyaluronic acid or a “viscous fill” product is injected into the knee joint once a week (2 cc) for 3 weeks or in a larger single dose (6 cc; Chevalier 2010). The injected hyaluronic acid product remains in the joint space for a short time, from a few hours to a few days. Although some patients experience relief from joint pain for weeks to months (Cohen 1998), multiple clinical trials have failed to demonstrate a clinically meaningful treatment benefit. The American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons state that “we do not recommend the use of hyaluronic acid in patients with symptomatic OA of the knee.” (AAOS Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2nd Edition, May 18, 2013). (http: / / www.aaos.org / cc_files / aaosorg / research / guidelines / treatmentofosteoarthritissofthekneeguideline)

[0008] Articular cartilage degeneration and current status of treatment

[0009] It is well known that osteoarthritis involves the progressive degeneration of articular cartilage. Degeneration of articular cartilage in the knee, hip, and elbow joints usually progresses slowly with age. Joint degeneration may be accelerated following joint injury or in situations where chronic or excessive stress is placed on the joint by strenuous physical labor or exercise (Sandmark 2000, Felson 1991).

[0010] Articular cartilage enables smooth, nearly frictionless movement of joints. It buffers cyclic loading and counteracts shear forces on the joint. Articular cartilage consists of chondrocytes embedded in an extracellular matrix of non-collagenous proteins, water, proteoglycans such as aggrecan, and collagen. Proteoglycans are hydrophilic molecules that hydrate the surface layer of cartilage. This increases the ability of articular cartilage to buffer biomechanical stresses. Articular cartilage is biologically unique and cannot be matched by any artificially engineered material or by the fibrocartilage ("scar" cartilage) formed after injury or microfracture surgery.

[0011] Unfortunately, articular cartilage cannot regenerate naturally, either after trauma or from the chronic "wear and tear" of aging (Buckwalter 2002).

[0012] To date, only surgical methods and symptomatic (pain) management are approved for patients with knee OA. During surgery, microfracture and abrasion of the subchondral bone are used to induce the formation of fibrocartilage (scar cartilage). However, the structural strength and stability of fibrocartilage are much poorer than normal articular cartilage and degenerates more rapidly. Other invasive surgical procedures for knee cartilage repair include drilling into the subchondral bone and implanting a packing of cartilage cells (chondrocytes) or their progenitors taken from a non-weight-bearing part of the patient's body or from a cadaver (autologous osteochondral transplantation / allogeneic bone transplantation, OATS surgery). Two surgeries are required and the patient cannot bear full weight for approximately 6 weeks after surgery. Treatment failure is common, as is the need for additional surgery to manage complications.

[0013] Autologous chondrocyte implantation (ACI) also requires two surgical approaches, where healthy cartilage is harvested from the knee joint under arthroscopy and grown in culture. The cultured chondrocytes are then implanted into the body. Open knee surgery is required. The patient's cartilage is cut (debrided) down to the bone, and a periosteum or bioengineered flap is sutured or glued in place. The cultured cells are then injected into the flap. In a study of more than 150 ACI patients, the researchers found that the cultured cells were not injected into the flap. In the study, 49% of patients required repeat surgery due to complications (Zaslav 2009). Common complications included delamination, graft failure, and impaired graft fusion (Niemeyer 2008).

[0014] The ultimate option for patients with knee OA is joint replacement surgery, an invasive and expensive option with the potential for significant morbidity and complications. A total knee replacement (TKR) for one knee costs $35,000-70,000, not including the cost of postoperative rehabilitation (at least 6 weeks) and lost productivity. Prosthetic joints have a limited life expectancy and must typically be replaced after 15-20 years; therefore, TKR is typically reserved for older patients. However, the average age of patients undergoing TKR has been declining. It was 68 years in 2000 and decreased to 65.9 years in 2014 (American Academy of Orthopaedic Surgeons, 2018). In 2014, more than 680,000 TKRs were performed, and it is estimated that by 2030, approximately 1.28 million TKRs will be performed in the United States (excluding revision surgeries) (American Academy of Orthopaedic Surgeons 2018: https: / / aaos-annualmeeting-presskit.org / 2018 / research-news / sloan_tjr / ).

[0015] Disease-Modifying Osteoarthritis Drugs (DMOADs)

[0016] Given the limitations and potential complications of currently available treatments, tremendous efforts have been made to develop treatments that slow knee joint degeneration by promoting articular cartilage formation or reducing cartilage degeneration.

[0017] For example, some research groups have attempted to develop inhibitors of matrix metalloproteinases, which are believed to be responsible for cartilage degeneration (Krsezki 2007). Others have attempted to inhibit nitric oxide, which is believed to accelerate cartilage destruction (Hellio1e Graverand 2013). Although many drugs thought to inhibit cartilage degeneration in knee OA have been tested in controlled clinical trials, to date none has successfully slowed or stopped cartilage loss.

[0018] Research on cartilage regeneration represents another treatment approach for knee OA. A variety of growth factors have been tested for their efficacy in cartilage regeneration, including molecules from the TGFβ (transforming growth factor β) family, such as bone morphogenetic protein-7 (BMP-7). To date, all growth factors studied have failed to show efficacy in clinical trials (Guermazi, 2017). Although fibroblast growth factor-18 (FGF-18, also known as Sprifermin) showed a slight but statistically significant increase in tibiofemoral cartilage thickness in subjects with knee OA, active treatment failed to show improvement in knee function or pain in subjects compared to placebo (Hochberg 2017, Hochberg 2018).

[0019] Drugs under development that can regenerate articular cartilage or slow its degeneration are considered potential disease-modifying osteoarthritis drugs (DMOADs).

[0020] TPX-100 is a peptide of SEQ ID NO: 1 that has demonstrated articular chondrogenic activity in a goat cartilage injury model and is a candidate DMOAD (U.S. Patent Nos. 7,888,462 and 8,426,558). The SEQ ID NO: 1 peptide was tested in patients with bilateral knee OA in a randomized, double-blind, placebo-controlled trial. TPX-100-treated knees demonstrated statistically significant and clinically meaningful improvements in knee function as well as other clinical outcomes compared to placebo-treated knees (McGuire 2017). Improvements in knee function were robust in TPX-100-treated knees and persisted through the end of the one-year study. Improvements in knee function were associated with increased or stabilized tibiofemoral cartilage thickness at 12 months, as measured by MRI (McGuire 2018).

[0021] Problems with cartilage structure in osteoarthritis pathology

[0022] Articular cartilage degeneration is considered the main pathological mechanism of knee OA. However, clinical observations have led some researchers to question whether changes in other parts of the joint may lead to cartilage degeneration.

[0023] For example, with severe loss of articular cartilage, the underlying bone is exposed. It is reasonable to expect that this "bone-on-bone" arthritis is associated with severe pain, given the dense innervation of pain fibers to the bone. However, it is uncommon for subjects with knee OA to have little or no pain despite complete loss of cartilage on imaging. On the other hand, many OA patients experience severe pain and limited function with little to no measurable degeneration of the articular cartilage.

[0024] The discrepancy between clinical symptoms and changes in cartilage thickness has been demonstrated in studies of the candidate DMOAD FGF-18 (also known as sphiformin), a putative chondrocyte growth factor. In a clinical trial of more than 500 patients with knee OA, four FGF-18 dose groups were compared to a placebo group. Subjects received intra-articular injections of FGF-18 or placebo three times per week (i.e., days 0, 7, and 14). The series of active or placebo injections was repeated at months 6, 12, and 18. Interval changes in tibiofemoral cartilage thickness were measured by MRI, and clinical outcomes were measured by the Western Ontario and McMaster Universities Osteoarthritis Outcomes Score (WOMAC), a validated patient-reported outcome measure. At 24 months, there was a dose-dependent increase in tibiofemoral cartilage thickness in the FGF-18-treated groups compared with the placebo group. The difference in cartilage thickness in the two highest dose groups reached statistical significance compared with the placebo-exposed group. However, there was no difference in clinical benefit in any treatment group compared with placebo (Hochberg 2017). At 36 months, the FGF-18 treatment group also failed to show clinical benefit compared with the placebo treatment group (Hochberg 2018).

[0025] The FDA first issued a draft guidance for the development of DMOADs for knee OA in 1999, in which an increase in joint space width or a delay in joint space narrowing as measured by X-ray represented a potentially acceptable endpoint for drug approval. However, that draft guidance was superseded in August 2018, in which the FDA concluded that neither X-rays nor other imaging could be recommended as surrogate markers of efficacy in the development of DMOADs. The latest guidance is brief and states:

[0026] “…several issues remain in the development of such products, including the multifactorial and complex etiology of the disease, the recognized discordance between structural changes and signs / symptoms / function, the lack of a standard definition of disease progression, and correspondingly, the lack of endpoints to reliably assess the ability of products to alter OA disease progression.” (FDA 2018)

[0027] In summary, it is generally believed that the relationship between changes in cartilage thickness and clinical outcomes is not obvious. Specifically, changes in cartilage thickness may not be sufficient to explain the OA disease experienced by patients; increases in cartilage thickness cannot be considered to change the clinical outcomes of OA unless there is a convincing link between them and patient benefits.

