Method of treating chronic graft versus host disease in subpopulation of patient by administering Bruudil

Abstract

The present disclosure provides methods of administering a Bruudil mesylate to certain subpopulations of patients suffering from cGVHD.

Description

Technical Field

[0001] The present disclosure relates to the administration of berushudil mesylate (REZUROCK TM ) is a method for treating chronic graft-versus-host disease (cGVHD) in certain subsets of patients. Background Art

[0002] Chronic graft-versus-host disease (cGVHD) is an immune-mediated inflammatory and fibrotic disorder. It is a potentially serious complication after solid organ transplantation and allogeneic hematopoietic cell transplantation (alloHCT). cGVHD affects up to 70% of all alloHCT recipients, with an incidence of 20%-50% in children. It is the leading cause of non-relapse mortality more than 2 years after alloHCT. In the United States, the estimated prevalence of cGVHD is 14,000 patients (as of 2016). (Bachier CR et al.: Epidemiology and real-world treatment of chronic graft-versus-host disease post allogeneic hematopoietic cell transplantation: A USclaims analysis. Presented at ASH 2019, held in Orlando, FL, December 7-10, 2019) ("Bachier et al.").

[0003] As assessed by the Lee Symptom Scale (LSS) (which measures the impact of cGVHD on the function and health of patients), the quality of life (QOL) of cGVHD patients is severely impaired. It is reported that only one-third of patients with cGVHD and starting systemic treatment will survive, be in remission and stop immunosuppressive therapy before 5 years. (Lee SJ et al.: Success of immunosuppressive treatments in patients with chronic graft-versus-hostdisease.Biol Blood Marrow Transpl 24:555-562,2018) ("Lee et al.").

[0004] The pathophysiology of cGVHD can be divided into three stages: early inflammation caused by tissue damage, dysregulation of the adaptive immune system, and chronic inflammation and abnormal tissue repair with fibrosis.

[0005] The first-line therapy for moderate to severe chronic graft-versus-host disease (cGVHD) as defined by the National Institutes of Health (NIH) is corticosteroids alone or in combination with sirolimus or calcineurin inhibitors. However, up to 70% of patients require additional lines of therapy. (Bachier CR et al.). In addition, long-term use of corticosteroids is associated with significant side effects. (Lee et al.).

[0006] The management of cGVHD has continued to evolve with the advent of targeted therapies. cGVHD is characterized by overproduction of the proinflammatory cytokines IL-21 and IL-17 and overactivation of T follicular helper cells and B cells, which in turn leads to excessive antibody production.

[0007] In 2017, the U.S. Food and Drug Administration approved ibrutinib (a Bruton's tyrosine kinase inhibitor) for the treatment of adults with cGVHD after failure of one or more lines of systemic therapy. In patients with cGVHD requiring >25% body surface area erythematous rash or NIH oral score>4, a study using ibrutinib reported an overall response rate (ORR) of 67% and a discontinuation rate of 43% due to adverse events (TEAEs) during treatment. (Waller EK et al.: Ibrutinib for chronic graft-versus-host disease after failure of priortherapy: 1-Year update of a phase 1b / 2study. Biol Blood Marrow Transpl 25: 2002-2007, 2019).

[0008] There remains an opportunity to investigate other treatment options for patients with cGVHD, including female patients of reproductive potential and male patients whose female partners are of reproductive potential. Summary of the invention

[0009] The present disclosure provides methods for treating berushedil (in some embodiments, berushedil mesylate (REZUROCK TM )) Methods for treating cGVHD administered to certain risk patient subpopulations.

[0010] In one embodiment, the present disclosure provides 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating cGVHD in male or female patients of reproductive potential, comprising the step of advising the patient to use effective contraception during treatment and for at least one week after the last dose of the compound.

[0011] In another embodiment, the present disclosure provides use of 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) (in some embodiments, its mesylate salt (berushudil)) for treating female patients of reproductive potential with cGVHD, comprising the step of verifying the pregnancy status of the patient prior to initiating treatment with the compound.

[0012] In another embodiment, the present disclosure provides for the use of berushudil in treating chronic graft-versus-host disease (cGVHD) in a lactating patient, comprising advising the patient not to breastfeed during treatment with the compound and for at least one week after the last dose of the compound.

[0013] In other embodiments, the disclosure provides for the use of treating chronic graft-versus-host disease (cGVHD) in a patient at risk for pregnancy, comprising the step of informing said patient of the reproductive risks associated with treatment with a compound.

[0014] In another embodiment, the disclosure relates to a method for treating a patient with cGVHD, comprising a step of verifying whether the patient is a reproductive risk patient before treatment. If it is verified that the patient is not a reproductive risk patient, the disclosure further provides for administering a compound to the patient; or alternatively, if it is verified that the patient is a reproductive risk patient, the patient is informed of the potential reproductive risks of receiving treatment with belushudil; and / or during treatment with belushudil and within at least one week after receiving its last dose, effective contraception is used or recommended.

[0015] A more complete understanding of the embodiments of the present invention may be obtained by reference to the detailed description and examples which are intended to illustrate non-limiting embodiments. DETAILED DESCRIPTION Overview

[0016] Berushudil is an oral selective inhibitor of rho-associated coiled-coil-containing protein kinase 2 (ROCK2). ROCK2 inhibition plays a role in the dysregulated adaptive immune system and fibrosis due to abnormal tissue repair. Berushudil has an IC of approximately 100 nM and 3 μM, respectively. 50 Value inhibits ROCK2 and ROCK1.

[0017] Berushudil downregulates proinflammatory responses in ex vivo or in vitro human T cell assays by modulating STAT3 / STAT5 phosphorylation and altering Th17 / Treg balance. In vitro, berushudil also inhibits abnormal profibrotic signaling. By controlling ROCK2 activity, berushudil mediates signaling in immune cell function and fibrotic pathways, thereby alleviating the effects caused by this debilitating disease, such as inflammation of multiple tissues and fibrotic changes that may involve multiple organs including the lungs, hepatobiliary system, musculoskeletal system, gastrointestinal (GI) tract, and skin.

[0018] Berushudil mesylate is marketed in the United States and other countries as REZUROCK TM The compound berusudil is marketed for the treatment of patients with chronic GVHD (cGVHD) and, in some cases, for the treatment of patients with chronic GVHD after failure of at least two prior lines of systemic therapy. The chemical name of the compound berusudil is as follows: 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide. The compound berusudil is also known as KD025. REZUROCK TM The active pharmaceutical ingredient is berushudil mesylate, which has the molecular formula C 27 H 28 N 6 O 5 S, with a molecular weight of 548.62 g / mol, and a chemical name of 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide methanesulfonate (1:1).

[0019] The chemical structure of Belushudil mesylate is as follows:

[0020] Berushudil and processes for making the compound are described in the following U.S. Patents: U.S. Patent No. 8,357,693, U.S. Patent No. 9,815,820, U.S. Patent No. 10,183,931, and U.S. Patent No. 10,696,660.

[0021] Applicants have evaluated berushedil in multiple rat and rabbit embryo-fetal toxicology studies herein as described in Examples 1-5 below (i.e., Example 1, entitled “Preliminary Prenatal Developmental Toxicity and Toxicokinetic Study in Sprague-Dawley Rats”; Example 2, entitled “Preliminary Prenatal Developmental Toxicity and Toxicokinetic Study with Non-Pregnancy Dose Range Finding Phase in New Zealand White Rabbits”; Example 3, entitled “Embryo-Fetal Developmental Toxicity Study with Toxicokinetic Evaluation in Sprague-Dawley Rats”; Example 4, entitled “Embryo-Fetal Developmental Toxicity Study with Toxicokinetic Evaluation in New Zealand White Rabbits”; and Example 5, entitled “Combined Fertility and Early Embryonic Development to Implantation Study in Sprague-Dawley Rats”).

[0022] Based on the findings from the above studies, belusudil is likely to cause harm to the fetus when administered to pregnant women. In the above animal studies, belusudil was administered to pregnant rats at oral doses of 25, 50, 150 and 300 mg / kg / day in preliminary studies (Example 1 herein) and at doses of 15, 50 and 150 mg / kg / day in key studies (Example 3 herein). In preliminary studies, maternal toxicity and embryo-fetal development effects were observed. Maternal toxicity (reduced weight gain) occurred at doses of 150 and 300 mg / kg / day. Post-implantation loss increased at 50 and 300 mg / kg / day. Fetal malformations were observed at ≥50 mg / kg / day, including the absence of anus and tail, omphalocele and dome-shaped head. The exposure (AUC) of rats at 50 mg / kg / day was about 3 times that of humans at the recommended human dose of 200 mg.

