Saroglitazar and myristic acid for use in the treatment of focal segmental glomerulosclerosis (FSGS)

Abstract

The present invention relates to a pharmaceutical formulation comprising saroglitazar and myristic acid, or a salt or solvate thereof, for use in the treatment of focal segmental glomerulosclerosis (FSGS).

Description

[Technical Field]

[0001] The present invention relates to a pharmaceutical formulation comprising saroglitazar and myristic acid, or a salt or solvate thereof, for use in the treatment of focal segmental glomerulosclerosis (FSGS). [Background technology]

[0002] Focal segmental glomerulosclerosis (FSGS) is a severe glomerulopathy that often leads to end-stage renal disease. FSGS is used to refer to both diseases characterized by primary podocyte injury and secondary lesions in any type of chronic kidney disease (CKD). FSGS is defined by the presence of sclerosis in partial (segmental) or some glomeruli (focal) by light microscopy. FSGS can be found without an identifiable cause ("primary" or "idiopathic" FSGS accounts for 80% of cases) or in response to prior glomerular injury, such as hypertension or obesity ("secondary" FSGS accounts for 20% of cases).

[0003] The most common sign of FSGS is proteinuria, ranging from sub-nephrotic to nephrotic levels (severe proteinuria, hypoalbuminemia, and hyperlipidemia). Severe proteinuria leads to progressive loss of kidney function (glomerulosclerosis) and kidney failure. It accounts for approximately 15% of end-stage renal disease (ESRD). Massive proteinuria (>10–15 g / day) leads to rapid deterioration of kidney function and progression to ESRD within 2–3 years. FSGS patients with massive proteinuria have a survival rate of only 45%.

[0004] There are no approved medications for FSGS. The current standard of care for patients with FSGS includes steroids, ACE inhibitors or ARBs, immunosuppressants such as glucocorticoids followed by calcineurin inhibitors if needed for intolerance or inadequate response to glucocorticoids; diuretics, plasma exchange, dietary modifications, and statins.

[0005] WO2017 / 089979A1 discloses the use of saroglitazar for the treatment of diseases or conditions associated with diabetic kidney abnormalities. Kanjanabuch T. et al. (2007) investigated the protection of podocytes from injury by the peroxisome proliferator-activated receptor-γ (PPAR-γ) agonist pioglitazone.

[0006] Monserrat AJ et al. (2000) described the protective effect of myristic acid against renal necrosis occurring in rats fed a methyl-deficient diet. Rosenberg AZ and Kopp JB (2017) provide an overview of focal segmental glomerulosclerosis (FSGS) that focuses on a practical approach to FSGS evaluation based on clinical and histopathological evidence in the context of understanding disease mechanisms and genetics.

[0007] However, they have poor response rates. Renin-angiotensin-aldosterone (RAAS) blockers are also used to control proteinuria, a key feature of FSGS. However, existing treatments have achieved only limited success.

[0008] Approximately 5,400 patients are diagnosed with FSGS each year in the United States, and the number of cases is increasing faster than any other cause of nephrotic syndrome. Approximately 1,000 FSGS patients undergo kidney transplants each year. However, within hours to weeks of kidney transplantation, FSGS recurs in approximately 30-40% of patients. However, only 20% of patients achieve complete remission after 5 years of treatment, and 40% of patients do not experience remission (Troyanov S. et al., 2005). Summary of the Invention [Problem to be solved by the invention]

[0009] Despite best care, treatment failure is common and FSGS accounts for a significant proportion of end-stage renal disease. Thus, there is an unmet need for novel disease-modifying treatments for FSGS. [Means for solving the problem]

[0010] This object is solved by the subject matter of the present claims and the subject matter further described herein.Surprisingly, it has been found that the compounds of the present invention significantly reduce the urinary protein / creatinine ratio (UPCR) and the urinary albumin / creatinine ratio (UACR) in animal studies, thus demonstrating significant functional improvement and reduced proteinuria.

[0011] The present invention provides a pharmaceutical formulation comprising saroglitazar and myristic acid, or a salt or solvate thereof, for use in the treatment of focal segmental glomerulosclerosis (FSGS).

[0012] Specifically, FSGS is recurrent focal segmental glomerulosclerosis, primary FSGS or spontaneous FSGS, and is specifically a glomerulopathy characterized by any one of severe proteinuria, nephrotic syndrome, glomerulonephritis, membranoproliferative glomerulonephritis, IgA glomerulonephritis, progressive renal failure, or glomerular lesions in histopathology.Specifically, FSGS is not associated with or caused by diabetes.

[0013] According to certain embodiments of the invention, the pharmaceutical formulation is a medicine or drug product comprising saroglitazar and myristic acid, and a pharmaceutically acceptable carrier. Specifically, the pharmaceutical formulations described herein are administered systemically. According to a further embodiment, the saroglitazar present together with myristic acid in the formulations described herein has the structure:

[0014] [ka]

[0015] Includes. Specifically, the formulation contains about 1 mg to 100 mg of saroglitazar and about 1 mg to 1 g of myristic acid.

[0016] According to further embodiments, the pharmaceutical formulations described herein are formulated for systemic administration, preferably for intravenous, intramuscular, subcutaneous, intradermal, transdermal, or oral administration. According to further embodiments, the pharmaceutical formulations described herein are administered to a subject as a spray, powder, gel, ointment, cream, foam, or solution, lotion, mouthwash, aerosolized powder, aerosolized liquid formulation, granules, capsules, drops, tablets, syrup, lozenges, or an infusion or injectable formulation.

[0017] According to the present invention, the pharmaceutical formulation is for use in treating subjects suffering from or at risk of developing FSGS. In a further embodiment, the pharmaceutical formulations described herein are applied in an effective amount to a subject suffering from or at risk of developing FSGS.