[0028] Pathological role of subchondral (periarticular) bone in knee osteoarthritis

[0029] The bones beneath the articular cartilage are being studied to elucidate their role in the onset and progression of OA.

[0030] Therapeutic agents used to treat osteoporosis such as strontium ranelate (Reginster 2013), calcitonin (Karsdal 2015), and zolendronate (Laslett 2012) have been clinically tested as potential treatments for OA. These drugs promote new bone formation or inhibit bone resorption. Their efficacy in stabilizing or strengthening subchondral bone has not been clinically proven, and significant side effects have dampened enthusiasm for these drugs. For example, strontium ranelate was found to increase the risk of myocardial infarction, leading the European Medicines Agency to restrict its use.

[0031] A recently proposed marker of OA progression is the measurement of three-dimensional changes in periarticular bone shape. In a comparison of a large number of subjects in the National Institutes of Health Osteoarthritis Initiative (OAI) database, knees with radiographic OA demonstrated that periarticular bone area increased over time in all OA subjects compared with normal controls. Changes in bone area are more predictive of OA symptom progression and joint disability than changes in cartilage thickness or decreases in joint space width (Bowes 2015).

[0032] 3D analysis of periarticular bone shape changes in subjects from OAI revealed a consistent, unidirectional pattern associated with OA progression. Femora, tibia, and patella show bone flattening even in the absence of significant cartilage loss. Three-dimensional shape changes in periarticular bone can be measured using multiple anchor points ("principal components") defined on the bone surface. The position shifts of these anchor points over time are measured on MRI images and algorithmically analyzed using active appearance modeling (AAM). As OA progresses, bone shape, particularly that of the periarticular surface of the femur, changes in subjects in a predictable manner, regardless of demographic differences such as age, sex, and body mass index. In non-OA joints from the OAI database (defined as Kellgren-Lawrence (KL) scores of 0, reflecting the absence of OA by X-ray standards), the rate of periarticular bone shape change over 4 years was significantly slower than that of OA joints assessed by KL standards. Bone shape changes were standardized into a “B score” that represents the degree of bone shape change (standard deviation from the range of shape changes around the knee not affected by OA) (Neogi, 2013; Hunter 2016).

[0033] Changes in 3D periarticular bone shape better predicted knee OA pain progression compared with semiquantitative analysis of bone marrow lesions (Dube 2018).

[0034] The effect of bisphosphonate therapy on knee OA was evaluated using bone area measurements and 3D shape change assessments in OAI database subjects treated for osteoporosis. Bisphosphonate users had a statistically significant reduction in medial tibial bone area gain compared to non-bisphosphonate users; however, 3D bone shape changes did not differ between groups over time. No analyses were reported regarding differences in knee OA symptoms such as function or pain (Haj-Mirzaian, 2018).

[0035] Epidemiological reports have shown that high bone mass or high bone density is associated with an increased risk of knee OA or joint replacement (Nevitt 2010, Hardcastle 2013). Combined with the above bisphosphonate data, increasing or enhancing bone mass does not necessarily improve or reduce the risk of OA.

[0036] TPX-100 Peptide

[0037] TPX-100 is a synthetic peptide consisting of 23 amino acids with an amino acid sequence of TDLQERGDNDISPFSGDGQPFKD (SEQ ID NO: 1), which is derived from human matrix extracellular glycoprotein phosphoprotein (MEPE).

[0038] TPX-100 drug substance is produced as acetate and sodium salt, and the final formulation in both cases is a lyophilized powder with C-terminal amidation. The TPX-100 injection (drug product) used in clinical studies is formulated in water for injection.

[0039] TPX-100 has been shown to promote proper tissue regeneration of dentin, bone, and cartilage without any soft tissue calcification or ossification. TPX-100 can be administered via conventional methods such as subcutaneous or intra-articular injection.

[0040] TPX-100 was first tested for its bone-forming activity in nonclinical safety and efficacy studies. The TPX-100 peptide was identified as the “bone-forming active site” of human MEPE, demonstrating thickening of the calvaria in cultured newborn mice (Hayashibara 2004). Subsequently, TPX-100 administered subcutaneously was shown to accelerate fracture healing in a widely used rat long bone fracture model, also known as the Einhorn model (Lazarov 2004). Additionally, as part of early studies of the TPX-100 peptide, it was also found to promote dentin formation in a rat tooth defect model (Six 2007). In these in vivo bone formation and dentinogenesis studies, TPX-100 was well tolerated. The safety of the TPX-100 peptide was further confirmed in multiple GLP toxicology studies and a Phase 1 clinical study in healthy volunteers.

[0041] Based on these safety and bone and dentin formation data, TPX-100 was tested in two Phase 2 studies for alveolar bone and dentin formation activity, respectively. TPX-100 was well tolerated in both studies. One of the studies testing dental activity showed that TPX-100 administered in defects of human molars could reparably form dentin (Lazarov 2006). The other study testing alveolar bone formation did not show differences between the drug group and the placebo-exposed group.

[0042] It is important to note that in these nonclinical and clinical studies investigating the efficacy of TPX-100 on bone and / or dentin, there was neither data nor observation that TPX-100 affected the shape or other morphological characteristics of these hard tissues. TPX-100 repaired flat and thin bone or dentin only by augmenting these hard tissues and healing experimental fractures located in the central region of long bones in rodent models.

[0043] The cartilage regenerative properties of TPX-100 were subsequently confirmed in a goat model using standardized large cartilage defects. In a full-thickness cartilage defect model in active goats, a regimen of 4 weekly intra-articular (IA) injections of TPX-100 (125 mg and 250 mg) was associated with statistically significant histologically confirmed hyaline cartilage regeneration at 6 months post-surgery compared to cartilage regeneration in the vehicle control group. The drug was safe and well tolerated in these free-weight-bearing, active animals (U.S. Patent Nos. 7,888,462 and 8,426,558).

[0044] TPX-100 was studied in a randomized, double-blind, placebo-controlled clinical study in patients with mild to severe bilateral knee osteoarthritis. TPX-100 is expected to improve key knee joint functions affected by knee OA.

[0045] In this clinical study, the test article was administered 4 times per week for 3 consecutive weeks (Days 0, 7, 14, and 21) by intra-articular (IA) injection. TPX-100 was safe and well tolerated in this study.

[0046] The TPX-100 treated (index) knee demonstrated clinically meaningful and statistically significant improvements in knee function in activities of daily living (“ADL”) and recreational activities (“ADL”) as measured by the Knee Injury and Osteoarthritis Outcome Score (KOOS), as well as clinically meaningful and statistically significant improvements in knee-related quality of life (“knee-related QOL”) and pain ascending and descending stairs. In addition, “Function” and “Total” scores as measured by the Western Ontario and McMaster Universities Osteoarthritis Scale (WOMAC) showed significant improvements in favor of the Index knee. TPX-100 treated knees showed improvements at 6 months or 12 months, or both. There were no measurable differences between the Index and Control knees on MRI in the change in total cartilage thickness from baseline to 6 or 12 months. However, in TPX-100-treated “responder” knees (those with clinically meaningful functional improvement), tibiofemoral (TF) cartilage thickness increased significantly from baseline to 12 months (McGuire 2018).

[0047] As described above, TPX-100 is derived from human MEPE. Several other orthologs of MEPE are known, and therefore, orthologs of TPX-100 are also known. Examples of TPX-100 orthologs are as follows:

[0048] TDLQERGDNDMSPFSGDGQPFKD (Macaca mulatta) (SEQ ID No. 2)

[0049] PDLQERGDNDISPFSGDGQPFKD(dog)(SEQ ID No.3)

[0050] PDLQGRGDNDLSPFSGDGPPFKD(cow)(SEQ ID NO.4)

[0051] PDLLVRGDNDVPPFSGDGQHFMH (rat / mouse) (SEQ ID No.5)

[0052] The amino acid sequences of the rat / mouse orthologs are the least homologous to the human orthologs (15 / 23 identical, 65% homology). Since the rat orthologs are known to promote the incorporation of tritiated-thymidine by human osteogenic mesenchymal stem cells (U.S. Pat. Nos. 7,888,462 and 8,426,558), it is reasonable to assume that these orthologs and their analogs have the same biological function as TPX-100. These peptides contain a common amino acid sequence DLXXRGDNDXXPFSGDGXXF (SEQ ID NO: 6), where X can be any amino acid. SUMMARY OF THE INVENTION

[0054] A new approach to treating osteoarthritis (OA) is proposed. The approach includes any therapeutic intervention that can delay, arrest or reverse the pathological changes in three-dimensional (3D) periarticular bone shape associated with disease development and progression. This marks the first time a therapeutic intervention for pathological periarticular bone shape changes has been demonstrated and shown to be significantly associated with significant improvements in many disabling symptoms of knee OA.

[0055] One aspect of the present invention is a method for altering pathological changes in three-dimensional (3D) periarticular bone shape by administering (possibly by local injection) a therapeutically effective amount of a peptide formulation of SEQ ID NO: 1 to a patient (who may be a person diagnosed with osteoarthritis).