[0023] In the embryo-fetal development study of rabbits (Example 4 herein), oral doses of berushudil were administered to pregnant animals at 50, 125 and 225 mg / kg / day during the organogenesis period, resulting in maternal toxicity and embryo-fetal development effects. Maternal toxicity (weight loss and death) was observed at a dose of ≥125 mg / kg / day. Embryo-fetal effects were observed at a dose of ≥50 mg / kg / day, including spontaneous abortion, increased post-implantation loss, reduced percentage of live fetuses, malformations and fetal weight loss. Malformations included the following malformations: tail (short), ribs (branched, fused or deformed), sternum (fused) and neural arches (fused, dislocated and deformed). The exposure (AUC) of rabbits at 50 mg / kg / day was approximately 0.07 times that of humans at the recommended dose of 200 mg.

[0024] In a combined male and female rat fertility study (Example 5 herein), male animals treated with belusudil were mated with untreated female animals, or untreated male animals were mated with female animals treated with belusudil. Belusudil was orally administered to male rats at a dose of 50, 150 or 275 mg / kg / day 70 days before mating and throughout the mating period, and was orally administered to female rats 14 days before mating and until the 7th day of gestation. At a dose of 275 mg / kg / day, adverse findings in female rats (treated with belusudil or untreated but mated with treated males) included increased pre-implantation or post-implantation losses and reduced numbers of viable embryos. Belusudil was administered to male rats at a dose of 275 mg / kg / day, resulting in the discovery of sperm abnormalities (reduced motility, decreased counts, and increased percentages of abnormal sperm) and testicular / epididymal organ changes (weight loss and degeneration). At a dose of 275 mg / kg / day, fertility was reduced in both treated males and females, and statistical significance was achieved in males. Adverse changes in male and female reproductive organs also occurred in general toxicology studies; findings included sperm degeneration in dogs at a dose of 35 mg / kg / day of berushedil, and reduced follicular development in the ovaries of rats at a dose of 275 mg / kg / day. Changes were partially or completely reversed during recovery. The exposure (AUC) in dogs at a dose of 35 mg / kg / day and in rats at a dose of 275 mg / kg / day was 0.5 times and 8-9 times the clinical exposure at the recommended dose of 200 mg per day, respectively.

[0025] The present disclosure provides methods for treating berushedil (in some embodiments, berushedil mesylate (REZUROCK TM )) The method is administered to certain patient subpopulations including females of reproductive potential and partners at risk of pregnancy. This subpopulation also includes lactating women because of the potential for adverse reactions in breastfed children of patients taking berushudil. definition

[0026] As used herein, "about" includes the exact amount modified by the term about as well as the amount expected to be within experimental error (such as within 15%, 10% or 5%). For example, "about 200 mg" means "200 mg" as well as mg ranges within experimental error (e.g., plus or minus 15%, 10% or 5% of 200 mg). As used herein, the term "about" can be used to modify ranges as well as specific values.

[0027] As used herein (e.g., with respect to the administration of an API (including a Compound or belusudil) to a subject), "administering" or "administering to" refers to the act of prescribing one or more drugs containing the API for a subject to take during treatment, the act of dispensing the one or more drugs to the subject, and / or the act of physically receiving or ingesting the one or more drugs. Thus, an API (e.g., a Compound or belusudil) can be "administered" by a physician or other medical professional who writes a prescription for the one or more drugs; and / or "administered" by a pharmacist who fills the prescription and / or dispenses the one or more drugs to a subject; and / or "administered" by a patient or subject and / or his or her partner or caregiver who ingests the drug.

[0028] "API" means "active pharmaceutical ingredient."

[0029] "Allogeneic hematopoietic stem cell transplantation (allo-HSCT)" (also called bone marrow transplantation or stem cell transplantation) or "allogeneic hematopoietic cell transplantation (allo-HCT)" refers to a procedure in which hematopoietic cells from a donor are transplanted into a recipient who is not an identical twin. The source of hematopoietic stem cells for allogeneic transplantation can be peripheral blood stem cells (PBSC) or bone marrow (BM). In some cases, umbilical cord blood can be used. The human leukocyte antigen (HLA) genes of the donor and recipient may match, such as brothers and sisters. The donor and recipient may be parents and children who are only half-matched (haploid matched).

[0030] Unless the context clearly indicates otherwise, "Belusudil" as used herein refers to any form of the compound Belusudil and its pharmaceutically acceptable salts. The term "Belusudil" refers to both the compound Belusudil (e.g., free base form, amorphous form or crystalline form), and pharmaceutically acceptable salts of Belusudil (e.g., as described in REZUROCK TM The mesylate form used in the invention refers to any form of berushudil that can be used in a formulation or pharmaceutical composition for administering the compound to a patient.

[0031] "Breastfeeding" means delivering milk produced by lactation to a child, and includes administering milk from the breast to a child and / or collecting breast milk and delivering it by other means (eg, from a bottle or container).

[0032] "Clinical endpoint" or "study endpoint" refers to an event or outcome in a clinical trial, which can be objectively measured to determine the outcome and potential beneficial effects of a drug or administration regimen designed in a clinical trial. Examples of clinical endpoints include the following. Overall response rate (ORR) is the percentage of people with partial response (PR) or complete response (CR) to treatment in a certain period of time in a study or treatment group. Failure-free survival (FFS) refers to the time from the first dose of belusudil to the failure event, or the interval between the beginning of belusudil and the addition of a new cGVHD therapy, the recurrence of the underlying disease or non-recurrent death (NRM). Overall survival (OS) means the length of time from the diagnosis date of the disease or the start of treatment. Duration of response (DOR) means from the initial response time (e.g., PR or CR) until the time recorded from the best response progress of cGVHD, from the initial response to the start of another systemic cGVHD therapy or the time of death. Time to the next treatment (TTNT) means the time to start subsequent systemic cGVHD therapy.

[0033] "Clinically recommended amount" or "clinically recommended dose" refers to the amount or dose of the API recommended and / or approved by a person skilled in the art of medicinal chemistry for administration to a patient to treat the disease state in question after clinical trials. In some embodiments, the clinically recommended amount of berushedil is 200 mg, once a day, taken with food, until chronic GVHD progresses to the point where new systemic therapy is required.

[0034] As used in the claims and embodiments herein, and where clear from the context of use, "compound" is synonymous with the above inclusive definition of Berushedil.

[0035] "CYP3A" refers to the CYP3A family of p-450 isozymes, including CYP3A4.

[0036] "Effective contraception" is the use of artificial methods or other techniques that effectively prevent pregnancy from sexual intercourse. Examples of contraception include barrier methods, such as condoms; hormonal methods (e.g., birth control pills); intrauterine devices, such as the IUD; and male or female sterilization. The definition of effective contraception takes into account the use of multiple forms of contraception at the same time and improves the effectiveness of contraception.

[0037] As used herein, "fetus" encompasses an unborn offspring in the process of development, including a fertilized egg, an embryo, or a fetus at a later stage of development.

[0038] "Pregnancy" means the period of intrauterine development from conception to birth.

[0039] "Immunosuppressive therapy" (IST) refers to therapy that is usually administered for at least six months after allo-HSCT in an attempt to prevent GVHD. Examples of IST include sirolimus, prednisone, and calcineurin inhibitors (such as tacrolimus and cyclosporine).

[0040] "Lactating patient" means a patient who is able to produce breast milk.

[0041] The Lee Symptom Scale (LSS) total score measures the impact on patient function and well-being. The Lee Symptom Scale is a 30-item scale developed to measure symptoms of cGVHD and is described in Lee SJ et al., Development and validation of a scale to measure symptoms of chronic graft-versus host disease. Biol Blood Marrow Transplant 2002; 8:444-452.

[0042] "Line of treatment" or "line of therapy" describes the order or sequence in which different therapies are given to a patient as his or her disease progresses. The initial treatment (first-line therapy) may not work or may stop working after a period of time. After the first-line therapy is discontinued, a second, different treatment (second-line therapy) may be given. When the second-line therapy does not work or stops working, a subsequent line of therapy may be given. Some patients may be given multiple lines of therapy during the course of their disease.