[0018] Specifically, the formulation is administered as the sole substance, or the treatment or formulation is combined with an additional treatment or formulation having one or more active agents. More specifically, the formulation is administered in combination with an active agent selected from the group consisting of antivirals, anticoagulants, immunomodulators, antibody preparations derived from human sources, monoclonal antibodies, intensive care medications, antihypertensives, statins, vasodilators, steroids, cytotoxic agents, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), cholesterol or triglyceride lowering agents. [Brief explanation of the drawings]

[0019] [Figure 1]FSGS was induced with adriamycin (ADR) and assessed for proteinuria at the indicated times (in days) after induction. UPCR = urinary protein creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (ctrl) = control mice with FSGS; white boxes (saroglitazar + myristic acid) = mice with FSGS treated with saroglitazar + myristic acid; box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are shown above the data for each time point. [Figure 2] FSGS was induced with adriamycin (ADR) and assessed for proteinuria at the indicated times (in days) after induction. UACR = urinary albumin creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (ctrl) = control mice with FSGS; white boxes (saroglitazar + myristic acid) = mice with FSGS treated with saroglitazar + myristic acid; box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are shown above the data for each time point. [Figure 3] FSGS was induced by overexpression of miR-193a and the resulting suppression of the Wilms' tumor 1 (WT1) gene (Gebeshuber et al., 2013). Proteinuria was assessed at the indicated times (in days) after induction. UPCR = urinary protein creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (ctrl) = control mice with FSGS; boxes (labeled Saro + myristic acid) = mice with FSGS treated with saroglitazar + myristic acid. Box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are indicated above the data for each time point. [Figure 4]FSGS was induced by overexpression of miR-193a and the resulting suppression of the Wilms' tumor 1 (WT1) gene (Gebeshuber et al., 2013). Proteinuria was assessed at the indicated times (in days) after induction. UACR = urinary albumin creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (labeled "ctrl2") = control mice with FSGS; boxes labeled Saro + myristic acid = mice with FSGS treated with saroglitazar + myristic acid. Box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are indicated above the data for each time point. [Figure 5] Experiment 1. UPCR of all individual urine from control (Ctrl) and Saro, Myr, or Saro+Myr treated animals after tail vein injection. p-values ​​were calculated by Student's t-test and reveal significant improvement across time points for Saro+Myr. [Figure 6] Experiment 2. UPCR of all individual urines of control (Ctrl) and Saro+Myr-treated animals after tail vein injection. p-values ​​were calculated by Student's t-test. [Figure 7] Experiment 3. UPCR of all individual urines of control (Ctrl) and Saro+Myr treated animals after induction of miR-193. p-values ​​are calculated by Student's t-test and reveal significant improvements across multiple time points. [Figure 8] The mean reduction in UPCR with Saro+Myr treatment is shown over time. The mean reduction in UPCR across all time points is indicated by the dotted line. [Figure 9] Histological evaluation using 20x magnification. Representative PAS staining of adriamycin nephropathy control (upper left panel), adriamycin nephropathy Saro+Myr-treated (upper right panel), miR-193a control (lower left panel), and adriamycin nephropathy Saro+Myr-treated (lower right panel). Black arrows indicate sclerotic glomeruli. Black asterisks indicate protein casts representing tubular dilation. [Figure 10]Histopathological effects of therapy. The mean percentages of sclerotic glomeruli (left) and tubular dilation stages (right) in the adriamycin nephropathy model are shown. Error bars represent SEM (standard error of the mean). Tubular dilation score: 0: none, 1: mild, 2: moderate, 3: severe. [Figure 11] Histopathological effects of the therapy. The mean percentages of sclerotic glomeruli (left) and tubular dilation stages (right) in the miR-193a FSGS model are shown. Error bars represent SEM (standard error of the mean). Tubular dilation score: 0: none, 1: mild, 2: moderate, 3: severe. DETAILED DESCRIPTION OF THE INVENTION

[0020] The terms "comprise," "containing," "having," and "include," as used herein, can be used interchangeably and are to be understood as open definitions that allow for additional members, moieties, or elements. "Consisting of" is considered the most closed definition, without additional elements characteristic of the definition that it comprises. Thus, "comprise" is broader and encompasses the definition of "consisting of."

[0021] The term "about" as used herein refers to the same value, or a value that differs by + / - 10% or + / - 5% from a given value. Saroglitazar, as described herein, may be used as a "physiologically acceptable salt." The choice of salt is determined primarily by how acidic or basic the chemical is (pH), the safety of the ionized form, the intended use of the drug, how the drug will be given (e.g., by mouth, injection, or on the skin), and the type of dosage form (e.g., tablet, capsule, or liquid).

[0022] An exemplary physiologically acceptable salt is sodium salt.However, instead of sodium salt, other physiologically acceptable salts, such as other alkali metal salts, alkaline earth metal salts, ammonium salts and substituted ammonium salts, can also be used.Pharmaceutically acceptable salts can be selected from organic or inorganic salts.Inorganic salts are selected from calcium, magnesium, sodium, potassium, zinc, ammonium and lithium. The organic salt is selected from L-arginine, tromethamine, L-lysine, meglumine, benethamine, piperazine, benzylamine, dibenzylamine, dicyclohexylamine, diethylamine, diphenylamine, α-naphthylamine, O-phenylenediamine, 1,3-diaminopropane, (S)-α-naphthylethylamine, (S)-3-methoxyphenylethylamine, (S)-4-methoxyphenylethylamine, (S)-4-chlorophenylethylamine, (S)-4-methylphenylethylamine, cinchonine, cinchonidine, (−)-quinine, benzathine, ethanolamine, diethanolamine, triethanolamine, imidazole, diethylamine, ethylenediamine, choline, epolamine, morpholine 4-(2-hydroxyethyl), N-N-diethylethanolamine, deanol, hydrabamine, betaine, adamantanamine, L-adamantanemethylamine, and tritylamine. Preferred substituted ammonium salts are those derived from, for example, lower mono-, di-, or tri-alkylamines, or mono-, di-, and trialkanolamines. The free amino acids themselves can also be used. Specific examples are ethylamine, ethylenediamine, diethylamine, or triethylamine salts.

[0023] The term "subject" or "patient," as used herein, refers to a human or non-human mammal, such as a dog, cat, horse, camel, cow, or pig, suffering from or at risk of developing FSGS. Specifically, it is a human.

[0024] The term "non-diabetic subject" refers to a subject who does not suffer from diabetes mellitus. A subject who is "at risk" of developing FSGS may or may not have detectable disease or disease symptoms, and may or may not have detectable disease or disease symptoms before the treatment methods described herein. "At risk" means that a subject has one or more risk factors, and risk factors are measurable parameters that correlate with the development of FSGS, as described herein and known in the art. A subject who has one or more of these risk factors has a higher probability of developing FSGS than a subject who does not have one or more of these risk factors.

[0025] A "subject" can be a "patient." A "patient" refers to a subject under the care of a treating physician. In another embodiment, the patient is a subject who has not been diagnosed with FSGS. In yet another embodiment, the patient is a subject who has been diagnosed with FSGS but is not receiving treatment to address FSGS.

[0026] The term "pharmaceutically acceptable," also referred to as "pharmacologically acceptable," means compatible with animal, and particularly human, treatment. The term pharmacologically acceptable salts also includes both pharmacologically acceptable acid addition salts and pharmacologically acceptable base addition salts.