[0056] Another aspect of the present invention is to treat OA by delaying, blocking or reversing changes in periarticular bone shape, wherein the method comprises diagnosing the periarticular bone shape of the affected joint by MRI-based three-dimensional joint shape analysis, administering to the patient a preparation comprising a therapeutically effective amount of the peptide of SEQ ID NO: 1, and measuring the changes in periarticular bone shape after a period of time (e.g., 6 months, 12 months, 24 months, etc.) to determine whether the bone shape has changed significantly compared to before drug treatment.

[0057] Bone shape analysis performed by alternative imaging techniques may be used, for example, using images of the joint obtained by computed tomography, ultrasound, or other imaging modalities.

[0058] MRI is often used to diagnose features of osteoarthritis, such as thinning of articular cartilage or meniscal lesions. Bone shape before and after treatment can be analyzed using image sequences obtained for cartilage evaluation. Combining bone shape and cartilage analysis may increase the sensitivity of assessing the effects of therapeutic interventions.

[0059] The peptide is formulated into an injectable preparation that may include water or saline and can be injected locally into the knee joint via an intra-articular or subcutaneous route. Several orthologs and analogs of the SEQ ID NO: 1 peptide are known to show similar activities to the peptide of SEQ ID NO: 1. Any of these peptides can be used by formulating it into an injectable preparation including water for injection, physiological saline, etc.

[0060] In one aspect of the invention, the method is practiced by administering the injection only once, only twice, three times, four times, five times, etc. The dosage may be delivered daily, every three days, every week, every ten days, every month, every other month, every quarter, every six months, once a year, or various combinations thereof.

[0061] In one aspect of the invention, the method comprises a follow-up assessment of the patient's knee function and / or pain using tools such as KOOS and / or WOMAC scales. The assessment may also be based on other appropriate patient-reported outcomes (PROs) and clinical assessments.

[0062] In one aspect of the invention, the dosage may be in the range of 50 mg to 500 mg, or 100 mg to 400 mg, or 200 mg, wherein all milligram dosages are ±20%, ±10%, ±5%.

[0063] In one aspect of the invention, patients are first evaluated based on the inclusion and exclusion criteria as described herein.

[0064] In one aspect of the invention, joint aging is delayed, arrested or reversed by modifying the inevitable age-related changes in periarticular bone shape.

[0065] One aspect of the invention includes methods of using compounds and / or uses of compounds to affect shape changes in subchondral bone in a patient's joint, the patient can be any animal, but includes humans and canines, the method or use comprising injecting locally into a joint of the patient a therapeutically effective amount of a formulation in an injectable carrier, the formulation comprising a peptide sequence of any one of SEQ ID NOs: 1, 2, 3, 4, 5 and 6. The injections may be intra-articular, and may be repeated as needed (PRN) or weekly for two weeks, three weeks, four weeks or longer, and the injections comprise an amount of peptide in the range of 50-400 mg + 20%, continuing treatment to affect shape changes in subchondral bone in the patient's joint, thereby affecting bone shape changes, wherein the shape changes may be in patients diagnosed with osteoarthritis.

[0066] One aspect of the present invention includes methods and / or uses as described above, wherein the dosage is adjusted based on multiple factors including the size, weight, sex and condition of the patient. In addition, the dosage is determined according to the type of patient (such as human or dog) and the specific joint being treated. Larger patients and larger joints require larger dosages, and smaller patients and smaller joints require smaller dosages. The basic concepts of the present invention are not limited to specific dosage ranges, as those skilled in the art will understand that the dosage varies depending on the factors as described above and other factors to be considered. The above-mentioned specific dosage is a preferred dosage range for the knee of an ordinary adult. Those skilled in the art can infer from the dosage to provide other dosage ranges for other joints and / or animals.

[0067] One aspect of the invention includes methods and / or uses as described above, wherein the sequence is that of SEQ ID NO: 1 and the patient is a human or a dog. The injection may be intra-articular and the change in bone shape may be due to osteoarthritis or aging.

[0068] Another aspect of the invention includes methods and / or uses as described above, wherein the dosage and / or further treatment is determined at least in part by obtaining images and comparing images before and / or during treatment to determine the effect on bone shape due to the injection, wherein measurements and re-measurements can be made using active appearance model (AAM) software. BRIEF DESCRIPTION OF THE DRAWINGS

[0069] The present invention will be better understood through the following detailed description in conjunction with the accompanying drawings. It should be emphasized that, as a matter of convention, the various features of the drawings are not to scale. Instead, the sizes of the various features are arbitrarily enlarged or reduced for clarity. The drawings section includes the following drawings:

[0070] Figure 1is a graph showing actual clinical study results in which changes in knee function from baseline to 12 months were measured using the Activities of Daily Living scale of the Knee Injury and Osteoarthritis Outcome Score ("KOOS ADL").

[0071] Figure 2 is a graph showing the results of an actual clinical study in which changes in knee function from baseline to 12 months were measured using the Sports and Leisure Activities subscale of the KOOS ("KOOS Sports and Leisure").

[0072] Figure 3 is a graph showing actual clinical study results where the change from baseline to 12 months was measured using the KOOS Knee-Related Quality of Life subscale ("KOOS Knee-Related QOL").

[0073] Figure 4 Showing the questions and scoring system for the KOOS pain subscale.

[0074] Figure 5 is a graph showing actual clinical study results where the change from baseline to 12 months was measured using components of the KOOS pain subscale specifically for “pain going up and down stairs.”

[0075] Figure 6 is a graph showing actual clinical study results where the change from baseline to 12 months was measured using components of the KOOS pain subscale specifically for knee pain frequency.

[0076] Figure 7 Contains graphs showing actual clinical study results, which show the difference in the rate of change of bone area around OA and non-OA knees in four areas of the knee.

[0077] Figure 8 is a graph showing actual clinical study results showing the change in medial femoral periarticular bone area from baseline to 12 months.

[0078] Fig. 9 The differences in the rate of change of periarticular bone area in the three regions of the index (TPX-100 treated) and control (placebo exposed) knees are shown.

[0079] Fig.10 is a graph showing actual clinical study results showing the change in femoral bone shape score from baseline to 12 months.

[0080] Fig.11 is a graph showing actual clinical study results showing the change in pain frequency from baseline to 12 months comparing responders to active treatment with the peptide of SEQ ID NO: 1 to non-responders.

[0081] Fig.12 is a graph showing actual clinical study results showing that changes in three-dimensional bone shape of the patella from baseline to 12 months correlated with pain frequency in responders (vs. non-responders) to active treatment with the peptide of SEQ ID NO: 1.

[0082] Fig.13 is a graph showing actual clinical study results, showing the three-dimensional bone shape of the femur from baseline to 12 months.

[0083] Fig.14 is a graph showing actual clinical study results showing the change in pain frequency from baseline to 12 months comparing responders to active treatment with the peptide of SEQ ID NO: 1 to non-responders.

[0084] Fig.15 is a graph showing actual clinical study results showing that changes in three-dimensional bone shape of the patella from baseline to 12 months correlated with pain frequency in responders (vs. non-responders) to active treatment with the peptide of SEQ ID NO: 1.

[0085] Specific embodiments of the invention

[0086] Before describing the present compositions and methods, it should be understood that the present invention is not limited to the specific embodiments described, as they may of course vary. It should also be understood that the purpose of the terms used herein is only to describe specific embodiments and is not intended to be limiting, as the scope of the present invention is limited only by the appended claims.

[0087] When providing a numerical range, it should also be considered that each intermediate value between the upper and lower limits of the range is specifically disclosed, unless the context clearly indicates otherwise. The present invention also includes a smaller range between any set value or intermediate value in the set range and any other set value or intermediate value in the set range. Depending on any explicitly excluded limits in the set range, the range may independently include or exclude the upper and lower limits of these smaller ranges, and the present invention also includes each range where these smaller ranges do not include limits, include any one or two limits. When the set range includes one or two limits, the present invention also includes a range that excludes one or two of the limits.

[0088] Unless otherwise indicated, all scientific and technological terms used herein have the same common meanings as understood by those of ordinary skill in the art to which the present invention belongs. Although any methods and materials similar or equivalent to those described herein may be used to implement or test the present invention, some potential and preferred methods and materials are described herein. All publications mentioned herein are incorporated herein by reference to disclose and describe methods and / or materials related to the cited publications. It should be understood that in the event of a conflict, the disclosure of the present invention replaces the disclosure of any publication contained herein.

[0089] It must be noted that as used herein and in the appended claims, the singular forms "a", "an", and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "an injection" includes a plurality of such injections and reference to "the measurement" includes one or more measurements and equivalents thereof known to those skilled in the art, and so forth.

[0090] The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein should be construed as an admission that the present invention is not entitled to antedate such publications by virtue of prior invention. Further, the dates of publication provided may be different from the actual publication dates, which may need to be independently confirmed.