[0043] The first-line therapy for moderate to severe chronic graft-versus-host disease (cGVHD) defined by the National Institutes of Health (NIH) can be a single corticosteroid or a combination of corticosteroids and sirolimus or a calcineurin inhibitor. (Carpenter PA et al.: A phase II / III randomized, multicenter trial of prednisone / sirolimus versus prednisone / sirolimus / calcineurin inhibitor for the treatment of chronic graft-versus-host disease: BMT CTN 0801. Haematologica 103: 1915-1924, 2018).

[0044] The example of corticosteroid therapy for the treatment of cGVHD includes but is not limited to prednisone, prednisolone, methylprednisolone and budesonide. The example of previous systemic therapy for the treatment of cGVHD includes but is not limited to prednisone, tacrolimus, extracorporeal photopheresis (ECP), sirolimus, ibrutinib, ruxolitinib, mycophenolate mofetil (MMF), rituximab, methotrexate (MTX), cyclosporine, imatinib, ixazomib and ofatumumab.

[0045] A "malformation" is a permanent deviation that is generally incompatible with or seriously detrimental to normal postnatal survival or development. "Malformation" means an abnormality of structure that alters general body conformity, disrupts or interferes with body function, or is generally considered incompatible with life. Specific examples of processes that cause malformations include obvious or severe malformation of shape, asymmetry, or irregularity of a structure caused by fusion, splitting, disarticulation, malalignment, hiatus, enlargement, elongation, thickening, thinning, or branching. The absence of part or all of a structure is also considered a malformation.

[0046] "Myeloablative transplant" refers to a transplant procedure that uses very high doses of chemotherapy or radiation before transplanting autologous or allogeneic hematopoietic stem cells. A nonmyeloablative transplant or reduced-intensity transplant involves the patient undergoing less intensive chemotherapy before transplanting allogeneic hematopoietic stem cells.

[0047] The “NIH Pulmonary Symptom Score” or “NIH cGVHD Pulmonary Score” is a score based on clinical symptoms ranging from 0 to 3. A score of 0 is used for no symptoms, 1 for symptoms of shortness of breath when climbing stairs, 2 for symptoms of shortness of breath on level ground, and 3 for shortness of breath at rest or requiring oxygen.

[0048] Unless the context requires otherwise, "or" is used in its inclusive sense (equivalent to "and / or").

[0049] As used herein, "patient" includes an animal or a human, and in one embodiment, includes a human in need of treatment with or in need of receiving treatment with belushudil or a human who is a candidate for treatment with or receiving treatment with belushudil.

[0050] As used herein, "pregnancy" or "pregnancy" means a state in which a female patient has a fertilized egg, embryo, or fetus developing in her uterus, and encompasses all stages of fetal development from conception until birth.

[0051] As used herein, "pregnancy risk patient" means any patient whose age, sex and / or living environment poses a risk of pregnancy for themselves or for another person. Thus, "pregnancy risk patient" includes female patients of reproductive potential, as well as male patients who have sexual activity with one or more females of reproductive potential. The term "pregnancy risk patient" does not include pregnant patients.

[0052] As used herein, "pregnancy risk partner" means any person in a relationship with a pregnancy risk patient who may create a risk of pregnancy in the patient by any means (eg, via natural means or in vitro fertilization).

[0053] "Reproductive potential" when used with respect to a female patient means that the patient is physiologically capable of producing an egg cell (egg or oocyte) and / or capable of carrying a fetus in utero (e.g., once implanted via artificial insemination). A female patient of "reproductive potential" does not include a female who has been confirmed or verified (e.g., via laboratory testing) to be pregnant. "Reproductive potential" when used with respect to a male patient means a male who is capable of producing sperm to fertilize a female's egg cell.

[0054] "Reproductive risks" include risks of adverse effects on fetal or embryonic development, including, for example, weight loss, injury and / or malformation, as well as risks to fertility and risks to children fed with breast milk obtained from a patient being treated.

[0055] "Reproductive risk patient" means a patient who can cause or create a reproductive risk as defined herein, including a female patient of reproductive potential, a male patient of reproductive potential, a lactating patient, or a pregnant patient.

[0056] "Risk" as used herein, for example in the definitions of "pregnancy risk patient" and "pregnancy risk partner," means that there is a possibility (even if slight or minimal) that pregnancy may occur.

[0057] "Side effects" means physiological responses other than the desired effects of a treatment that are attributable to the treatment. In certain embodiments, side effects may include embryo-fetal developmental effects and malformations. Side effects may be detected directly or indirectly.

[0058] "Steroid-refractory" (SR) cGVHD is defined as cGVHD that progresses on the use of steroids or corticosteroids (in one embodiment, on the use of prednisone).

[0059] "Subject" means an animal, including an animal or human subject, that is being treated with berushudil.

[0060] A "therapeutically effective amount" of an API means an amount sufficient to achieve treatment of the disease state being treated when administered to a human to treat a disease (e.g., cGVHD). As applied to human cGVHD, "treating" or "treatment" includes (1) reducing the risk of developing cGVHD and / or inhibiting cGVHD, i.e., preventing or reducing the development of cGVHD or its clinical symptoms; (2) alleviating cGVHD, i.e., causing regression, reversal or improvement of cGVHD or reducing the number, frequency, duration or severity of its clinical symptoms.

[0061] The therapeutically effective amount of the API may vary depending on the health and physical condition of the subject to be treated, the extent of disease progression, the assessment of the medical condition, and other relevant factors. It is expected that the therapeutically effective amount may fall within the range that can be determined by experimentation and by reference to clinical trial data and results as described, for example, in Examples 1 and 2 herein and in the scientific literature.

[0062] "Verification" as used herein with respect to the step of verifying the pregnancy status of a female subject includes any form or manner of investigation to determine the pregnancy status of a female subject, including through a physical examination, an inquiry, and / or one or more diagnostic tests. It should be understood that a person can "verify" the pregnancy status of a female subject by making an inquiry, performing a physical examination, asking about a diagnostic test being performed, ordering or prescribing a diagnostic test, performing a diagnostic pregnancy test, and / or receiving the results of any such test or examination to confirm the pregnancy status of the female subject. Exemplary embodiments

[0063] In one embodiment, the present disclosure provides 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) or a mesylate thereof (berushudil) for use in treating cGVHD in certain patient subpopulations who are reproductive risk patients.

[0064] In one embodiment, the reproductive risk (RR) patient is a female patient of reproductive potential; in another embodiment, the RR patient is a male patient with a female partner of reproductive potential; in another embodiment, the RR patient is a lactating patient; and in another embodiment, the RR patient is a pregnant patient.

[0065] In some embodiments, the RR patients are female patients of reproductive potential who use effective contraception during treatment; in some embodiments, the female patients use effective contraception during treatment and for at least one week after the last dose of the compound; in some embodiments, the RR patients are male patients of reproductive potential who use effective contraception during treatment; in some embodiments, the male patients use effective contraception during treatment and for at least one week after the last dose of the compound;

[0066] In one embodiment, the disclosure provides the use of a compound or its mesylate (Berushudil) in the treatment of cGVHD in RR patients, comprising informing the patient of the reproductive risks to a fetus or embryo and / or to a child being breastfed from treatment with the compound or Berushudil. In another embodiment, the disclosure provides for verifying the status of a RR patient (e.g., in the case of a woman, whether she is pregnant) before administering the compound or Berushudil.

[0067] In another embodiment, the disclosure provides for use of a compound or its mesylate salt (belusudil) for treating cGVHD in female patients of reproductive potential, comprising advising the patient to use effective contraception during treatment and for at least one week after the last dose of the compound.

[0068] In another embodiment, the disclosure provides the use of a compound or its mesylate salt (Berushudil) for treating cGVHD in a female patient who is pregnant or becomes pregnant while taking the compound, including informing the female patient of the potential risks to the fetus of receiving treatment with the compound while pregnant.

[0069] In some embodiments, the patient being treated for cGVHD may be pregnant while receiving treatment with the compound. In such embodiments, the disclosure contemplates informing the female patient of the potential risks to the fetus of receiving treatment with the compound while pregnant.

[0070] In some embodiments, the present disclosure provides for use of a compound or its mesylate salt (belusudil) for treating cGVHD in a male patient whose female partner has reproductive potential, comprising the step of advising the male patient to use effective contraception during treatment with the compound and for at least one week after the last dose of the compound.

[0071] In another embodiment, the present disclosure provides use of a compound or its mesylate salt (belusudil) for treating cGVHD in a lactating patient, comprising the step of advising the patient not to breastfeed during treatment with the compound and for at least one week after the last dose of the compound.