[0027] The term "pharmacologically acceptable acid addition salt" as used herein refers to any non-toxic organic or inorganic salt of any base compound of the present disclosure, or any of its intermediates. Basic compounds of the present disclosure that can form acid addition salts include, for example, compounds containing a basic nitrogen atom. Exemplary inorganic acids that form suitable salts include hydrochloric acid, hydrobromic acid, sulfuric acid, and phosphoric acid, as well as metal salts such as sodium monohydrogen orthophosphate and potassium hydrogen sulfate. Exemplary organic acids that form suitable salts include mono-, di-, and tricarboxylic acids such as glycolic acid, lactic acid, pyruvic acid, malonic acid, succinic acid, glutaric acid, fumaric acid, malic acid, tartaric acid, citric acid, ascorbic acid, maleic acid, benzoic acid, phenylacetic acid, cinnamic acid, and salicylic acid, and sulfonic acids such as p-toluenesulfonic acid and methanesulfonic acid. Mono-, di-, or tri-acid salts can be formed, and such salts may exist in either hydrated, solvated, or substantially anhydrous form. Generally, the acid addition salt of the compound of the present disclosure is more soluble in water and various hydrophilic organic solvents, and generally shows a higher melting point compared with their free base form.The selection of suitable salt is known to those skilled in the art.For example, in the isolation of the compound of the present disclosure, for laboratory use or for subsequent conversion into pharmacologically acceptable acid addition salt, other pharmacologically unacceptable acid addition salts such as oxalate can be used.

[0028] Specifically, saroglitazar can exist as saroglitazar magnesium salt. Saroglitazar (S)-2-ethoxy-3-(4-(2-(2-methyl-5-(4-(methylthio)phenyl)-1H-pyrrol-1-yl)ethoxy)phenyl)propanoic acid, (S)-alpha-ethoxy-4-[2-[-methyl-5-[4-(methylthio)phenyl]-1H-pyrrol-1-yl]ethoxy]benzene-propanoic acid. The compound ((2S)-2-ethoxy-3-[4-(2-{2-methyl-5-[4-(methylsulfanyl)phenyl]-1H-pyrrol-1-yl}ethoxy)phenyl]propanoic acid), present together with myristic acid in the formulation, has the structure

[0029] [ka]

[0030] It has. Saroglitazar, marketed under the name Lipagrin, is a novel first-in-class drug that acts as a dual peroxisome proliferator-activated receptor (PPAR) agonist at both the alpha and gamma subtypes of PPAR. Agonism at PPARα lowers elevated blood triglycerides, while agonism at PPARγ improves insulin resistance, thereby lowering blood glucose.

[0031] Saroglitazar is approved in India for the treatment of type 2 diabetes mellitus and dyslipidemia. Saroglitazar is indicated for the treatment of diabetic dyslipidemia and hypertriglyceridemia associated with type 2 diabetes mellitus uncontrolled by statin therapy.

[0032] Following activation of PPAR-α and PPAR-γ, saroglitazar has been reported to have anti-inflammatory and anti-fibrotic effects through its regulatory effect on TGFB1 / SMAD3 signaling (Makled MN et al., 2020). It also reduces renal levels of NFKB1 and MMP9 (Makled MN et al., 2020). In addition, saroglitazar has been shown to suppress Toll-like receptor 4 activation (Hassan NF et al., 2019).

[0033] Myristic acid is a long-chain fatty acid containing 14 carbon atoms. It has the molecular formula CH3(CH2) 12Myristate is a common saturated fatty acid with a COOH group. Its salts and esters are commonly called myristate or tetradecanoate. It is named after the binomial name of nutmeg, from which it was first isolated. Myristate plays an important role in protein N-myristoylation, a co-translational lipid modification specific to the alpha-amino group of N-terminal glycine residues of many eukaryotic and viral proteins. N-myristoyltransferase, a ubiquitous eukaryotic enzyme, catalyzes the myristoylation process. Specifically, the attachment of the myristoyl group increases specific protein-protein interactions and triggers the intracellular localization of myristoylated proteins with their signaling partners (Udenwobele DI et al., 2017).

[0034] According to the present invention, myristic acid belongs to the group of calcineurin inhibitors, since it plays a role in myristoylation, which regulates the calcium sensitivity of calcineurin activation via N-myristoyltransferase and prevents constitutive calcineurin activity.

[0035] According to alternative embodiments, myristic acid may be replaced by one or more other calcineurin inhibitors, such as, but not limited to, tacrolimus, pimecrolimus, and cyclosporine.

[0036] According to further embodiments, saroglitazar and myristic acid may also be combined with one or more calcineurin inhibitors known in the art. Saroglitazar contains about 1 to 100 mg of saroglitazar per dose. Specifically, it may contain 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50, 60, 70, 80, 90, or 100 mg of saroglitazar. It may be administered continuously at the same dose, or at a higher dose, and further as a reduced or lower maintenance dose, or as a bolus administration.

[0037] Myristic acid is present in combination with saroglitazar in an amount of about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 500, 1000 mg.

[0038] FSGS is a unique clinicopathological medical condition characterized by focal and segmental sclerosis in renal glomeruli and podocyte foot process loss (D'Agati V., 2003; Rosenberg AZ and Kopp JB, 2017; Bose B. and Cattran D., 2014). The pathophysiology of FSGS can arise within the glomerulus ("primary FSGS") or can be secondary to other causes (e.g., hypertension; D'Agati V., 2003; Rosenberg AZ and Kopp JB, 2017; Bose B. and Cattran D., 2014). Primary FSGS often leads to nephrotic syndrome, characterized by proteinuria, hypoalbuminuria, hyperlipidemia, and edema (D'Agati V., 2003; Rosenberg AZ and Kopp JB, 2017; Bose B. and Cattran D., 2014). For many cases, the exact cause of FSGS remains elusive (idiopathic; D'Agati V., 2003; Rosenberg AZ and Kopp JB, 2017; Bose B. and Cattran D., 2014). The known etiologies of FSGS are diverse and include genetic mutations, drugs, viruses, hypertension, and circulating factors—but not diabetes (D'Agati V., 2003; Rosenberg AZ and Kopp JB, 2017; Bose B. and Cattran D., 2014). Diabetic nephropathy—including diabetic glomerulosclerosis—represents the chronic loss of kidney function as a consequence of the pathophysiology of diabetes mellitus ( Qi et al., 2017 ).

[0039] Podocytes are atypical epithelial cells in Bowman's capsule in the kidney, which surround the capillaries of the glomerulus. As used herein, FSGS is glomerular scarring (sclerosis) and damage to podocytes, either induced by endogenous factors that specifically recognize podocytes as their target (podocytopathy, idiopathic or primary FSGS) or caused by identifiable causes that indirectly injure podocytes, such as genetic disorders, hypertension, inflammation, deregulated proliferation, or mechanical stress (secondary FSGS).