[0091] Cartilage structure in the pathophysiology of osteoarthritis

[0092] As described in the Background section above, the long-standing explanation for the pathogenesis of osteoarthritis (OA) is the degeneration of articular (joint) cartilage, which is thought to lead to dysfunction and pain in the affected joints. Multiple candidate DMOADs have been tested in clinical trials to target changes in articular cartilage structure. However, few have actually demonstrated any cartilage structural changes in human clinical trials. Even when small increases in cartilage have been observed in clinical studies, no corresponding patient benefits, such as improvements in knee function or pain, have been observed compared to placebo.

[0093] To date, the only published clinical data demonstrating an association between increased / stabilized cartilage thickness and statistically significant clinical improvement in patients with knee OA are the results of a randomized, placebo-controlled study of the peptide of SEQ ID NO: 1 (McGuire 2018).

[0094] Clinical benefits and cartilage thickening efficacy in osteoarthritic knees

[0095] The peptide of SEQ ID NO: 1 (also known as TPX-100) is known to promote new cartilage formation (see US Pat. Nos. 7,888,462 and 8,426,558).

[0096] For this activity, the clinical safety and efficacy of the peptide of SEQ ID NO: 1 was tested in a Phase 2 randomized double-blind placebo-controlled clinical trial in patients with mild to severe knee osteoarthritis (OA) cartilage damage. See Examples.

[0097] The expected clinical benefit of the peptide is improved knee joint function. If the peptide can repair damaged cartilage, maintain living cartilage, and / or make cartilage more resilient to the wear and tear of aging, then better joint function can be expected.

[0098] At the 6-month and 12-month post-treatment time points, knee function as measured by the KOOS ADL and WOMAC functional subscales demonstrated clinically meaningful and statistically significant improvements in the knee treated with the peptide of SEQ ID NO: 1 ("index knee") compared to the placebo-treated knee ("control knee") (p=0.008). Figure 1 .

[0099] The index knee also showed clinically meaningful and statistically significant improvements in the sports and leisure and knee-related QOL subscales of the KOOS compared with the control knee. Figure 2 and 3 .

[0100] Although the KOOS pain subscale showed only a statistically significant trend toward improvement in the index knee compared with the control knee at 12 months (p<0.09), pain frequency and stair climbing pain in the index knee were statistically significantly improved compared with the control knee (p<0.05). Figure 5 and 6 .

[0101] Regarding the primary endpoint of the clinical study, change in patellar cartilage thickness at 6 months, there was no statistically significant difference between the index knee and the control knee. Only 16% of the patellar cartilage showed any change compared to baseline, which limited the practical sample size for this measurement. Nevertheless, the strong clinical benefit demonstrated by TPX-100 can be reasonably attributed to the cartilage repair, formation and / or stabilization brought about by the peptide of SEQ ID NO: 1.

[0102] In a post hoc analysis, an association was observed between positive changes in tibiofemoral cartilage thickness and improved knee function at 12 months, as measured by KOOS ADL and WOMAC function, in the index knees but not in the control knees (McGuire 2018). Of the many clinical studies of DMOAD drug candidates to date, this is the first to demonstrate that positive changes in cartilage are associated with clinical benefit significantly above placebo.

[0103] Subsequent to publication of this report, further analyses were performed. These analyses confirmed that at 12 months post-treatment, there was a significant association between increased / stabilized tibiofemoral (TF) cartilage thickness and improved knee function in the index knee but not in the control (placebo-exposed) knee. See Table 1.

[0104] Table 1: Correlation between tibiofemoral joint cartilage thickening / stabilization and knee joint function improvement at 6 and 12 months after treatment

[0105]

[0106] Based on these results, it has been demonstrated that the peptide of SEQ ID NO: 1 improves clinical benefits in knee OA patients and increases / stabilizes TF cartilage thickness.

[0107] Given the robust findings of multiple clinical benefits associated with treatment with the peptide of SEQ ID NO: 1 in a patient population dominated by moderate to severe knee OA, other biological activities beyond chondrogenesis / stabilization may contribute to the efficacy of this peptide.

[0108] Analysis of periarticular bone area and shape

[0109] To address this question, we measured and compared periarticular bone surface area and three-dimensional (3D) bone shape between index and control knees.

[0110] Studies have shown that periarticular bone shape changes predictably during normal aging, and that accelerated bone shape changes are closely associated with the development and progression of knee OA. The pattern of periarticular bone shape changes is common to all knees that develop OA. The periarticular bone shape flattens and becomes irregular, and the bone surface area increases. This bone shape change precedes the radiographic changes that can be detected in patients who develop OA (Reichenbach 2008).

[0111] 3D bone shape variation can be quantified using active appearance modeling (AAM). AAM allows encoding the 3D shape and appearance of an object using multiple anchor points (“principal components”) on the object’s surface. These principal components computationally describe the specific 3D shape of the object. Neogi et al. (Neogi 2013) describe in detail the use of AAM to represent the shape of the femur, tibia, and patella.

[0112] Using this approach, changes in bone area and bone shape around OA and non-OA knees were compared in subjects enrolled in the National Institute of Health Osteoarthritis Initiative (OAI). Differences in percent bone area change and changes in bone shape scores were compared between OA and non-OA knees over a four-year period in the femur, tibia, patella, and trochlear femur (the anterior subregion of the femur that articulates with the patella; this region is also referred to as the patellofemoral (PF)) as described in detail by Bowes et al (Bowes 2015) and Hunter et al (Hunter 2016). Bone area in all regions, regardless of OA status, showed an increase from baseline. Bone shape scores also increased in all regions from baseline. Changes were unidirectional and irreversible, consistent with the natural history of disease.

[0113] The bone area increase rate in each region of OA knees was significantly higher than that in non-OA knees. Figure 7 Measurements of periarticular bone in OA knees over a one-year period showed a statistically significant increase in bone area in OA knees compared to non-OA knees (Bowes 2015). The bone shape score of periarticular bone in OA knees also increased significantly faster than in non-OA knees.

[0114] Clinical trial results for TPX-100, with only four doses of the test article at the beginning of the study period (Days 0, 7, 14, and 21), without any intensive treatment thereafter, showed a slower rate of change in periarticular three-dimensional bone shape and bone area in the index (TPX-100 treated) knees compared to control knees, as measured by iMorphics' AAM analysis (www.imorphics.com). The MRI images of each knee used to measure cartilage thickness were used to measure periarticular bone surface area on the lateral and medial sides of the femur, lateral and medial sides of the trochlear femur, lateral and medial sides of the tibia, and lateral and medial sides of the patella. Bone shape scores were also measured for the femur, trochlear femur, tibia, and patella using the same MRI images.

[0115] Changes in periarticular bone area in all eight regions were compared between the index knee and control knee from the current clinical study.

[0116] Control knees (placebo-treated knees) from clinical studies showed sustained increases in periarticular bone area in all regions, similar to OA knees in the OAI Natural History Database.

[0117] At 6 months, there was a trend toward less increase in medial femoral periarticular bone area in the index knees compared with the control knees (p = 0.08). Figure 8 Shown are changes in medial femoral bone area in the index and control knees for 6 and 12 months, respectively, following test article administration.

[0118] Fig. 9Bone area changes are shown for the lateral femur, lateral patella, and medial patella of the index knee versus the control knee, respectively. Although these comparisons did not show statistically significant differences between treatment groups, it is noteworthy that bone area changes in the index knee were almost zero in all regions during the first 6 months.

[0119] When comparing 3D bone shape changes, the index knees had a statistically significant reduction in shape change compared to the control knees. This difference was significant at both 6 and 12 months (p = 0.005 and 0.007, respectively). Of note, the mean bone shape change rate of the index knees in the first 6 months was 0.03, which is very similar to the mean bone shape change rate of non-OA subjects in the OAI database. Fig.10 .

[0120] Based on an analysis of the population participating in OAI, all knees experience an increase in bone area and changes in 3D shape with age. These changes are accelerated in knee OA. Slowing, arresting, or reversing these bone changes in OA would be disease-modifying.

[0121] As previously described, treatment of mild to severe OA knees with the peptide of SEQ ID NO: 1 reduced the rate of change of 3D bone shape and bone area in the femur compared to placebo-treated knees. This suggests that the progression of OA is delayed, blocked, or in some cases even reversed by the peptide of SEQ ID NO: 1. In this study, the peptide of SEQ ID NO: 1 was used in only one series (days 0, 7, 14, and 21, 4 times). If the peptide of SEQ ID NO: 1 is administered repeatedly periodically, for example, every few months, every year or two years, etc., the pathological 3D bone shape and bone area changes should be reduced or normalized over a longer period of time.

[0122] These data also indicate that treatment with the peptide of SEQ ID NO: 1 delays, arrests, or even reverses the increase in periarticular bone area, thereby delaying, arresting, or reversing OA progression and delaying or eliminating joint disability associated with natural aging.

[0123] Notably, after treatment with the peptide of SEQ ID NO: 1, the increase in pathological bone area and the changes in the 3D shape of periarticular bone occurred within a relatively short period of time, namely 6 and 12 months after treatment.

[0124] Surprisingly, the peptide of SEQ ID NO: 1 reduced pathological bone shape changes around joints in such a short period of time, and despite the relatively small sample size, the treatment differences were robust and statistically significant.