[0072] In another embodiment, the disclosure provides the use of a compound or its mesylate (Belusudil) in the treatment of cGVHD in a patient at risk of pregnancy, wherein the patient at risk of pregnancy is using effective contraception during treatment with the compound or Belusudil. In some embodiments, the patient at risk of pregnancy is a female; in other embodiments, the patient at risk of pregnancy is a male. In another embodiment, the patient at risk of pregnancy uses effective contraception during treatment and within at least one week after the last dose of the compound.

[0073] In another embodiment, the present disclosure provides for use of a compound or its mesylate salt (Berushudil) in treating cGVHD in a non-lactating patient.

[0074] In some embodiments, the compound or its mesylate salt (Berushudil) is administered to the patient at a dose of 200 mg per day.

[0075] The present disclosure further provides a method for treating cGVHD in a patient with a compound or its mesylate salt (berushudil), comprising the steps of: (a) verifying whether the patient is a reproductive risk patient; and (b) (i) if the patient is verified to be not a reproductive risk patient, administering berushudil to the patient, or (ii) if the patient is verified to be a reproductive risk patient, informing the patient of the potential reproductive risks of treatment with berushudil, and / or advising the use of effective contraception during treatment with the compound and for at least one week after the last dose of the compound; and / or in the case of a lactating patient, advising not to breastfeed during treatment with the compound and for at least one week after the last dose of the compound.

[0076] In some embodiments, it can be verified that the patient is a lactating patient; or a pregnant patient; or a male or female patient at risk of pregnancy. In such embodiments, the present disclosure contemplates informing the patient of the reproductive risks from belusudil; and / or recommending the use of effective contraception during treatment with the compound and for at least one week after the last dose of the compound; and / or, where applicable, recommending not breastfeeding during treatment with belusudil and for at least one week after receiving the last dose thereof.

[0077] In some embodiments, the present disclosure provides a method of treating cGVHD in a patient, comprising: (a) verifying whether the patient is a reproductive risk patient; and (b) (i) if the patient is verified to be not a reproductive risk patient, administering belusudil to the patient, or (ii) if the patient is verified to be a reproductive risk patient, using effective contraception during treatment with belusudil and for at least one week after receiving the last dose.

[0078] In some embodiments, the subject (or patient) has undergone an allogeneic hematopoietic stem cell transplant as a matched HSCT. In some embodiments, the allogeneic hematopoietic stem cell transplant is a haploidentical HSCT.

[0079] In some embodiments, belusudil treatment is continued based on the patient's tolerance until active cGVHD symptoms subside or progress. The number of cycles and duration of treatment depend on the patient. In some embodiments, belusudil is administered to the patient in one or more 28-day cycles.

[0080] In some embodiments, the range of cycle number is 3 to 15. In some embodiments, the range of cycle number is 3 to 14, 3 to 13, 3 to 12, 3 to 11, 3 to 10, 3 to 9, 3 to 8, 3 to 7, 3 to 6, 3 to 5, or 3 to 4. In some embodiments, the range of cycle number is 5 to 11. In some embodiments, the range of cycle number is 6 to 12. In some embodiments, the range of cycle number is 5 to 10, 5 to 9, or 5 to 8. In some embodiments, the range of cycle number is 5 to 7. In some embodiments, the range of cycle number is 5 to 6. In some embodiments, the number of cycles is 5. In some embodiments, the number of cycles is 6. In some embodiments, the number of cycles is 7. In some embodiments, the number of cycles is 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15.

[0081] In some embodiments, the subject has chronic graft-versus-host disease and has failed one to three prior lines of systemic therapy for chronic graft-versus-host disease. In some embodiments, the subject has chronic graft-versus-host disease and has failed at least two prior lines of systemic therapy for chronic graft-versus-host disease. In some embodiments, the subject has chronic graft-versus-host disease and has failed two to five prior lines of systemic therapy for chronic graft-versus-host disease. In another embodiment, the subject has failed at least once, at least twice, at least three times, at least four times, or at least five times.

[0082] In some embodiments, the subject experienced a complete response to the last treatment for graft-versus-host disease prior to berushudil. In some embodiments, the subject experienced a partial response to the last treatment for graft-versus-host disease prior to berushudil. In some embodiments, the subject experienced stable disease during the last graft-versus-host disease treatment prior to berushudil.

[0083] In some embodiments, a prior line of systemic therapy for chronic graft-versus-host disease has been discontinued.

[0084] In some embodiments, the prior line of systemic therapy is selected from prednisone, tacrolimus, ECP, sirolimus, ibrutinib, ruxolitinib, MMF, rituximab, MTX, cyclosporine, imatinib, ixazomib, and ofatumumab.

[0085] In some embodiments, the cGVHD is steroid refractory (SR) cGVHD.In some embodiments, the subject is refractory to the last line of treatment prior to berushudil treatment.

[0086] In some embodiments, the subject is receiving concomitant corticosteroid therapy. In some embodiments, the concomitant corticosteroid therapy is selected from prednisone, prednisolone, methylprednisolone and budesonide. In some embodiments, the concomitant corticosteroid therapy is prednisone. In some embodiments, the dosage of the concomitant corticosteroid therapy is reduced after at least 1 cycle of Belushudil treatment. In some embodiments, the dosage of the concomitant corticosteroid therapy is reduced by at least about 10%, at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60% or at least about 70% after at least 1 cycle of Belushudil treatment. In some embodiments, the dose of concomitant corticosteroid therapy is reduced by at least about 10% to about 70%, about 15% to about 65%, about 20% to about 60%, about 30% to about 60%, about 35% to about 60%, about 40% to about 60%, or about 45% to about 55% after at least 1 cycle of belushudil treatment. In some embodiments, concomitant corticosteroid therapy is discontinued after at least 1 cycle of belushudil treatment.

[0087] In some embodiments, the subject is receiving concomitant calcineurin inhibitor therapy. Belushudil Tablets

[0088] In one embodiment, belushudil is formulated into tablets for oral administration. Belushudil mesylate is a yellow powder that is almost insoluble in water. Belushudil tablets can be prepared for oral administration. Each tablet contains 200 mg of free base, equivalent to 242.5 mg of belushudil mesylate. The tablets may also contain the following inactive ingredients: microcrystalline cellulose, hypromellose, cross-linked sodium carboxymethyl cellulose, colloidal silicon dioxide, and magnesium stearate. The tablet film is composed of polyvinyl alcohol, polyethylene glycol, talc, titanium dioxide, and yellow iron oxide. Each 200 mg tablet is a light yellow film-coated oval tablet with a concave pattern "KDM" on one side and a concave pattern "200" on the other side. The tablets are stored at room temperature 20°C to 25°C (68°F to 77°F); short-term travel allows 15°C to 30°C (59°F to 86°F).

[0089] The following abbreviations may be helpful in considering the description herein. abbreviation Example Example 1: Preliminary Prenatal Developmental Toxicity and Toxicokinetic Studies in Sprague-Dawley Rats Study objectives and design

[0090] This preliminary study was conducted to provide information on the selection of belusudil doses for use in subsequent embryo-fetal developmental toxicity studies in Sprague-Dawley rats (Example 3). The second part of this study was a preliminary developmental toxicity study, i.e., to determine the toxicokinetics of belusudil and its two metabolites, KD025m1 and KD025m2, when belusudil was administered once daily to pregnant rats via oral gavage from gestational day (GD) day 6 to day 17. The design of the study is shown in Table 1. Table 1: Design of the Dose Pilot / Rat Study for Example 1

[0091] A total of 52 Sprague-Dawley (SD) rats were used in this study. Vehicle (0.4% (w / w) methylcellulose (400 cps) in distilled water) or berushidil was administered once daily to regularly mated female SD rats at approximately the same time each day from gestational day (GD) 6 to 17, via oral gavage, at a dose volume of 10 mL / kg, at varying dose levels as shown in Table 1. Animals were assigned to groups as shown in Table 1. observe

[0092] Observations of the animals included cage-side assessments (twice daily), evaluation of clinical signs (daily from GD 6 to 20), body weight (at arrival - GD 2 or 3 - and GD 6, 9, 12, 15, 18, and 20), food intake (GD 6-20), and anatomical pathology including uterine examination. Toxicokinetic assessments were performed for berushudil and metabolites. External examinations were performed on all fetuses.

[0093] Clinical signs were limited to 300 mg base / kg / day and had a low incidence but were considered possibly treatment related.Clinical signs consisted of an unkempt and / or emaciated appearance and a hunched posture.