[0040] The distinctive morphological picture of primary FSGS is diffuse podocytopathy (with at least one FSGS lesion), which is clinically more prevalent than nephrotic syndrome. Diffuse podocyte toxicity involves almost all podocytes and results in foot process loss of more than 50% on electron microscopy. Hypoalbuminemia, as well as massive urinary albumin loss, are common but uncommon in the secondary form, even in the presence of nephrotic-range proteinuria. Microvilli alterations, cytoplasmic shedding, increased actin cytoskeleton density in effaced foot processes, and increased numbers of lysosomes and autophagocytic bodies are common features. Due to structural reorganization, there is an increased risk of podocyte detachment from the glomerular basement membrane (GBM), leaving large areas of exposed GBM. These "sticky" areas can develop adhesions, followed by the deposition of hyaline material and expansion of the mesangial matrix, which gradually narrows the capillary lumen until the affected area becomes occluded and sclerotic. Reversible glomerular escape into the proximal tubule is sometimes observed, a sign of rapid enlargement of the tuft and a precursor to "apical lesions" (Angioi A., and Pani, A., 2016): Primary FSGS is part of the full spectrum of podocytopathies, including minimal change disease (MCD).

[0041] Genetic forms of FSGS show changes similar to those described for primary FSGS. Hypertension and adaptive mechanisms may be the primary causes of secondary FSGS, both of which lead to glomerular hypertension with enlarged and elongated podocytes. Mechanical stress on the podocyte scaffolding, the foot processes, results in structural reorganization of the cytoskeleton, leading to focal loss.

[0042] The most malignant form of FSGS is collapsing glomerulopathy, which is histologically manifested by foot process effacement, segmental to total collapse of the capillary plexus surrounded by a crown of hyperplastic podocytes (Angioi A., and Pani, A., 2016).

[0043] Symptoms of FSGS are defined by glomerulosclerosis, glomerulonephritis (e.g., membranoproliferative glomerulonephritis (MPGN), IgA glomerulonephritis), nephrotic syndrome (hypoalbuminuria, hyperlipidemia, edema), progressive renal failure, severe proteinuria with histopathological glomerular lesions specifically classified according to Haas M. et al., 2013, and optional biopsy confirmation of FSGS with podocyte fusion and injury.

[0044] FSGS can be diagnosed by methods well known in the art, including, but not limited to, determination of the urinary protein / creatinine ratio (UPCR), urinary albumin / creatinine ratio (UACR), light microscopy of kidney biopsies, e.g., glomerular size, histological variants of FSGS, microcystic tubular changes, and tubular hypertrophy; immunofluorescence, e.g., to rule out other primary glomerulopathies; and electron microscopy, e.g., the degree of podocyte foot process effacement, podocyte microvilli changes, and tubuloreticular inclusions.

[0045] Specifically, FSGS refers to non-diabetic kidney disease when used herein.Specifically, diabetic nephropathy caused by diabetes mellitus is excluded from the use of saroglitazar for treating FSGS.Non-diabetic kidney disease and diabetic kidney disease can be confirmed and identified by methods known in the art, such as biopsy.

[0046] In diabetic patients, nodular and diffuse lesions are often observed. Classification methods for diabetic nephropathy are well known to those skilled in the art and are described by Qi C. et al., 2017, Tervaert TWC et al., 2010, and Fioretto P. et al., 1996. Fioretto's classification includes tubular, interstitial, and vascular lesions, and divides diabetic nephropathy into three categories according to pathological changes under light microscope: C1, normal / near normal; C2, typical diabetic nephropathy, with mostly glomerular changes; and C3, atypical pattern of injury, disproportionately associated with damage, such as tubulointerstitial or arteriolar hyalinization, and with no or only mild diabetic glomerular changes. Tervaert's pathological classification divides diabetic nephropathy into four categories according to glomerular changes, with separate scoring systems for tubular, interstitial, and vascular lesions.

[0047] Specifically, patients suffering from diabetes, particularly those who have had diabetes for more than two years, are excluded from being treated with saroglitazar as described herein.

[0048] Diabetes-related nephropathy includes diabetic retinopathy, diabetic nephropathy, and diabetes-related glomerulosclerosis. The use of "FSGS" extends to spontaneous FSGS, primary FSGS as well as recurrent FSGS, but specifically excludes diabetic FSGS.

[0049] Glomerulonephritis is a manifestation of inflammation of the membranes in the kidneys that act as filters, separating waste products and excess fluid from the blood. MPGN is a form of glomerulonephritis caused by an abnormal immune response: antibody deposits build up in a part of the kidney called the glomerular basement membrane.

[0050] Glomerulosclerosis is a manifestation of scarring and hardening of the small blood vessels within the kidney. Although glomerulonephritis and glomerulosclerosis have different causes, they can both lead to kidney failure.

[0051] Nephrotic syndrome is a kidney disorder that causes the body to pass too much protein into the urine. Nephrotic syndrome is usually caused by damage to clusters of tiny blood vessels in the kidneys.

[0052] As used herein, recurrent FSGS (rFSGS), or recurrence of FSGS, is defined by heavy proteinuria with optional biopsy confirmation of FSGS with glomerular sclerosis and podocyte fusion and injury without evidence of acute rejection, glomerulitis, or allograft glomerulopathy. As used herein, a subject or patient with recurrent FSGS (rFSGS) is defined as one who had FSGS before kidney transplantation and subsequently developed recurrent FSGS (rFSGS) after kidney transplantation.

[0053] As used herein, a subject or patient with non-recurrent FSGS (nrFSGS) is defined as one who has FSGS before kidney transplant but does not develop FSGS after kidney transplant.

[0054] As used herein, a subject or patient with native FSGS (nFSGS) is defined as one who has FSGS (severe proteinuria with optional biopsy confirmation of FSGS with glomerular sclerosis and podocyte fusion and injury) in their own kidney prior to transplant.

[0055] The pharmaceutical formulation may be a medicine or drug product comprising saroglitazar and myristic acid, and a pharmaceutically acceptable carrier. The formulations described herein may also be used as dietary supplements.

[0056] Also provided herein is a method for treating FSGS, wherein the pharmaceutical formulation comprises effective amounts of saroglitazar and myristic acid. The term "effective amount" or "pharmaceutically effective amount" refers to the amount of a compound that produces the desired effect for which the compound is administered (e.g., amelioration of FSGS symptoms, reduction in the severity of FSGS or FSGS symptoms, and / or reduction in the progression of FSGS or FSGS symptoms). The exact amount of an effective dose depends on the purpose of treatment and can be ascertained by one of ordinary skill in the art using known techniques (see, e.g., Lloyd VA, 2016).