[0125] Because the clinical benefits to the knee as measured by KOOS ADL, KOOS Sports and Leisure, and KOOS Knee-Related QOL were clinically and statistically significant in favor of the index knee at 6 months, 12 months, or both; and OA progression as measured by periarticular bone structural changes was delayed, blocked, or reversed in the index knee compared to the control knee, it is believed that the peptide of SEQ ID NO: 1 alters the pathophysiology of OA by altering periarticular bone structural changes.

[0126] In order to elucidate the possible influence of the peptide of SEQ ID NO: 1 on the clinical benefit of improving periarticular bone shape, correlation analysis was performed using Pearson and Spearman statistical analysis methods.

[0127] The femur is the largest periarticular bone in all knee joint regions. Alterations in femoral structure are believed to play an important role in the pathophysiology and progression of knee OA. Within 6 months after administration, the peptide of SEQ ID NO: 1 significantly reduced pathological 3D bone shape changes in the femur ( Fig.10 ). Both Pearson and Spearman analyses indicated that in knees treated with the peptide of SEQ ID NO: 1 (index knee), there was a correlation between the reduction in pathological femoral 3D bone shape changes and tibiofemoral (TF) cartilage thickening / stabilization, which was robustly statistically significant at 12 months. See Table 2. Cartilage thickening / stabilization of the entire TF cartilage and the lateral and medial TF and femoral condyle cartilage were significantly correlated with the reduction in femoral 3D bone shape changes. At 6 months, a trend towards significant correlation was observed in the entire TF region, the medial TF region, and the femoral condyle. These results indicate that the significant reduction in pathological 3D femoral bone shape changes brought about by the peptide of SEQ ID NO: 1 manifested relatively early (within the first 6 months) and that the peptide of SEQ ID NO: 1 induced TF cartilage thickening / stabilization. At 12 months, the reduction in pathological femoral bone shape changes was highly significantly correlated with the increase / stabilization of TF cartilage.

[0128] Table 2. Correlation between reduction in femoral pathological three-dimensional bone shape change and tibiofemoral joint cartilage thickening / stabilization at 6 and 12 months after treatment

[0129]

[0130]

[0131] The same analysis was performed in subjects with bilateral tibiofemoral OA (excluding the isolated posterior patellofemoral OA knee), and although the sample size was limited, no significant differences were found in the total TF area, medial TF area, and femoral TF area at 12 months.

[0132] There was a statistically significant correlation between reduction in pathological femoral 3D bone shape change and tibiofemoral (TF) cartilage thickening / stabilization in the condyle. See Table 3.

[0133] In either of these analyses, these associations were found only in the index knees and not in the control knees.

[0134] Table 3. Correlation between reduction in femoral pathological three-dimensional bone shape change and tibiofemoral joint cartilage thickening / stabilization at 6 and 12 months after treatment in subjects with bilateral tibiofemoral OA

[0135]

[0136] The peptide of SEQ ID NO: 1 reduces pathological 3D bone shape changes of the patella. At 12 months, both Pearson and Spearman analyses showed a significant correlation between the reduction in pathological 3D bone shape changes of the patella and the frequency of pain in the knee treated with the peptide of SEQ ID NO: 1 (index knee). See Table 4. The frequency of pain was significantly reduced in responders to treatment during the 12-month follow-up period. See Fig.11 In the responder group, the baseline pain frequency score was 3, indicating "daily" pain. At 12 months, the score improved by about 1.5 points, indicating their pain frequency had decreased to "half a week." During the study, participants reduced their pain medication use by 62.5%.

[0137] In addition, the change in 3D bone shape of the patella remained essentially zero in the pain frequency responder group over 12 months, whereas it continued to increase in the non-responder group. The change in 3D bone shape of the patella from baseline to 12 months showed a highly statistically significant difference between the two groups. Fig.12 .

[0138] These combined results suggest that the peptide of SEQ ID NO: 1 reduces or potentially reverses pathological three-dimensional bone shape changes in the patella, thereby significantly reducing knee pain frequency and analgesic use.

[0139] Table 4. Correlation between pathological three-dimensional bone shape changes of the patella and reduction in pain frequency at 12 months after treatment in the index knee

[0140]

[0141] The correlation between the reduction of pathological three-dimensional bone shape changes of the patella and the improvement of pain frequency was demonstrated in the index knees but not in the control knees.

[0142] The pathological 3D bone shape changes of the patella have not been characterized, nor have those of the femur. Although the severity of knee pain is most consistent with the severity of patellar pathology (Joseph 2016), this invention is the first to clearly propose that 3D bone shape changes of the patella are the pathophysiological mechanism of OA knee pain. In the routine clinical setting of specific pain treatment, patients can determine whether pain is reduced in the short term after treatment. In such disease-modifying therapies that delay, block or reverse pathological 3D bone shape changes, pain reduction occurs due to a structural effect on the bone, which appears to take several months based on current clinical data. Therefore, monitoring such post-treatment bone shape changes provides patients and caregivers with useful information about prognosis, such as whether the patient's current knee pain can be reduced or prevented from worsening and / or whether repeated treatment can further benefit. Treatment and prevention of knee pain by reducing pathological patellar shape changes is one of the most important components of the present invention.

[0143] In summary, administration of the peptide of SEQ ID NO: 1 in patients with knee OA can significantly slow down or even reverse pathological periarticular 3D bone shape changes in multiple knee joint cavities, resulting in expected clinical benefits, including improved function and reduced frequency of knee pain. In the same time course, the peptide of SEQ ID NO: 1 has a positive effect on both periarticular bone and cartilage structures; therefore, pathological changes in both components of the knee joint can be treated by a therapeutic composition comprising the peptide of SEQ ID NO: 1 as a single pharmaceutical ingredient. Depending on the dosing regimen, the peptide of SEQ ID NO: 1 not only treats OA, but also delays, blocks or reverses pathological changes in joint aging, indicating that the peptide can be used prophylactically to prevent or delay the onset of OA. Since the basic mechanism of OA is common to many joints, the therapeutic or prophylactic use of the peptide of SEQ ID NO: 1 is not limited to knee OA, but can include hip, ankle, elbow, shoulder, neck, spine, wrist and finger joints. Additionally, this approach could be used to repair, rebuild or stabilize joints affected by other arthritises, such as rheumatoid arthritis, after their disease-specific causes, such as autoimmunity and inflammation, have been addressed.

[0144] A new approach to treating osteoarthritis

[0145] Based on the clinical research results summarized above, a new approach to treating osteoarthritis (OA) has been established.

[0146] The method includes any therapeutic intervention that can delay, block or reverse pathological periarticular bone shape changes to treat OA. Although natural history study data of OA patients participating in OAI support the pathological nature of periarticular bone shape changes in the occurrence and progression of knee OA, the clinical study results described herein are the first to demonstrate that this natural irreversible periarticular bone shape change associated with OA can be delayed, blocked or even reversed. Most importantly, the delay, block or reversal of periarticular bone shape changes is associated with clinically significant patient benefits, including function and pain in the affected joints. The present invention has demonstrated in controlled human clinical trials that it is possible to slow down pathological periarticular bone shape changes and is associated with improvements in the severe symptoms of knee OA.

[0147] An important component of the method involves injecting a therapeutically effective amount of a formulation of the peptide of SEQ ID NO: 1 into a patient suffering from OA, thereby reducing the rate of bone area and bone shape change in the affected joint. Osteoarthritic periarticular bone exhibits a more rapid increase in bone area and three-dimensional shape change compared to non-arthritic joints, so reducing the rate of these changes means slowing, arresting, or even reversing the progression of OA. These changes in periarticular bone structure begin before measurable cartilage loss and continue throughout the progression of the disease, and this new approach can be used across the entire spectrum of OA from onset to severe disease.

[0148] In addition to the peptide of SEQ ID NO: 1, orthologous peptides derived from species other than humans (including but not limited to primates, dogs, cows and mice) are expected to have similar activities against periarticular bone structural changes in humans and other species and are therefore within the scope of the present invention. Examples are the peptides of SEQ ID NO: 2-5.

[0149] Similar peptides of the peptide of SEQ ID NO: 1 and its orthologs, which are believed to have similar biological activities as the peptide of SEQ ID NO: 1, including those that share a common amino acid sequence as shown in SEQ ID NO: 6, are also within the scope of the present invention.

[0150] Furthermore, since the knee is known to undergo increases in periarticular bone area and changes in 3D bone shape during aging, this approach, by reducing the rate of pathological periarticular bone area and shape changes, may prevent, delay or arrest the otherwise inevitable process that increases OA risk.

[0151] The new method is particularly applicable to knee OA, as demonstrated in the examples.

[0152] An important component of the present invention is a novel approach to reducing the frequency of knee pain in knee OA by delaying, arresting or reversing three-dimensional bone shape changes in the patella.

[0153] Pharmaceutical compositions containing the peptide of SEQ ID NO: 1, which treat OA by delaying, arresting or reversing pathological structural changes in periarticular bone, are within the scope of the present invention.