[0094] The average weight gain and food intake at 25 and 50 mg alkali / kg / day were slightly reduced from GD 6-9, GD 6-18 and GD 6-20 (dose-related). At 150 mg alkali / kg / day, the average body weight was reduced throughout the gestational period, weight loss occurred from GD 6-9, and a decrease in weight gain was noted from GD 12-15, GD 6-18 and GD 6-20. During these same intervals, the food intake at 150 mg alkali / kg / day was correspondingly reduced. After treatment with 25, 50 and 150 mg alkali / kg / day (GD 18-20), the increase in weight gain and food intake was considered to be a rebound / recovery effect. After GD 6 was started to be administered with 300 mg alkali / kg / day, the average body weight value, average weight gain and food intake were all adversely affected at each time interval.

[0095] No adverse maternal necropsy findings were noted in any treatment group. The number of litters available for examination was 5 in each of the 0, 25, 50, 150 and 300 mg base / kg / day groups. All females maintained pregnancy to the scheduled necropsy date of GD 20 at the 25, 50 and 150 mg base / kg / day dose levels.

[0096] At 25, 50 and 150 mg base / kg / day, the dose response was not obvious in the intrauterine data, but the average number of early resorption (resorption) was significantly increased in the 50 mg base / kg / day group, and the average number of viable fetuses was slightly reduced. The average post-implantation loss (% / litter) at 0, 25, 50, 150 and 300 mg base / kg / day was 4.41, 4.00, 11.62, 4.51 and 24.51, respectively. The average number of viable litters at these same dose levels was 12.8, 13.2, 11.6, 12.2 and 10.0, respectively.

[0097] The average fetal weight (female fetus) at 0, 25, 50, 150 and 300 mg alkali / kg / day was 1.36, 4.19, 4.39, 4.18 and 3.34 g, respectively. The combined average fetal weight (male and female) at these same dosage levels was 4.50, 4.37, 4.50, 4.22 and 3.42 g, respectively. At 300 mg alkali / kg / day, post-implantation loss (early resorption) increased (including females with total embryo loss), and the average fetal weight was significantly reduced.

[0098] Although the historical incidence of external fetal malformations in dose-ranging discovery studies in rats is atypical, in this study, litter incidence was significant, ranging from 40% and 20% of litters affected at 50 and 150 mg base / kg / day, respectively, to 25% of litters affected at 300 mg base / kg / day. In the 50 mg base / kg / day group, one fetus was edematous (whole body), and another fetus / litter in this dose group had an absent anus and tail. In the 150 mg base / kg / day group, one fetus had an omphalocele. At 300 mg base / kg / day, one fetus had a dome-shaped head. result

[0099] In this oral preliminary prenatal developmental toxicity study with berushudil, maternal toxicity was considered mild at 25 and 50 mg base / kg / day and moderate at 150 mg base / kg / day (Moderate is defined as more pronounced with a significant increased likelihood of severity. Tissue or organ function may be limited.) Maternal, embryonic, and fetal toxicity was considered excessive at 300 mg base / kg / day and this dose level would be precluded from selection for subsequent developmental toxicity studies in rats.

[0100] For the parent compound berushudil, the dose level of 25 mg base / kg / day corresponds to a decrease in the parent C at the end of the dosing regimen (GD 17). max is 1800 ng / mL, and the parent AUC 0-24 is 20400ng·hr / mL; for KD025m1, the parent C max was 176 ng / mL and AUC 0-24 is 2230ng·hr / mL; and for KD025m2, the parent C max was 127 ng / mL and AUC 0-24 It is 1480ng·hr / mL. Example 2: Preliminary Prenatal Developmental Toxicity and Toxicokinetic Study with Non-Pregnant Dose-Range Finding Phase in New Zealand White Rabbits Study objectives and design

[0101] This study was conducted to provide information for belusudil dose selection for use in subsequent embryo-fetal developmental toxicity studies (Example 4) in New Zealand white (NZW) rabbits. The study was conducted in two phases: Phase A was a dose range-finding tolerance study with non-pregnant rabbits, and Phase B was a preliminary developmental toxicity study. Vehicle (0.4% (w / w) methylcellulose (400 cps) in distilled water) or belusudil was administered to non-pregnant or regularly mated female NZW rabbits for two consecutive groups for 5 consecutive days (Phase A) or once a day from the 6th day of gestation (GD) to the 18th day (Phase B). The design of the study is further listed in Table 2 below. Table 2: Design of the Dose Pilot / Rabbit Study for Example 2 a Animals are administered the test article for 5 consecutive days, followed by a 10-day washout period, and then administered the test article at a higher dose level for 5 consecutive days; b Dose levels were presented as ascending doses; however, one female (animal 105) was replaced after the first dose. As a result, the second dose (300 mg base / kg / day) was administered only to the replacement animal; the total number of animals studied in Phase A was 9. observe

[0102] Observations on the animals included clinical signs, body weight, food intake, and anatomical pathology including uterine examination. Toxicokinetic evaluations were performed for berushudil and both metabolites. Appropriate external examinations were performed on all fetuses.

[0103] Survival was not affected at any dose level administered in Phase A. All animals survived to the scheduled termination date. In Phase A, clear treatment-related effects were evident at dose levels of 300 and 400 mg base / kg / day and consisted of slight weight loss and reduced food intake.

[0104] A potentially treatment-related clinical finding seen at the corresponding dose levels of 100, 200, 300 and 400 mg base / kg / day administered from Study Days 15 to 19 was abnormal stools (little / none) with brown discoloration in the anogenital area on the last day of the study (Study Day 20) for Female No. 108 at 400 mg base / kg / day.

[0105] In Phase B, survival was not affected at any of the doses administered. Dose-dependent maternal responses occurred at the 100 and 250 mg base / kg / day dose levels and consisted of decreased / reduced weight gain, decreased food intake, clinical signs (loss of appetite, stool abnormalities, emaciated appearance), and an overall dose-related increase in the amount of veterinary intervention (food fortification). No treatment-related maternal necropsy findings were observed, and treatment-related embryo- or fetal toxicity was not apparent at any dose level.

[0106] result

[0107] When berushudil was administered to pregnant rabbits at 25, 50, 100 and 250 mg base / kg / day from gestation day 6 to 18, no toxicologically relevant maternal toxicity was observed at 25 or 50 mg base / kg / day. Dose-dependent maternal responses at 100 and 250 mg base / kg / day were clearly demonstrated by decreased / reduced body weight gain, reduced food intake, clinical signs (loss of appetite, abnormal stools, emaciated appearance), and an overall dose-related increase in the amount of veterinary intervention (food fortification).

[0108] At the NOAEL for maternal toxicity (50 mg base / kg / day), for berushudil, the 50 mg base / kg / day dose level corresponds to a maternal C max was 621 ng / mL, and the parent AUC 0-24 is 2480ng·hr / mL; for KD025m1, the parent C max was 528 ng / mL and AUC 0-24 is 1320ng·hr / mL; and for KD025m2, the parent C max 1090 ng / mL and AUC 0-24 At the NOAEL for developmental toxicity (250 mg base / kg / day), for berushudil, the 250 mg base / kg / day dose level corresponds to a maternal C max is 2100 ng / mL, and the parent AUC 0-24 is 15600ng·hr / mL; for KD025m1, the parent C max 1040 ng / mL and AUC 0-24 is 4760ng·hr / mL; and for KD025m2, the parent C max is 3080ng / mL and AUC 0-24 It is 19700ng·hr / mL.

[0109] Based on the results of this study, dose levels of 0, 50, 125 and 225 mg base / kg / day were selected for embryo-fetal developmental toxicity studies in New Zealand White rabbits (Example 4). Example 3: Embryo-Fetal Developmental Toxicity Study with Toxicokinetic Evaluation in Sprague-Dawley Rats Study Objectives and Design

[0110] This study was conducted to determine the embryo-fetal developmental toxicity of belusudil in Sprague-Dawley rats, including teratogenic potential. The study also included a toxicokinetic (TK) evaluation to determine the exposure / toxicity relationship of belusudil and its metabolites (KD025m1 and KD025m2). From gestational day (GD) 6 to 17, vehicle (0.4% (w / w) methylcellulose (400 cps) in distilled water) or belusudil was administered once daily to regularly mated SD rats via oral gavage.