[0057] As used herein, the term "treatment" and its cognates refer to slowing or halting disease progression. As used herein, "treatment" and its cognates include, but are not limited to, complete or partial remission, renal failure (e.g., ESRD), and a lower risk of disease-related complications (e.g., edema, susceptibility to infection, or thromboembolic events). Improvement or reduction in the severity of any of these symptoms can be readily assessed according to methods and techniques known or later developed in the art. Desired effects of treatment include preventing the onset or recurrence of FSGS, particularly non-diabetic FSGS, or the condition or symptoms thereof; alleviating the condition or symptoms of FSGS; diminishing any direct or indirect pathological consequences of FSGS; reducing the rate or severity of FSGS progression; and / or ameliorating or alleviating FSGS. In some embodiments, the methods and compositions of the present invention are used with patient subpopulations identified as at risk for developing FSGS. In some cases, the methods and compositions of the present invention are useful in attempts to delay the onset of FSGS.

[0058] In some embodiments, the compound of the pharmaceutical formulation described herein (i.e., saroglitazar in combination with myristic acid), or a pharmaceutically acceptable salt or solvate thereof, is not administered with any other therapeutic compound. In some embodiments, the compound is not administered simultaneously or sequentially with any other therapeutic compound. In some embodiments, the compound is administered alone.

[0059] In some embodiments, the method further comprises administering to the patient one or more additional therapeutic compounds, in some embodiments, the one or more additional therapeutic compounds are selected from one or more of an antiviral agent, an anticoagulant, an immunomodulatory agent, an antibody preparation derived from a human source, a monoclonal antibody, an intensive care medication, an antihypertensive agent, a statin, a vasodilator, a steroid, a cytotoxic agent, a diuretic, a nonsteroidal anti-inflammatory drug (NSAID), a cholesterol or triglyceride lowering agent, or a PPAR agonist.

[0060] As used herein, at least one pharmaceutically acceptable carrier includes any solvent, diluent, other liquid vehicle, dispersing aid, suspending aid, surfactant, isotonicity agent, thickener, emulsifier, preservative, solid binder, and lubricant suitable for the desired specific dosage form. Remington: The Science and Practice of Pharmacy, 22nd edition, 2013, Pharmaceutical Press, and Encyclopedia of Pharmaceutical Technology, 2004, Taylor & Francis disclose various carriers used to formulate pharmaceutical compositions and known techniques for their preparation. Unless any conventional carrier is incompatible with the compounds of the present disclosure, for example, by producing any undesirable biological effect or otherwise interacting in a harmful manner with any other component of the pharmaceutical formulation, its use is contemplated within the scope of the present disclosure.Non-limiting examples of suitable pharmaceutically acceptable carriers include, but are not limited to, ion exchangers, alumina, aluminum stearate, lecithin, serum proteins (e.g., human serum albumin), buffer substances (e.g., phosphate, glycine, sorbic acid, and potassium sorbate), partial glyceride mixtures of saturated vegetable fatty acids, water, salts, and electrolytes (e.g., protamine sulfate, disodium hydrogen phosphate, potassium hydrogen phosphate, sodium chloride, and zinc salts), colloidal silica, magnesium trisilicate, polyvinylpyrrolidone, polyacrylates, waxes, polyethylene-polyoxypropylene-block polymers, wool fat, sugars (e.g., lactose, glucose, and sucrose), starches (e.g., corn starch and potato starch), cellulose and its derivatives (e.g., sodium carboxymethylcellulose, ethylcellulose, and cellulose acetate, microcrystalline cellulose, methylcellulose, carboxymethylcellulose, cellulose acetate ... sodium), lactose, dextrin, mannitol, sucrose, corn starch, pregelatinized starch, precipitated calcium carbonate and calcium hydrogen phosphate, powdered tragacanth, malt, gelatin, talc, excipients (e.g., cocoa butter and suppository wax), oils (e.g., peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil, and soybean oil), glycols (e.g., propylene glycol and polyethylene glycol), esters (e.g., ethyl oleate and ethyl laurate), agar, buffers (e.g., magnesium hydroxide and aluminum hydroxide), alginic acid, pyrogen-free water, isotonic saline, Ringer's solution, ethyl alcohol, phosphate buffer solution, non-toxic compatible lubricants (e.g., sodium lauryl sulfate and magnesium stearate), coloring agents, release agents, coating agents, sweetening agents, flavoring agents, fragrances, preservatives, and antioxidants, or any mixtures and combinations thereof. [Example]

[0061] The foregoing description will be more fully understood with reference to the following examples, which, however, are merely representative of methods of practicing one or more embodiments of the invention and should not be read as limiting the scope of the invention.

[0062] Example 1 In vivo testing For biological testing of final candidate compounds, we selected accepted mouse models of FSGS, such as adriamycin-induced nephropathy or miR-193a-overexpressing mice, which suffer from FSGS due to suppression of the Wilms' tumor 1 (WT1) gene (Gebeshuber et al., 2013). All animal experiments and handling were in accordance with Austrian law on animal protection and were approved by the Animal Ethics Committee of the Austrian Ministry of Science and Research.

[0063] Adriamycin-dependent nephropathy (active compound: doxorubicin) was induced in 10-week-old BALB / c mice by tail vein injection at a dose of approximately 9 mg per kg of mouse. Control mice were injected with 0.9% saline. At least six mice per group were analyzed. Mice were monitored daily for signs of pain, altered movement, or reduced food intake and sacrificed by cervical dislocation. Test drugs were administered orally via premixed chow at drug doses based on literature review.

[0064] result Urinary albumin levels were assessed by ELISA, and urinary total protein and urinary creatinine levels were measured using a Roche Cobas system using routine laboratory kits. Urinary protein / creatinine (UPCR) ratio and urinary albumin / creatinine ratio (UACR) were assessed at various time points. Weight and physical fitness scores were monitored daily. At the end of the experiment, tissue sections, plasma, and urine samples were collected and stored for further analysis. For successful drug candidates, significantly reduced UPCR and UACR values ​​were found, demonstrating functional improvement and reduced proteinuria.

[0065] In the adriamycin model, urinary protein creatinine ratio (UPCR) was evaluated, and the effects of drug administration (saroglitazar + myristic acid) and time point (in days) were significant with p-values ​​of 0.004 (drug) and 0.025 (time point), respectively. The p-value for the interaction (drug:time point) was 0.291 (see Figure 1).