[0154] Although the present invention is based on clinical trial data of patients with knee OA, it is also applicable to OA of other joints such as hip, ankle, elbow, shoulder, neck, spine, wrist, fingers, etc., because similar lesions may also occur in the periarticular bone structures of these other joints.

[0155] Because periarticular bone is often damaged in many joint diseases and disorders, and because the peptide of SEQ ID NO: 1 is able to delay, block or reverse pathological periarticular bone structural changes, this new approach can be used to treat joint diseases other than OA, including but not limited to, rheumatoid arthritis and traumatic arthritis. Example

[0156] The purpose of providing the following examples is to fully disclose and describe how to prepare and use the present invention to those of ordinary skill in the art, and these examples are not intended to limit the scope of the invention as considered by the inventors, nor do they represent that the following experiments are all or the only experiments performed. Efforts have been made to ensure the accuracy of the values ​​used (such as amounts, temperatures, etc.), but some experimental errors and deviations should be allowed. Unless otherwise indicated, parts are parts by weight, molecular weight is weight average molecular weight, temperature is degrees Celsius, and pressure is atmospheric pressure or near atmospheric pressure.

[0157] Example 1

[0158] A randomized, double-blind, placebo-controlled study of TPX-100 in patients with knee osteoarthritis

[0159] Clinical Research Methods

[0160] Research Outline

[0161] A multicenter, randomized, double-blind, placebo-controlled study was designed to investigate the safety, tolerability, pharmacokinetics, and efficacy of TPX-100 given four times weekly in subjects with bilateral patellofemoral knee osteoarthritis. This study was conducted under an open IND (Investigational New Drug Application) from the U.S. FDA (U.S. Food and Drug Administration) CDER (Center for Drug Evaluation and Research) in compliance with GCP (Good Clinical Practice) and ICH (International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use) guidelines. Eighteen (18) orthopedic, rheumatology, and family practice centers in the United States participated in the study.

[0162] This study was divided into two parts, A and B. Part A was designed to evaluate the safety of TPX-100 at different dose levels (20, 50, 100, or 200 mg / injection in consecutive groups) given intra-articularly (IA) to subjects with knee osteoarthritis and to select the dose for Part B. Part B was to evaluate the safety and efficacy of the selected dose of TPX-100.

[0163] Subjects in Part A were enrolled in consecutive groups and randomized to receive 20, 50, 100, or 200 mg TPX-100 in one knee (index knee) and the same placebo in the contralateral (control) knee. Subjects, sites, sponsors, and central MRI inspectors were blinded to treatment assignment. The Safety Review Committee (SRC) evaluated the safety of each dosing group. The SRC evaluated safety and determined whether the next higher dose regimen could be added. The safety of all dosing groups in Part A was completed and analyzed prior to dose selection and initiation of Part B.

[0164] Part A consisted of four (4) intra-articular (IA) injections, once a week, in sequential dosing groups of 20, 50, 100, and 200 mg TPX-100 and placebo. Six (6) subjects were enrolled in the 20, 50, and 100 mg groups, and nine (9) subjects were enrolled in the 200 mg group.

[0165] Based on the safety review and approval of the SRC, the 200 mg dose was selected for Part B. There were no dose-limiting toxicities at this dose or the 3 lower doses studied in Part A. 87 subjects were enrolled in Part B (200 mg dose). According to the statistical analysis plan, these subjects were combined with the 9 subjects in the 200 mg group in Part A for efficacy analysis. A total of 93 subjects' drug efficacy data were analyzed, each of whom received 4 weekly injections of 200 mg / dose of TPX-100 in the index knee and the same placebo in the contralateral knee, and were randomly assigned.

[0166] In Parts A and B, subjects received 4, weekly doses of active drug in the knee, randomized to active drug in the index knee and placebo in the contralateral (control) knee, administered via the intra-articular route. No other doses of drug or placebo were given. All subjects visited their respective clinical sites 3, 6, and 12 months after the first dose for safety and efficacy assessments.

[0167] Object Filtering

[0168] After informed consent was obtained, subjects underwent clinical and laboratory screening evaluations to assess their initial study eligibility. Screening included the following procedures:

[0169] Medical history including medication history

[0170] Focus on physical examination

[0171] Vital signs including resting blood pressure, pulse, respiratory rate, and temperature

[0172] Weight, height and BMI

[0173] Knee X-ray (if not obtained within 3-month screening)

[0174] Laboratory evaluation including hematology, coagulation profile, comprehensive metabolic panel, etc.

[0175] Concomitant medication records

[0176] Subjects meeting all clinical and laboratory eligibility criteria underwent standard bilateral knee MRI.

[0177] Inclusion and Exclusion Criteria

[0178] Inclusion and exclusion criteria for screening Part A or Part B subjects are as follows:

[0179] Inclusion criteria

[0180] 1. Age ≥ 25 and ≤ 75

[0181] 2. Mild to moderate bilateral patellofemoral osteoarthritis, intact menisci, stable ligaments (cruciate ligaments and collateral ligaments)

[0182] Clinically, as determined by screening questionnaire, principal investigator judgment (may be supported by imaging studies of the knee); confirmed by central reading screening MRI of both knees, ICRS grade 1-3, or grade 4, only focal defects, no defects larger than 1 cm.

[0183] Intact meniscus (MRI degeneration signal is the most and includes acceptable grade II)

[0184] Cruciate and collateral ligament stability as defined by clinical examination

[0185] 3. Ability to read, understand, sign and date the subject's informed consent form

[0186] 4. Willingness to use only acetaminophen as the primary analgesic (pain relief) study medication. The maximum dose of acetaminophen should not exceed 4 grams / day (4000 mg / day).

[0187] 5. Willing to use hydrocodone / acetaminophen or hydrocodone alone to treat breakthrough pain during the injection period (study day 30).

[0188] 6. Willingness not to use nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, or naproxen (NSAIDS) during the first 30 days of the study.

[0189] 7. Sexually active (non-abstinent) female subjects of childbearing potential must agree and comply with two highly effective contraceptive methods (oral contraceptives, implants, injectable or indwelling intrauterine devices, condoms with spermicide, or sexual abstinence) while participating in the study.

[0190] Exclusion criteria

[0191] 1. Contraindications to MRI, including: metal fragments, clips, or devices in the brain, eyes, or spinal canal; implanted magnetic procedural devices; weight > 300 pounds; moderate or severe claustrophobia; previous MRI procedural intolerance

[0192] 2. ICRS greater than 3, except for 4 with focal defects no larger than 1 cm confirmed by central reading screening MRI

[0193] 3. MRI evidence of inflammatory or hypertrophic synovitis or significant cartilage calcification

[0194] 4. Previous knee surgery, excluding debridement surgery

[0195] 5. Knee replacement or any other knee surgery planned within the next 12 months

[0196] 6. History of rheumatoid arthritis, psoriatic arthritis, or any other autoimmune or infectious arthritis

[0197] 7. Knee joint effusion >2+, meeting the following clinical scale:

[0198] 0 = No wave is generated during downstroke

[0199] Trace = inner wavelet during downstroke

[0200] 1+ = Larger inner bulge during downstroke

[0201] 2+ = After the upstroke, the accumulated fluid returns to the inner side spontaneously (no downstroke is required)

[0202] 3+ = Too much fluid, unable to move exudate away from the inside of the knee

[0203] 8. Less than 3 months before screening, the last viscous supply (e.g. or similar hyaluronic acid products) into either knee

[0204] 9. Last intra-articular knee corticosteroid injection less than 2 months before screening

[0205] 10. Use of any steroids within one month prior to screening (except inhaled corticosteroids for respiratory problems)

[0206] 11. Known allergy to TPX-100

[0207] 12. Known allergy to acetaminophen or hydrocodone

[0208] 13. Any history of knee endoscopic examination within 3 months before screening

[0209] 14. Screening for a history of suppurative arthritis, gout or pseudogout in any knee joint in the previous year

[0210] 15. Clinical signs of an acute meniscal tear (such as locking or new acute mechanical symptoms consistent with a meniscal tear)

[0211] 16. X-ray manifestations of patellar chondrocalcinosis

[0212] 17. Skin problems, rashes or allergies affecting either knee at the injection site

[0213] 18. Bleeding problems, insufficient platelets or coagulation, prohibition of intra-articular injection

[0214] 19. Active systemic infection

[0215] 20. Treatment for any malignancy other than basal cell carcinoma or squamous cell carcinoma of the skin, currently or within 2 years before the screening visit, unless special written permission is provided by the medical supervisor of the sponsor

[0216] 21. Women of childbearing potential who are pregnant, breastfeeding, or planning to become pregnant, and women who do not agree to continue using an acceptable method of birth control throughout the study period

[0217] 22. Participated in other clinical osteoarthritis drug research within one year before screening (except analgesic research)

[0218] 23. Currently taking paclitaxel (mitotic inhibitor) and / or natalizumab (anti-integrin).

[0219] 24. Have a history of severe liver disease or drink more than 3 drinks a day. (One drink is defined as: 12 ounces of beer, 8 ounces of malt liquor, 5 ounces of wine, 1.5 ounces or a "single cup" of 80-proof distilled liquor (such as gin, rum, vodka or whiskey)).