[0111] For this study, a total of 140 regularly mated female rats (approximately 8 to 10 weeks old) were obtained from Charles River Laboratories in Raleigh, North Carolina, and were acclimated to the environment from the time of arrival until the dosing time of GD 6. During the acclimation period, the general health of the animals and any signs of disease were observed twice a day. All animals were given a detailed clinical examination and body weight was recorded before selection. Animals assigned to the study had a body weight within ± 20% of the mean body weight. Food intake was collected during the acclimation period.

[0112] Using standard randomization procedures by weight measurements, 133 female animals (weighing 162 g to 226 g, randomized) were assigned to control, treatment, and TK groups as shown in Table 3. Table 3: Group allocation for Example 3 study Application

[0113] From GD 6 to 17, vehicle and berushedil were administered once daily via oral gavage at approximately the same time each day (±2 hours from GD 6 administration). The dose levels for the treatment groups were 15, 50, and 150 mg base / kg / day, and the dose volume was 10 mL / kg. The control group received vehicle in the same manner as the treatment group. In addition, TK animals received vehicle or berushedil in the same manner as the main study group at the same dose level and volume. Before and throughout the dose administration period, the vehicle and berushedil formulations were continuously stirred at room temperature for at least 30 minutes. Individual doses were based on recent body weight. observe

[0114] Animals underwent in-life and post-mortem evaluations. In-life evaluations included cage-side observations (for morbidity, mortality, lesions), detailed clinical signs, body weight, food intake, and anatomical pathology including uterine examination. Toxicokinetic assessments were performed for berushedil and metabolites (KD025m1 and KD025m2). External and visceral or skeletal examinations were performed on all fetuses. Cage-side and clinical observations.

[0115] No treatment-related deaths were observed at any dose level. Five females on 150 mg base / kg / day suffered suspected gavage injuries. These five females were not included in the tabulation of the summary data for clarity of discussion of the study results.

[0116] Detailed clinical observations were performed daily from GD 6 to 20 (4 hours ± 1 hour after administration on the administration day). The observations included, but were not limited to, evaluations of the skin, fur, eyes, ears, nose, oral cavity, chest, abdomen, external genitalia, limbs and feet, and evaluations of respiration. The clinical observations are summarized in Table 4. Number of observations / total number of animals weight.

[0117] Body weights of all animals were measured and recorded at GD 6, 9, 12, 15, 18, and 20. Individual body weight changes were calculated for the following GD intervals: 6-9, 9-12, 12-15, 15-18, 18-20, 6-18, and 6-20. Adjusted body weight (GD 20 body weight minus gestating uterus weight) and adjusted body weight change (GD 6 to 20) were also calculated.

[0118] Maternal body weight and weight changes are summarized in Tables 5 and 6 below:

[0119] Mean maternal body weights decreased in a statistically significant manner in a dose-related manner at 50 and 150 mg base / kg / day throughout the treatment period and post-treatment period (GD 9, 12, 15, 18, and 20).

[0120] 150mg base / kg / day, mean weight gain also decreased in a dose-related manner; from GD 6-9 and 9-12, at 50 and 150mg base / kg / day, the decrease in weight gain was statistically significant. From GD 12-15, the weight gain at 50mg base / kg / day was comparable to the control group, but during this same time period, the weight gain at 150mg base / kg / day remained significantly reduced. During the last few days of the treatment period (GD 15-18), at both dose levels, weight gain remained slightly reduced (statistically significant), and after the treatment period (GD 18-20), the mean weight gain was similar (50mg base / kg / day) or greater (150mg base / kg / day; statistically significant) compared to the control group, indicating a recovery response. Evaluation of the combined intervals (GD 6-18 and 6-20) revealed consistent dose-related reductions in mean maternal weight gain at both 50 and 150 mg base / kg / day (statistically significant at both dose levels). Food intake.

[0121] The food intake of the main research animals was measured and recorded on the corresponding body weight day, and calculated for the same interval. Throughout the treatment period (GD 6-9, 9-12, 12-15, 15-18, 6-18 and 6-20), at 50 and 150 mg alkali / kg / day, the average maternal food intake was reduced with statistical significance in a dose-related manner. After the treatment period (GD 18-20), the food intake was similar to that in the control group, indicating a recovery response.

[0122] Maternal food intake is summarized in Table 7 below: Postmortem examination of the uterus, ovaries, and fetus

[0123] All animals in the study were pregnant, resulting in a 100% pregnancy index in each study group. The number of litters available for examination was 25, 25, 25, and 20 in the control, 15 mg base / kg / day, 50 mg base / kg / day, and 150 mg base / kg / day groups, respectively.

[0124] At GD 20, each surviving main research female was euthanized by carbon dioxide inhalation, followed by peritoneal venous exsanguination and immediate cesarean section. The skin was turned over from the ventral midline incision to examine the mammary tissue and locate any subcutaneous masses. The abdominal cavity was then opened and the uterus was exposed. The uterus was removed and the weight of the gestational uterus was recorded. Starting from the distal end of the left uterine horn, the position of the viable and non-viable fetuses, the early and late absorptions of each uterine horn, and the total number of implantations were recorded. The number of corpora lutea on each ovary was also recorded.

[0125] The fetuses were removed by making a dorsal incision longitudinally along both uterine horns. The embryonic membranes of each fetus were gently removed and each fetus was peeled away from the placenta, leaving the umbilical cord fully extended. The placenta was grossly inspected.

[0126] The apparently non-pregnant uterus from females was opened and placed in a 10% ammonium sulfide solution to detect the implantation site. If a lesion was detected, it was considered to be an early resorption and the data from this female were included in the mean calculation.

[0127] At 150 mg base / kg / day, mean gestational uterine weights were slightly reduced. However, at 150 mg base / kg / day, mean final body weights, adjusted final body weights, and adjusted final body weight changes were statistically significantly reduced when compared to corresponding control values ​​and are considered treatment-related.

[0128] The mean gestational uterine weights at 50 mg base / kg / day were similar to control values. However, the mean final body weight, adjusted final body weight, and adjusted final body weight change at 50 mg base / kg / day were statistically significantly reduced when compared to the corresponding control values ​​and are considered treatment related.

[0129] Gestational uterine weights and adjusted body weight / weight change are summarized in Table 8. Fetal weights are summarized in Table 9. N = number of measurements used to calculate the mean SD (standard deviation) b = significantly different from control (p < 0.01)

[0130] For subjects treated with 15 and 50 mg base / kg / day, none of the fetal weight values ​​were statistically significant when compared to the corresponding control group values. At 150 mg base / kg / day, all mean fetal weight values ​​for males, females, and sexes combined were statistically significantly reduced; these values ​​were reduced between -7% and -8% compared to the corresponding control values. Toxicokinetic analysis

[0131] Exposure to belusudil, KD025m1, and KD025m2 increased as belusudil dose levels increased from 15 mg base / kg to 150 mg base / kg. max The increase in values ​​was generally less than dose proportional at GD 6 and GD 17, and AUC 0-24 The increase was generally dose-proportional at GD 6 and GD 17. KD025m1 C in pregnant rats maxThe increase in values ​​was generally dose-proportional at GD 6 and GD 17, and AUC 0-24 The increase was greater than dose proportional at GD 6 and GD 17. max Value and AUC 0-24 The increase in values ​​was generally dose-proportional on GD 6 and greater than dose-proportional on GD 17. No significant accumulation of berusudil, KD025m1, and KD025m2 was observed after multiple administrations of berusudil in pregnant rats. AUC 0-24 Metabolite to maternal ratios indicated that belusudil was converted to KD025m1 and KD025m2 in pregnant rats following oral gavage administration of belusudil. The metabolite to maternal ratios ranged from 0.0799 to 0.188 and from 0.0482 to 0.125 for KD025m1 and KD025m2, respectively.

[0132] These TK results are summarized in Table 10 below. result

[0133] When belusudil was administered to pregnant rats at 15, 50 and 150 mg base / kg / day from gestation day 6 to day 17, maternal and fetal developmental toxicity occurred at 150 mg base / kg / day; the reduction in mean maternal body weight, weight gain and food intake was significant. Mean fetal weight was also significantly reduced and was considered unfavorable. The dose level of 50 mg base / kg / day resulted in an adverse dose-related reduction in mean maternal body weight, weight gain and food intake. The dose level of 15 mg base / kg / day did not produce any adverse maternal or fetal developmental effects. The dose level of 50 mg base / kg / day is considered the NOAEL for fetal developmental toxicity.