[0066] In Figure 1, FSGS was induced with adriamycin (ADR) and assessed for proteinuria at the indicated times (in days) after induction. UPCR = urinary protein creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (ctrl) = control mice with FSGS; white boxes (saroglitazar + myristic acid) = mice with FSGS treated with saroglitazar + myristic acid; box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are shown above the data for each time point. Results for repeated measures ANOVA across time points are described above.

[0067] In the adriamycin model, the urinary albumin creatinine ratio (UACR) was evaluated, and the effect for drug administration (saroglitazar + myristic acid) was significant with a p-value of 0.017 (drug). The p-values ​​for time point (in days) and the interaction were 0.088 (time point) and 0.090 (drug:time point), respectively (see Figure 2).

[0068] In Figure 2, FSGS was induced with adriamycin (ADR) and assessed for proteinuria at the indicated times (in days) after induction. UACR = urinary albumin creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (ctrl) = control mice with FSGS; white boxes (saroglitazar + myristic acid) = mice with FSGS treated with saroglitazar + myristic acid; box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are shown above the data for each time point. Results for repeated measures ANOVA across time points are described above.

[0069] In the miR193 model, urinary protein creatinine ratio (UPCR) was evaluated, and the effects of drug administration (saroglitazar + myristic acid) and time point (in days) were significant with p-values ​​of 2.21e-11 (drug) and 1.21e-07 (time point), respectively. The p-value for the interaction (drug:time point) was 0.121 (see Figure 3).

[0070] Figure 3 shows that FSGS was induced by overexpression of miR-193a and the resulting suppression of the Wilms' tumor 1 (WT1) gene (Gebeshuber et al., 2013), and proteinuria was assessed at the indicated times (in days) after induction. UPCR = urinary protein creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (ctrl) = control mice with FSGS; boxes (labeled Saro + myristic acid) = mice with FSGS treated with saroglitazar + myristic acid; box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are shown above the data for each time point. Results for repeated measures ANOVA across time points are described above.

[0071] In the adriamycin model, the urinary albumin creatinine ratio (UACR) was evaluated, and the effects of drug administration (saroglitazar + myristic acid) and time point (in days) were significant with p-values ​​of 0.0001 (drug) and 0.0003 (time point), respectively. The p-value for the interaction (drug:time point) was 0.821 (see Figure 4).

[0072] Figure 4 shows that FSGS was induced by overexpression of miR-193a and the resulting suppression of the Wilms' tumor 1 (WT1) gene (Gebeshuber et al., 2013), and proteinuria was assessed at the indicated times (in days) after induction. UACR = urinary albumin creatinine ratio—a marker for proteinuria and kidney damage; gray boxes (labeled "ctrl2") = control mice with FSGS; boxes (labeled Saro + myristic acid) = mice with FSGS treated with saroglitazar + myristic acid; box plots show the median (midline), interquartile range (box), and 95% confidence interval (whiskers) in addition to individual data points (dots). P values ​​for t-tests are shown above the data for each time point. Results for repeated measures ANOVA across time points are described above.

[0073] Example 2 In vivo testing For biological testing of final candidate compounds, we selected accepted mouse models of FSGS, such as adriamycin-induced nephropathy and miR-193a-overexpressing mice, which suffer from FSGS due to suppression of the Wilms' tumor 1 (WT1) gene (Gebeshuber et al., 2013). All animal experiments and handling were in accordance with Austrian law on animal protection and were approved by the Animal Ethics Committee of the Austrian Ministry of Science and Research.

[0074] material and method Adriamycin (doxorubicin, Sigma, D1515-10 mg) was diluted in ddH2O. To induce FSGS, a dose of 10.5 mg per kg of mouse, i.e., a total volume of 200 μl per 25 g of mouse, was injected intravenously into the tail vein using a 27 G needle.

[0075] For tail vein injection, mice were anesthetized using ketanest (Pfizer, 25 mg / ml vial) and rompun (Bayer, 20 mg / ml injection solution). A final mixture of 12.5 mg / ml ketanest and 0.25% rompun in 0.9% NaCl solution was prepared, and 200 μl was injected per 25 g mouse. For induction of miR-193a overexpression, mice were given 1 mg / ml doxycycline hyclate (Sigma, D9891-10G) in 5% sucrose solution ad libitum. A combination of saroglitazar (from Aldrich partners via Sigma, ADVH7F37A3EA-100MG) and myristic acid (Sigma, M3128-10G) was used for therapy experiments.

[0076] Animals / Animal Control Mice and FSGS models Male Balb / c mice were obtained from the animal care facility of the Medical University (Abteilung fur Labortierkunde, Himberg, Austria). Male mice overexpressing miR-193 on a Balb / c background were kept in the Medical University animal house. Animals aged 16 to 22 weeks and weighing >18 g were used for experiments and were adjusted for weight and age. Animals were allowed to acclimate for at least 7 days. Animals were marked with ear or toe clip codes to allow identification.

[0077] diet The standard commercial feed from ssniff (ssniff Spezialdiaten GmbH, Soest, Germany) contained crude protein (19%), crude fat (3.3%), crude fiber (4.9%), crude ash (6.4%), starch (36.5%), and sugars (4.7%). Animals in the control group were fed the standard feed, and animals in the test group were fed the standard feed produced by ssniff plus saroglitazar (25 mg / kg) and myristic acid (625 mg / kg). All animals were allowed to eat ad libitum and received an average daily intake of approximately 4 g / mouse (according to the animal care guidelines of Johns Hopkins University, Baltimore, MD, USA; http: / / web.jhu.edu / animalcare / procedures / mouse.html), i.e., approximately 4 mg saroglitazar per kg mouse per day (Jain et al. 2015) and approximately 100 mg myristic acid per kg mouse per day (Takato et al. 2017).

[0078] Residence Animals were maintained in Makrolon cages 375mm x 215mm x 150mm under standard conditions (23±1°C, 55±10% humidity, 12-hour day / night cycle) and checked daily. Food and water were provided ad libitum.

[0079] Urine collection and measurement Spot urine was collected weekly and creatinine and protein levels were measured. Urinary albumin was measured by ELISA. 96-well plates were coated overnight at 4°C with 100 μl of antibody solution anti-mouse serum albumin antibody (Abcam ab34807, lot GR3242102-4, 1:2,000 dilution) in coating buffer (3.7 g NaHCO3, 0.64 g Na2CO3, 1 L distilled water). The remaining procedures were performed at room temperature. Wells were washed three times with HBSS (Sigma H8264-500ML) + 0.05% Tween-20 (Bio-Rad, #1706531), blocked in ELISA / ELISPOT diluent (eBioscience, 00-4202-56), and washed three times again. Both samples and the standard curve were diluted in ELISA / ELISPOT diluent and incubated for 2 hours, followed by three washing steps with HBSS + 0.05% Tween-20, and then incubated with HRP antibody anti-mouse serum albumin antibody (Abcam ab19195, lot GR3242102-4, 1:100,000 dilution) for 1 hour, followed by five washing steps. The reaction was developed with TMB One Solution (Promega, G7431) and stopped with 2N H2SO4. A standard curve was generated using mouse albumin (Merck / Sigma, 126674-25MG). Absorbance at 450 nm was measured on an Epoch microplate reader (BioTek) using Gen5 1.10 software.