[0220] Randomization

[0221] If all clinical inclusion and exclusion criteria were met, MRI of both knees was obtained and evaluated by a central reviewer to determine the ICRS grade (gICRS) of each knee as the final screening criterion. Subjects were enrolled if the cartilage of the patellofemoral joint cavity of both knees was within the ICRS grade range of 1-3, or grade 4 with only small focal defects no larger than 1 cm. The randomization center randomized each subject to "right knee active" or "left knee active." The active knee received TPX-100 and the contralateral knee received the same placebo.

[0222] For enrolled subjects, within-subject randomization was performed, with one knee receiving an injection of active drug and the contralateral knee receiving an identical placebo injection. When a person's two knees form a matched set, the effects of individual-level confounding factors (such as activity level, genetic and epigenetic factors, pain threshold) are eliminated, thereby increasing the study's power to detect a treatment effect, if one exists.

[0223] Subjects randomized to Part A were excluded from recruitment into Part B.

[0224] Drug administration

[0225] On the first dosing day, randomized subjects were assessed by physical examination and vital signs. In addition, they completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), which includes the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The KOOS questionnaire assesses knee-specific daily life, sports and leisure activities, knee-related quality of life, and other symptoms such as stiffness and knee pain. KOOS has been widely used in longitudinal studies of knee osteoarthritis. After the assessment was completed, the subjects received one intra-articular injection in each knee, and each injection was prepared from a vial labeled for that knee. One knee received TPX-100 and the contralateral knee received placebo, and the subjects, sites, and sponsors were unaware of the treatment assignment. Subjects were monitored for adverse events during and for several hours after the injection. Vital signs were also monitored after the injection.

[0226] Subjects received a second, third, and fourth (final) dose of the same study material on days 7, 14, and 21 after the first dose, respectively. Safety and adverse event assessments were performed starting from the first dosing day.

[0227] Follow-up after treatment

[0228] Subjects returned to their respective study sites for follow-up assessments at 3, 6, and 12 months after the first dosing day. In addition, study sites monitored subjects' condition by telephone contact 9 months after the first day of dosing. Subjects were evaluated on-site at 3, 6, and 12 months post-treatment by physical examination, vital signs, serum chemistries, and completion of patient-reported outcomes including KOOS. Adverse events and concomitant medications were recorded. MRIs of both knees were obtained at 6 and 12 month follow-up.

[0229] Efficacy analysis

[0230] All KOOS subscale scores, WOMAC total and subscale scores, MRI-based patellofemoral and tibiofemoral cartilage thickness, MRI-based periarticular bone area, and 3D bone shape were analyzed.

[0231] MRI images were provided to a central reviewer for cartilage and periarticular bone measurements. The central reviewer was blinded to treatment allocation.

[0232] These parameters were analyzed using AAM software developed by iMorphics (www.imorphics.com) specifically for the assessment of periarticular bone area and three-dimensional shape in the osteoarthritic knee.

[0233] Statistical analysis was performed using a two-sided paired t-test at the 5% significance level. The outcome variables were the difference in change in KOOS subscale scores, change in cartilage thickness, change in periarticular bone area, and change in 3D bone shape score ("B-score") from baseline to 6 and 12 months in treated knees ("index knees") compared with placebo-exposed knees ("control knees").

[0234] Possible correlations between any two selected parameters (eg, knee function and cartilage thickness) were tested using Pearson and Spearman correlation analyses.

[0235] result

[0236] According to the statistical analysis plan, 93 subjects who received TPX-100 200 mg / dose in one knee and placebo in the contralateral knee and who had at least one follow-up MRI were included in the efficacy analysis.

[0237] Approximately 47% of all knees had gICRS 4 (most severe) knee OA, all located in the tibiofemoral (TF) cavity. Another approximately 40% of patients had gICRS 3 (less severe) knee OA in the patellofemoral joint (PF) and / or TF cavity, and the remaining approximately 20% of patients had gICRS2 (moderate) PF and / or TF in one or both knees. There were no subjects with gICRS1 (mild) knee OA. The average body mass index (BMI) of all subjects was over 30, which was in the obese range, consistent with the average BMI of the OA population in the United States. The average age of the subjects was 58.1 years, and 58% of the subjects were female, which is also consistent with the demographics of the OA population in the United States. Most subjects had severe OA in one or both knees.

[0238] Treatment with TPX-100 was safe and well tolerated. No serious adverse events related to TPX-100 treatment occurred. Treatment-related adverse events were mild or moderate, transient, and common in many subjects at baseline.

[0239] Several patient-reported outcomes (PROs), including the majority of KOOS subscales, demonstrated clinically meaningful and statistically significant improvements in the index (TPX-100-treated) knee compared to the control (placebo-exposed) knee.

[0240] The KOOS ADL (Function in Activities of Daily Living) subscale consists of 17 questions covering a variety of daily activities that are critical to daily knee function. Results for the KOOS-ADL domain at the 6- and 12-month time points showed clinically meaningful and statistically significant improvements in the index knee compared to the control knee (p<0.05). Figure 1 The WOMAC Functional subscale, which consists of the same questions as the KOOS-ADL, not surprisingly showed similarly robust improvements in the index knee compared with the control knee.

[0241] The KOOS Sports and Leisure subscale includes five questions related to physical activities such as jumping, running, and squatting. At 6 months, the KOOS Sports and Leisure showed clinically meaningful and statistically significant improvements in the index knee compared with the control knee. Figure 2 .

[0242] The KOOS knee-related quality of life (QOL) subscale consists of four questions, including general difficulties with the subject's knee and awareness of problems (confidence regarding each of their knees). At 12 months, the KOOS knee-related QOL showed clinically meaningful and statistically significant improvements in the index knee compared with the control knee. Figure 3 .

[0243] The KOOS pain subscale consists of 9 questions regarding 1) the frequency of pain and 2) the amount of pain during different activities. Figure 4 At 12 months, the KOOS pain subscale showed clinically meaningful improvement in the index knee compared with the control knee, with a trend toward statistical significance (p<0.09). Figure 4 The improvement in the index knee at 12 months was clinically meaningful compared with the control knee, although the difference did not reach statistical significance.

[0244] One of the questions that make up the KOOS pain (and WOMAC pain) subscale is “pain going up and down stairs.” Pain with this common activity is one of the most common complaints of patients with knee OA, and at 12 months, pain was significantly improved in the index knee compared to the control knee (p<0.05). Figure 5 .

[0245] One of the questions in the KOOS pain subscale (question 1) is, “How often do you experience pain in your right / left knee?” This is the only question that is related to pain frequency. This question is unique to the KOOS pain subscale and is not included in the WOMAC pain domain. At 12 months, the frequency of pain in the index knee was significantly reduced compared to the control knee (p<0.05). Figure 6 .

[0246] The change from baseline in patellofemoral cartilage thickness at 6 months, as measured by MRI, was the primary efficacy outcome measure. There were no measurable differences between the index and control knees at 6 or 12 months. The vast majority (84%) of knees had changes in cartilage thickness in the patellofemoral joint cavity that were less than the minimum detectable change during the 12-month study period. Because only 16% of knees showed a measurable change in cartilage, either an increase or a decrease, the effective sample size was clearly limited, and the power to detect a treatment difference was correspondingly low.

[0247] Similarly, there were no measurable differences in the change from baseline in overall tibiofemoral cartilage thickness between the index and control knees at the 6-month or 12-month time points. However, increased or stable tibiofemoral cartilage thickness in the knee with improved function was significantly associated with improved knee function in the index knee at 12 months, as measured by the KOOS-ADL and WOMAC functional domains. No such association was found in the control knees. See Table 1.

[0248] Differences in changes in periarticular bone area and three-dimensional bone shape measured by MRI were also compared between the index and control knees. Of note, eight subjects had poor MRI image quality and were excluded from the bone area and shape analyses. Therefore, each evaluable treatment group consisted of 85 knees.

[0249] On the medial side of the femur, at 6 months, the index knee showed a trend toward less increase in pathological bone area compared with the control knee (p = 0.08). Figure 8 .

[0250] The increase in pathological bone area at the lateral femur, lateral patella, and medial patella in the index knees was almost zero in the first 6 months and increased more slowly at 12 months compared with the control knees. Fig. 9 .

[0251] These data indicate that treatment of knee OA with the peptide of SEQ ID NO: 1 can delay, block, or even reverse the increase in bone area around the knee joint, which is associated with the development and progression of OA.

[0252] At 6 and 12 months, the changes in three-dimensional bone shape around the femoral joint, quantified by the bone shape (B) score, showed statistically significant differences in favor of the index knee compared with the control knee (p<0.05). Fig.10 .

[0253] Although not statistically significant, the three-dimensional periarticular bone shape changes of the tibia and patella also showed slower changes in the index knee compared to the control knee. These data also indicate that treatment of knee OA with the peptide of SEQ ID NO: 1 slows, arrests or reverses the pathological periarticular bone structural changes that are associated with the progression of knee OA.