[0134] For the parent compound belusudil, the dose level of 50 mg base / kg / day corresponds to a decrease in the parent C max is 4360ng / mL, and the parent AUC0-24 is 33300ng·hr / mL; for KD025m1, the parent C max was 434 ng / mL and AUC0-24 was 4780 ng·hr / mL; and for KD025m2, the parent C max 350 ng / mL and AUC 0-24 The dose level of 15 mg base / kg / day was considered the NOAEL for maternal toxicity. For the parent compound belusudil, the dose level of 15 mg base / kg / day corresponds to a maternal C maxis 1320 ng / mL, and the parent AUC 0-24 is 11900ng·hr / mL; for KD025m1, the parent C max was 93.3 ng / mL and AUC 0-24 is 948ng·hr / mL; and for KD025m2, the parent C max was 55.6 ng / mL and AUC 0-24 It is 572ng·hr / mL. Example 4: Embryo-Fetal Developmental Toxicity Study with Toxicokinetic Evaluation in New Zealand White Rabbits

[0135] The purpose of this study is to determine the embryo-fetal developmental toxicity of berushudil in New Zealand white (NZW) rabbits, including teratogenic potential. The study also includes a toxicokinetic evaluation to determine the exposure / toxicity relationship of berushudil and metabolites (KD025m1 and KD025m2). From gestational day (GD) day 6 to day 18, vehicle (0.4% (w / w) methylcellulose (400cps) in distilled water) or berushudil was administered once a day to regularly mated female New Zealand white (NZW) rabbits via oral gavage. Using a standard randomization procedure of measurements by weight, 111 female animals (weighing 2.64 to 3.56kg, randomized) were assigned to the control group, treatment group, and TK group identified in Table 11 below.

[0136] The animals assigned to the study had a body weight within ± 20% of the mean body weight. The animals were housed individually in suspended stainless steel cages in an environmentally controlled room. Animal nutrition fortification was provided according to SOP. Fluorescent lighting was provided for approximately 12 hours per day. Due to the activity associated with the study, the dark cycle was interrupted intermittently. Temperature and humidity were monitored and recorded, and maintained within the range of 61 ° F-72 ° F and 30%-70% to the greatest extent possible. Food was provided from 08:00 to 12:00 in the morning starting on the second day of acclimatization and continued throughout the study. During the dosing period, food was provided 1.5 hours ± 30 minutes before dosing, and maintained until the next food provision as needed. Application

[0137] From GD 6 to 18, vehicle and berushedil were administered once daily via oral gavage at approximately the same time each day (at GD 6, ±2 hours from the first dose). The dose levels for the treatment groups were 50, 125, 225 mg base / kg / day, and the dose volume was 10 mL / kg. The control group received vehicle in the same manner as the treatment group. In addition, TK animals received vehicle or berushedil in the same manner as the main study group at the same dose level and volume. Before and throughout the dose administration period, the vehicle and berushedil formulations were continuously stirred at room temperature for at least 30 minutes. Individual doses were based on recent body weight. observe

[0138] Observations on the animals included clinical signs, body weight, food intake, and anatomical pathology including uterine examination. Toxicokinetic evaluations were performed for berushudil and metabolites (KD025m1 and KD025m2). External, visceral, and skeletal examinations were performed on all fetuses. Cage-side and clinical observation

[0139] All animals were observed by cage twice a day (for morbidity, death, injury). From GD 6 to 29 every day (4 hours ± 1 hour after administration on the administration day), each main research animal was removed from the cage and a detailed clinical examination was given. Sometimes, clinical observations were recorded at irregular intervals. The observations included, but were not limited to, the evaluation of skin, fur, eyes, ears, nose, oral cavity, chest, abdomen, external genitalia, limbs and feet, and the evaluation of breathing. Two animals aborted at GD 19, each at 125 and 225 mg alkali / kg / day (animal numbers were 251 and 282, respectively). Another animal death at 225 mg alkali / kg / day was found at GD 9. These events were considered to be undesirable and were relevant to treatment.

[0140] In the 225mg alkali / kg / day group, see the clinical findings of body emaciation, and may be relevant to the reduction seen in weight gain and food intake data, which are considered to be treatment-related and bad. For two animals that aborted at 125 and 225mg alkali / kg / day respectively, red material was seen in the cage tray, and it was considered that its abortion was treatment-related and bad (referring to the previous part). Maternal survival and pregnancy status are summarized in the following table 12. Clinical observations are summarized in the following table 13. *Number of observations / total number of animals affected. weight.

[0141] The body weights of all animals were measured and recorded at GD 0, 6, 10, 13, 16, 19, 21, 25 and 29. Individual body weight changes were calculated for the following GD intervals: 0-6, 6-10, 10-13, 13-16, 16-19, 19-21, 21-25, 25-29, 6-19, 19-29 and 0-29. Adjusted body weight (GD 29 body weight minus gestational uterine weight) and adjusted body weight change (GD 0 to 29) were also calculated. Individual body weight values ​​for TK animals were recorded.

[0142] No adverse treatment-related effects were seen in the body weight data (mean body weight and mean body weight change) at 50 mg base / kg / day. On GD 19, at 125 mg base / kg / day, there were no statistically significant differences and the largest percentage difference (-5.1%) when comparing mean body weight values ​​to the control group.

[0143] However, during the treatment period with 125 mg base / kg / day, there was a trend toward a decrease in mean weight gain. The following differences were statistically significant; mean weight loss occurred from GD 6-10, and mean weight gain decreased from GD 13-16, resulting in an overall decrease in mean weight gain during the treatment period (GD 6-19). After the treatment period at 125 mg base / kg / day, mean weight gain increased with statistical significance from GD 25-29, resulting in an overall mean weight gain from GD 19-29 after treatment.

[0144] For the entire study period (GD 0-29), the weight gain at 125 mg base / kg / day remained reduced compared to the corresponding control values; the difference from the control group was -8.6%. At 225 mg base / kg / day, the mean body weight decreased with statistical significance throughout the treatment period and initially after the treatment period (GD 10, 13, 16, 19, and 21); the difference from the control group ranged from -6.3% to -9.2%. When evaluating the mean body weight changes at 225 mg base / kg / day, the following differences were statistically significant; mean weight loss occurred from GD 6-10, and mean weight gain decreased from GD 10-13 and GD 13-16, resulting in an overall mean weight loss for the treatment period (GD 6-19). However, there was a trend toward increased mean weight gain after treatment at 225 mg base / kg / day compared to the control group; the increased mean weight gain from GD 19-21 and GD 21-25 was statistically significant when compared to the control group, resulting in an overall increased mean weight for the post-treatment period (GD 19-29). For the entire study period (GD 0-29), weight gain at 225 mg base / kg / day remained reduced (statistically significant); the difference from the control group was -24.2%.

[0145] For the entire treatment period, there was a trend toward decreased body weight gain at 125 and 225 mg base / kg / day, associated with decreased food intake, considered an adverse dose-related response to berushudil. The trend toward increased mean body weight gain and food intake following treatment with 125 and 225 mg base / kg / day was considered indicative of a rebound / recovery effect.

[0146] Maternal body weight and weight change are summarized in Tables 14 and 15 below: Food intake

[0147] When the food intake at 50 mg base / kg / day was compared to the control group for the entire treatment period GD 6-19, the percent difference was -8.8%. At 125 mg base / kg / day, food intake was reduced throughout the treatment period; the following differences were statistically significant; food intake was reduced from GD 6-10, 10-13, 13-16, and 16-19, resulting in reduced food intake throughout the treatment period (GD 6-19).

[0148] For the total treatment period (GD 6-19) at 125 mg base / kg / day, the percent difference from the control group was -34.1%. After the treatment period at 125 mg base / kg / day, food intake increased with statistical significance from GD 21-25 and GD 25-29, resulting in an overall increase in food intake from GD 19-29 after treatment. For the entire study period (GD 0-29), food intake at 125 mg base / kg / day remained reduced (statistically significant); the difference from the control group was -11.6%.

[0149]

[0136] At 225 mg base / kg / day, food intake was reduced throughout the treatment period; the following differences were statistically significant; food intake was reduced from GD 6-10, 10-13, 13-16, and 16-19, resulting in reduced food intake throughout the treatment period (GD 6-19). For the total treatment period (GD 6-19) at 225 mg base / kg / day, the percent difference from the control group was -49.7%. Following the treatment period at 225 mg base / kg / day, food intake increased statistically significantly from GD 21-25 and GD 25-29, resulting in an overall increase in food intake from GD 19-29 after treatment. Food intake remained reduced (statistically significant) at 225 mg base / kg / day for the entire study period (GD 0-29); the difference from the control group was -17.8%

[0150] For the entire treatment period, the trend toward decreased food intake (associated with decreased body weight gain) at 125 and 225 mg base / kg / day was considered an adverse dose-related response to berushudil treatment. The trend toward increased food intake and mean body weight gain following treatment with 125 and 225 mg base / kg / day was considered indicative of a rebound / recovery effect.