[0080] histology At the end of the experiment, kidneys were removed, embedded in paraffin, and stained with periodic acid-Schiff (PAS). Histology was thoroughly evaluated, and the amount of sclerotic glomeruli and protein casts was quantified.

[0081] statistics R version 4.0.2 was used for statistical analysis. Student's t-test was used to compare UPCR and UACR values ​​between samples from treated and control mice for each individual time point and to evaluate differences in histological parameters. Repeated measures ANOVA was performed to analyze the effects of drugs on UPCR and UACR over time using the respective functions in the rstatix ​​package (V0.6.0). The ggplot2 (V3.3.2) and ggpubr (V0.4.0) packages were used to generate graphical visualizations.

[0082] Experimental setup In three independent experiments, 51 Balb / c mice were induced to overexpress miR-193a by tail vein injection of 10.5 mg / kg adriamycin or by doxycycline. Two days (adriamycin nephropathy) or 14 days (miR-193), respectively, after the start of the experiment, the active group received standard chow supplemented with 25 mg / kg saroglitazar and / or 625 mg / kg myristic acid, while control mice remained on standard chow. Spot urine samples were collected at least once weekly, and kidneys were harvested at the time of sacrifice.

[0083] Adriamycin (10.5 mg / kg) was injected into the tail vein. Two days later, the Saro+Myr diet was initiated. Urine was collected and weighed weekly. The experiment lasted for 4 weeks. miR-193 overexpression was induced by 1 mg / ml doxycycline. After 14 days, the Saro+Myr diet was initiated. On day 24, Dox treatment was stopped. Urine was collected and weighed at least once per week. The experiment lasted for 5 weeks.

[0084] Table 1 provides an overview of the mice used in the experiments ( * One animal was found dead shortly after ADR injection).

[0085] [Table 1]

[0086] result Saro+Myr therapy significantly reduces albuminuria and proteinuria The effects of saroglitazar and myristic acid, either individually or in combination, on FSGS in the adriamycin nephropathy model were determined (Figure 5). The level of proteinuria, a central clinical parameter for the diagnosis and therapy of FSGS, was determined by the urinary protein to creatinine ratio (UPCR).

[0087] As can be seen in Figure 5, saroglitazar alone can improve proteinuria to some extent, especially at the two later time points. Myristic acid alone did not reduce UPCR. However, the strongest positive effect on proteinuria was obtained with the combination of the two compounds, which caused a significant reduction in UPCR values ​​across all time points.

[0088] Repeated measures ANOVA also demonstrated a beneficial effect of Saro+Myr treatment over time on outcomes determined based on UPCR in this study (p=6.97e-10). ANOVA Table (Type III Test) - UPCR

[0089] [Table 2]

[0090] Saro+Myr therapy strongly and significantly improved the most relevant clinical readout parameter, namely proteinuria. The positive impact of Saro+Myr was confirmed and analyzed in more detail in the adriamycin nephropathy model (Experiment 2, Figure 6) and also in the miR-193a model (Experiment 3, Figure 7).

[0091] FIG. 6 presents box plots and p-values ​​for all individual collected urines in Experiment 2. Repeated measures ANOVA also revealed a significant beneficial effect of Saro+Myr treatment over time on outcomes determined based on UPCR in experiment 2 (p=0.004). ANOVA Table (Type III Test) - UPCR

[0092] [Table 3]

[0093] FIG. 7 presents box plots and p-values ​​for all individual collected urines in experiment 3. Repeated measures ANOVA also showed a beneficial effect of Saro+Myr treatment over time on outcomes determined based on UPCR in experiment 3 (p=2.23e-11). ANOVA Table (Type II Test) - UPCR

[0094] [Table 4]

[0095] Thus, the beneficial effect of Saro+Myr therapy was confirmed in three independent experiments. Figure 8 shows a summary of the effects of experiments 1-3, representing the mean percent reduction in UPCR.

[0096] Taking all experiments together, Saro+Myr therapy demonstrated striking and significant protection of renal function, reducing UPCR by an average of 49.9% across all time points (repeated measures ANOVA p=5.00e-20). This is highly advantageous as improvement in UPCR is the primary outcome goal in clinical trials, slowing FSGS progression. ANOVA Table (Type III Test) - UPCR

[0097] [Table 5]

[0098] Weight change We assessed weight changes weekly over the course of the experiment. The mean weight loss in the control group across all time points and experiments compared to starting weight was 10.2% for the control and 11.8% for saroglitazar and myristic acid.

[0099] Histopathological evaluation The effect of Saro+Myr on pathological lesions in FSGS as a parameter associated with a strong improvement in proteinuria was evaluated (Figures 9-11).

[0100] Figure 9 shows the most affected samples from the adriamycin nephropathy and miR-193a models, age-matched samples were selected. In both models, Saro+Myr treatment ameliorated the severity of the disease and reduced the amount of sclerotic glomeruli and tubular dilation. Tubular dilation, determined by protein casts in PAS staining, seen as uniform areas in the image, is a surrogate measure for identifying failure in the renal filtration process.

[0101] FIG. 10 graphically depicts the effect of Saro+Myr therapy on histopathology in an adriamycin nephropathy model (Experiment 2). FIG. 11 graphically depicts the effect of Saro+Myr therapy on histopathology in the miR-193a FSGS model (Experiment 3).

[0102] Importantly, Saro+Myr therapy completely prevented severe FSGS at the histopathological level; no pathological lesions were found in any of the adriamycin-induced nephropathy samples. In the miR-193a model, which induces much more severe disease, no samples had more than 25% affected glomeruli or a tubular dilatation stage greater than 1.

[0103] Because reducing proteinuria is thought to slow the progressive course of FSGS, proteinuria is widely considered a key biomarker for monitoring treatment in FSGS. As a next step in clinical development, exploratory clinical trials in FSGS patients will repeatedly assess kidney function not only in timed urine samples for proteinuria and creatinine excretion to assess UPCR, but also in blood for serum creatinine to assess estimated glomerular filtration rate (eGFR).