[0254] As shown in Table 1, tibiofemoral cartilage thickening / stabilization was significantly associated with improved KOOS-ADL / WOMAC function in the index knee, but not in the control knee. Further analysis showed that less change in periarticular femoral 3D bone shape was significantly associated with tibiofemoral cartilage thickening / stabilization in the index knee, but not in the control knee. See Tables 2 and 3. These results indicate that treatment of knee OA patients with the peptide of SEQ ID NO: 1 slowed pathological changes in periarticular femoral bone shape, increased / stabilized tibiofemoral cartilage thickness, and simultaneously improved knee function.

[0255] In the literature on symptomatic knee OA, patellofemoral pathology is most clearly associated with complaints of pain. In the index knee, but not in the control knee, slower patellar shape change was significantly associated with reduced pain frequency. See Table 4.

[0256] Additionally, responders to TPX-100 demonstrated robust improvements in pain frequency, which, on average, decreased from daily pain at baseline to semi-monthly pain at 12 months. Fig.11 The robust improvement in pain frequency was also associated with no eventual change in the three-dimensional bone shape of the patella. Fig.12 Notably, total analgesic use decreased by 62.5% during the 12-month study period.

[0257] Based on clinical data from these patients with mild to severe knee OA, the peptide of SEQ ID NO: 1 significantly reduced, blocked, or even reversed pathological periarticular bone structural changes in multiple compartments of the knee joint and provided key benefits to patients, including improved knee function and pain.

[0258] Example 2 Randomized Double-Blind Placebo-Controlled Study of TPX-100 in Patients with Knee Osteoarthritis - Data Analysis for More Stringent Criteria for Qualification of MRI Images

[0259] Target

[0260] After the data analysis in Example 1, the technical quality of slightly more MRI images was questioned in order to be able to evaluate the changes in periarticular bone shape over time. In order to ensure the quality of the overall analysis results, more stringent identification criteria were applied to the MRI images used in Example 1 and re-identified. 79 subjects were re-identified. In the same manner as described in Example 1, the MRI knee images of these subjects were re-analyzed to determine their periarticular bone shape changes and their correlation with changes in tibiofemoral cartilage thickness and pain.

[0261] result

[0262] The 79 subjects who were re-identified were included in the efficacy analysis according to the statistical analysis plan.

[0263] Approximately 34% of all knees had gICRS 4 (most severe) knee OA, all located in the tibiofemoral (TF) compartment. Another approximately 44% of patients had gICRS 3 knee OA in the patellofemoral joint (PF) and / or TF compartment, and the remaining approximately 22% of patients had gICRS2 (moderate) PF and / or TF in one or both knees. The patient demographics were very similar to Example 1; the average body mass index (BMI) was 30.9, the average age was 58.1 years, and 62% were female.

[0264] Clinically meaningful and statistically significant (p<0.05) improvements in knee function and quality of life (QOL)-related patient-reported outcomes (PROs) were demonstrated in all (TPX-100-treated) knees compared to control (placebo-exposed) knees at 6 or 12 months or both time points: KOOS ADL (Activities of Daily Living Function), WOMAC Function, and KOOS Knee-Related QOL.

[0265] The KOOS pain subscale also showed similar results to Example 1: at 12 months, there was a statistically significant trend toward clinically meaningful improvement in the index knee compared to the control knee (p<0.09).

[0266] Among the 9 questions that make up the KOOS pain subscale, pain frequency, pain with fully flexed knee, and pain ascending and descending stairs were significantly improved in the index knee compared with the control knee at 12 months (p<0.05).

[0267] Regarding the changes in periarticular three-dimensional bone shape quantified by the Bone Shape Score, there was a statistically significant delay in femoral bone shape changes in the index knees compared with the control knees at both 6 and 12 months (p<0.05). Fig.13 .

[0268] As shown in Table 5, less change in the three-dimensional bone shape around the femoral joint was significantly associated with thickening / stabilization of the tibiofemoral joint cartilage in the index knees but not in the control knees.

[0269] Table 5. Correlation between reduction in femoral pathological three-dimensional bone shape change and tibiofemoral joint cartilage thickening / stabilization at 6 and 12 months after treatment

[0270]

[0271] In the index knee, but not in the control knee, slower patellar shape change was significantly associated with reduced pain frequency. See Table 6.

[0272] Table 6. Correlation between pathological three-dimensional bone shape changes of the patella and reduction in pain frequency at 12 months after treatment in the index knee

[0273]

[0274] Additionally, responders to TPX-100 demonstrated robust improvements in pain frequency, which, on average, decreased from daily pain at baseline to semi-monthly pain at 12 months. Fig.14 The robust improvement in pain frequency was also associated with no eventual change in the three-dimensional bone shape of the patella. Fig.15 .

[0275] In this Example 2, very similar results to those in Example 1 were obtained using a data set with more stringent control over the quality of MRI images. According to these data, the peptide of SEQ ID NO: 1 significantly reduces, blocks, or even reverses pathological periarticular bone structural changes in multiple compartments of the knee joint, and provides key benefits to patients, including improved knee joint function and pain.

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[0310] The foregoing is only to illustrate the principles of the present invention. It should be understood that those skilled in the art can design various arrangements, and although these arrangements are not explicitly described or shown herein, they all embody the principles of the present invention and are included in the concept and scope of the present invention. Moreover, all embodiments and conditional language described herein are mainly intended to assist readers in understanding the principles of the present invention and the contribution of the present invention to the development of the prior art, and are not limited to these specifically cited embodiments and conditions. Moreover, all statements herein about the principles, aspects, embodiments and specific embodiments of the present invention should include their structural and functional equivalents. In addition, these equivalents should include currently known equivalents and equivalents developed in the future, i.e., any newly developed element with the same function, regardless of its structure. Therefore, the scope of the present invention should not be limited to the exemplary embodiments shown and described herein. It is appropriate that the scope and concept of the present invention are defined by the appended claims.

Claims

1. A formulation for effecting a change in the shape of subchondral bone in an articular joint in a patient, comprising: An injectable liquid for local injection into a patient's joint, the liquid comprising a pharmaceutically acceptable injectable carrier and a therapeutically effective amount of a pharmaceutically active peptide, characterized in that it affects the shape change of the subchondral bone in the patient's joint, thereby affecting the shape change of the subchondral bone in the patient's joint.

2. The formulation of claim 1, wherein the peptide is a peptide selected from the group consisting of SEQ ID NO: 1, SEQ ID NO: 2, SEQ ID NO: 3, SEQ ID NO: 4, SEQ ID NO: 5 and SEQ ID NO:

6.

3. The formulation of claim 1, wherein the peptide is the peptide of SEQ ID NO:

1.

4. The formulation of any one of claims 1-3, wherein the patient has been diagnosed with osteoarthritis, and thereby reducing the progression of osteoarthritis in the patient.

5. The formulation of any one of claims 1 to 4, further comprising: A first image of the subchondral bone of the joint prior to injection is obtained; obtaining a second image of the subchondral bone of the joint after the injection; and comparing the first image to the second image; and determining the effect of the injection on bone shape change; and The need for additional injections is determined based on the comparison.

6. The formulation of any one of claims 1 to 5, wherein the peptide is the peptide of SEQ ID NO: 1, which is administered in an amount ranging from about 50 to 400 mg ± 20%.

7. The formulation according to any one of claims 1 to 6, wherein the use is for repeated injections over a period of weeks, wherein the peptide is injected in an amount ranging from 50 to 400 mg ± 20%.

8. A preparation for delaying, arresting or reversing the natural aging of joints, the preparation comprising: A peptide of SEQ ID NO: 1 for delaying the three-dimensional shape change of articular subchondral bone and increasing the native bone area.

9. A formulation for use in a method comprising: (a) measuring the bone shape of the patient's joint; (b) locally injecting into the patient's joint a therapeutically effective amount of a formulation comprising a pharmaceutically acceptable injectable carrier and SEQ ID NO: 1; (c) re-measuring the bone shape of the joint and comparing the resulting measurements with the measurements obtained prior to the local injection of step (b).

10. The preparation for use according to claim 9, further comprising: Repeat steps (a), (b), and (c).

11. The formulation for use as claimed in any one of claims 9 and 10, wherein the measuring and re-measuring are performed using Active Appearance Model (AAM) software, the injection is an intra-articular injection, and the patient has been diagnosed with osteoarthritis (OA).

12. A formulation for use in reducing the frequency of knee pain by influencing a change in the three-dimensional shape of the subchondral bone in the affected joint, the use comprising: A therapeutically effective amount of a formulation is locally injected into a joint of a patient, the formulation comprising a pharmaceutically acceptable injectable carrier and a pharmaceutically active peptide, characterized in that it affects the shape change of the subchondral bone of the joint in the patient, so that the shape change of the subchondral bone of the joint in the patient is affected.

13. The formulation for use according to claim 12, wherein the peptide is the peptide of SEQ ID NO: 1, for intra-articular injection; Wherein the bone is the patella.

14. The formulation of claim 13, wherein the shape change is due to osteoarthritis.

15. The formulation of claim 13, wherein the shape change is due to aging.

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