[0104] In summary, Saro+Myr treatment strongly and significantly improved proteinuria / UPCR, a core readout parameter for FSGS, in two different models, and also improved histopathological lesions.

[0105] References Cayla G. et al., Flow cytometric assessment of vasodilator-stimulated phosphoprotein: prognostic value of recurrent cardiovascular events after acute coronary syndromes, 2008, 101(11-12), 743-51 Chen A. et al., Soluble RARRES1 induces podocyte apoptosis to promote glomerular disease progression, 2020, J.Clin.Invest, 130(10), 5523-5535 Chung CF. et al., Intrinsic tumor necrosis factor-α pathway is activated in a subset of patients with focal segmental glomerulosclerosis, 2019, PLoS One, 14(5):e0216426 Gebeshuber CA, et al. Focal segmental glomerulosclerosis is induced by microRNA-193a and its downregulation of WT1, 2013, Nat Med., 19(4),481-487 Harris J.J. et al., Active proteases in nephrotic plasma lead to a podocin-dependent phosphorylation of VASP in podocytes via protease activated receptor-1, 2013, J Pathol., 229(5), 660-71 Hassan NF, et al., Saroglitazar Deactivates the Hepatic LPS / TLR4 Signaling Pathway and Ameliorates Adipocyte Dysfunction in Rats with High-Fat Emulsion / LPS Model-Induced Non-alcoholic Steatohepatitis, 2019, Inflammation, 42(3), 1056-1070. Jain, M.R., et al., Saroglitazar, a Novel PPARα / γ Agonist with Predominant PPARα Activity, Shows Lipid-Lowering and Insulin-Sensitizing Effects in Preclinical Models, 2015, Pharmacology Research & Perspectives, 3 (3), e00136. https: / / doi.org / 10.1002 / prp2.136 Kanjanabuch T, et al., PPAR-gamma agonist protects podocytes from injury., 2007, Kidney International, 71(12), 1232-1239. Lloyd V.A. Jr., 2016, The Art, Science, and Technology of Pharmaceutical Compounding, 5th Edition, eISBN: 1-58212-263-6 Makled MN, El-Kashef DH. Saroglitazar attenuates renal fibrosis induced by unilateral ureteral obstruction via inhibiting TGF-β / Smad signaling pathway, 2020, Life Sci., 253, 117729 Monserrat AJ, et al., Protective effect of myristic acid on renal necrosis occurring in rats fed a methyl-deficient diet., 2000, Research in Experimental Medicine, Berlin, 199(4), 195-206.Pedigo C.E. et al., Local TNF causes NFATc1-dependent cholesterol-mediated podocyte injury, 2016, J. Clin. Invest, 126(9), 3336-50 Rogacka D. et al., Regulation of podocytes function by AMP-activated protein kinase, 2020, Arch Biochem Biophys, 692, 108541 Rosenberg A.Z., Kopp J.B., Focal Segmental Glomerulosclerosis., Clin J Am Soc Nephrol., 2017, 12(3), 502-517. Sakata T. et al., Antiplatelet therapy effectively reduces plasma plasminogen activator inhibitor-1 levels, 2011, Artherosclerosis, 214(2), 490-1 Siller-Matula J.M. et al., Multiple electrode aggregometry predicts stent thrombosis better than the vasodilator-stimulated phosphoprotein phosphorylation assay, 2010, 8(2), 351-9 Takato, T. et al., Chronic Administration of Myristic Acid Improves Hyperglycaemia in the Nagoya-Shibata-Yasuda Mouse Model of Congenital Type 2 Diabetes, 2017, Diabetologia, 60 (10), 2076-83. https: / / doi.org / 10.1007 / s00125-017-4366-4. Tsai PY. et al., Antroquinonol reduces oxidative stress by enhancing the Nrf2 signaling pathway and inhibits inflammation and sclerosis in focal segmental glomerulosclerosis mice, 2011, Free Radic Biol Med, 50(11), 1503-16 Troyanov S, et al.; Toronto Glomerulonephritis Registry Group. Focal and segmental glomerulosclerosis: definition and relevance of a partial remission, 2005, J Am Soc Nephrol., 16(4),1061-1068 Udenwobele D.I. et al., 2017, Myristoylation: An Important Protein Modification in the Immune Response, Frontiers in Immunology, 8, 751, pp 1-16

Claims

1. A pharmaceutical formulation comprising saroglitazar and myristic acid, or a salt or solvate thereof, for use in treating a non-diabetic subject suffering from focal segmental glomerulosclerosis (FSGS).

2. 2. The pharmaceutical preparation for use according to claim 1, wherein the FSGS is recurrent FSGS, primary FSGS or spontaneous FSGS, specifically a glomerulopathy characterized by any one of heavy proteinuria, nephrotic syndrome, glomerulonephritis, membranoproliferative glomerulonephritis, IgA glomerulonephritis, progressive renal failure or glomerular lesions in histopathology.

3. 3. A pharmaceutical formulation for use according to claim 1 or 2, which is a medicine or drug product comprising saroglitazar and myristic acid, and a pharmaceutically acceptable carrier.

4. 4. The pharmaceutical formulation for use according to any one of claims 1 to 3, which is administered systemically.

5. Saroglitazar has the structure shown below. 【Chemistry 1】 5. A pharmaceutical formulation for use according to any one of claims 1 to 4, comprising:

6. 6. The pharmaceutical formulation for use according to claim 5, comprising about 1 mg to 100 mg of saroglitazar and 1 mg to 1 g of myristic acid.

7. 7. A pharmaceutical preparation for use according to any one of claims 1 to 6, formulated for systemic administration, preferably intravenous, intramuscular, subcutaneous, intradermal, transdermal or oral administration.

8. 8. The pharmaceutical formulation for use according to any one of claims 1 to 7, which is administered to a subject as a spray, powder, gel, ointment, cream, foam, or solution, lotion, mouthwash, aerosolized powder, aerosolized liquid formulation, granules, capsules, drops, tablets, syrup, lozenges, or an infusion or injectable formulation.

9. 9. The pharmaceutical formulation for use according to any one of claims 1 to 8, applied in an effective amount to a subject suffering from or at risk of developing FSGS.

10. 10. The pharmaceutical formulation for use according to any one of claims 1 to 9, wherein the formulation is administered as the sole substance or in combination with a further treatment with one or more active substances.

11. 11. The pharmaceutical formulation for use according to any one of claims 1 to 10, administered in combination with an active agent selected from the group consisting of antivirals, anticoagulants, immunomodulators, antibody preparations derived from human sources, monoclonal antibodies, intensive care medications, antihypertensives, statins, vasodilators, steroids, cytotoxic agents, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), cholesterol or triglyceride lowering agents, PPAR agonists.

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