[0151] Maternal food intake is summarized in Table 16 below: Postmortem examination of the uterus, ovaries, and fetus

[0152] At GD 29, each surviving main research female was euthanized by intravenous injection of sodium pentobarbital / euthanasia solution, followed by SOP-approved methods to ensure death and immediate laparotomy hysterectomy. The skin was turned over from the ventral midline incision to examine the mammary tissue and locate any subcutaneous masses. The abdominal cavity was then opened and the uterus was exposed. The uterus was removed and the weight of the gestational uterus was recorded. Starting from the distal end of the left uterine horn, the position of the viable fetus and the fetus that could not survive, the early absorption and late absorption of each uterine horn, and the total number of implantations were recorded. The number of corpora lutea on each ovary was also recorded.

[0153] The fetuses were removed by making a dorsal incision longitudinally along both uterine horns. The embryonic membranes of each fetus were gently removed and each fetus was peeled away from the placenta, leaving the umbilical cord fully extended. The placenta was grossly inspected.

[0154] The apparently non-pregnant uteri from females were opened and placed in a 10% ammonium sulfide solution to detect implantation sites. If no lesions were detected, the female was considered not pregnant.

[0155] When the intrauterine values ​​were compared to those in the control group, no treatment-related adverse effects were evident at 50 mg base / kg / day.

[0156] The post-implantation loss rate (% / litter) at 125 and 225 mg base / kg / day was 7.42% and 17.72%, respectively, compared to 4.07% / litter in the control group. The dose-related increase in post-implantation loss rate (% / litter) at 125 and 225 mg base / kg / day, the corresponding increase in the mean number of resorbed (early and late combined), and the reduction in the mean number of viable fetuses / litters were considered treatment-related and adverse.

[0157] At 225 mg base / kg / day, the mean fetal weight of male fetuses was reduced (statistically significant), resulting in a reduction in the mean fetal weight for the combined sexes. The male fetal weight value (litter incidence) was 38.92 g compared to the control value of 42.05 g; a difference of -7.44% from the control group. The mean fetal weight for the combined sex at 225 mg base / kg / day was 38.60 g compared to the control value of 40.96 g; a difference of -5.76% from the concurrent control group. The mean fetal weight for the combined sex in the historical data was 41.426 g. The effect on mean fetal weight at 225 mg base / kg / day was considered treatment related and adverse.

[0158] In utero data are summarized below in Table 17. Fetal weight data are reported below in Table 18.

[0159] Fetal malformation brachytail (whole) occurred only at 225 mg base / kg / day and was considered an adverse treatment-related reaction. Five fetuses from two litters had this abnormality at 225 mg base / kg / day. The litter / fetus incidence was 10.5% / 3.2%, compared to 5.0% / 0.6% in historical data.

[0160] Fetal external malformations are summarized in Tables 19 and 20 below:

[0161] At 225 mg alkali / kg / day, fetal variant tail curvature (overall) was seen in two fetuses from one litter, where in addition to the coccygeal deformity seen in the skeletal examination, both fetuses also showed the above-mentioned short tail abnormality. In this study, the litter (fetus) incidence of this variant was 5.3% (1.3%), and the incidence in the historical data was 4.3% (0.5%), respectively. Considering the association correlation with the short tail abnormality, the incidence is considered to be treatment-related and undesirable.

[0162] The overall incidence of fetal visceral variations was increased at 125 and 225 mg base / kg / day compared to controls, however, there was no dose-related trend and they were generally limited in incidence and typical of those seen in the historical data. This included the fetal variation ureteral malposition, which was increased (per litter) with statistical significance at 125 mg base / kg / day (21.1% litter incidence) and 225 mg base / kg / day (26.3% litter incidence). However, in the historical data, the litter (fetus) incidence of ureteral malposition was 42.1% (7.7%), therefore, this variation was not considered an adverse treatment-related effect.

[0163] Fetal visceral observations are summarized in Table 21, and fetal skeletal malformations are reported in Table 22.

[0164] At 50, 125 and 225 mg alkali / kg / day, the total incidence of fetal skeletal malformations increased, however, there was no obvious dose-related trend at 50 and 125 mg alkali / kg / day. However, at 225 mg alkali / kg / day, there was a trend in the fetal skeletal data, whereby the total incidence of fetal skeletal malformations increased, and specific skeletal malformations increased, which were typically not only increased compared to the parallel control group, but also outside the range seen in the historical control data. The fetal skeletal findings that mainly caused an overall increase in abnormalities at 225 mg alkali / kg / day consisted of thoracic and thoracic vertebral deformities, including the following findings: one or more rib branches (statistically significant), fusion or shape deformity, one or more sternal fusions, and neural arch fusions, dislocations, and shape deformities (statistically significant). The findings of one or more rib branches occurred at a litter / fetal incidence of 21.2% (2.6%); the incidence in the historical data was 5.0% (0.5%). The finding of one or more fused ribs occurred at an incidence of 15.8% (2.6%) of the pars / fetus; the incidence in the historical data was 14.3% (1.7%). The finding of one or more malformed ribs occurred at an incidence of 15.8% (1.9%) of the pars / fetus; the incidence in the historical data was 5.9% (0.7%). The finding of one or more fused sternums occurred at an incidence of 31.6% (4.5%) of the pars / fetus; the incidence in the historical data was 26.1% (3.9%).

[0165] The finding of neural arch (thoracic) fusion occurred at an incidence of 10.5% (1.9%) of litters / fetuses; the incidence in the historical data was 9.5% (1.1%). The finding of neural arch (thoracic) malposition occurred at an incidence of 10.5% (1.3%) of litters / fetuses; the incidence in the historical data was 5.3% (0.6%). The finding of neural arch (thoracic) shape malformation occurred at an incidence of 21.1% (2.6%) of litters / fetuses; the incidence in the historical data was 9.5% (1.1%). These skeletal malformations observed at 225 mg base / kg / day are considered to be related to berushedil and adverse.

[0166] In addition, two fetal skeletal variations were increased (statistically significant) at 225 mg base / kg / day and are considered to be potentially adverse and treatment related. One of these findings was seen in one or more cervical vertebrae, divided into central, semi-central, which occurred at a litter / fetus incidence of 21.1% (2.6%); the incidence in the historical data was 5.3% (0.6%). Another fetal skeletal variation that was increased at 225 mg base / kg / day was the finding of one or more extra sternal segments, which occurred at a litter / fetus incidence of 21.1% (4.5%); the incidence in the historical data was 5.3% (1.5%). Maternal macroscopic observation

[0167] In the planned autopsy examination performed on GD 29, the maternal autopsy findings of the three animals that did not survive revealed the following. Two animals aborted on GD 19, each at 125 and 225 mg alkali / kg / day (animal numbers 251 and 282, respectively). The bladder and uterus of one subject (administered at 125 mg alkali / kg / day) contained mild / minimal red fluid, and another animal administered at 225 mg alkali / kg / day was found to have died on GD 9. The cause of death was not determined at autopsy; the adipose tissue of this animal was discolored yellow (moderate, icteric) and there were multiple red lesions on the thymus (mild). Death was considered an adverse treatment-related effect. Toxicokinetic analysis

[0168] Exposure to belusudil, KD025m1, and KD025m2 increased as belusudil dose levels increased from 50 mg base / kg to 225 mg base / kg. Mean C values ​​of belusudil, KD025m1, and KD025m2 in pregnant rabbits max The increase in values ​​was generally dose-proportional at GD 6 and GD 18, and AUC 0-24 The increase in AUC was greater than dose proportional at GD 6 and GD 18; however, at the 225 mg base / kg dose level, AUC 0-24 The AUC of GD18 0-24The values ​​are generally similar to the AUC at GD 6. 0-24 The values ​​were similar or lower than those in the control group, indicating that no significant accumulation of belusudil, KD025m1, and KD025m2 was observed after multiple administrations of belusudil in pregnant rabbits.

[0169] Average AUC 0-24 The metabolite to maternal ratios indicated that belusudil was converted to KD025m1 and KD025m2 in pregnant rabbits following oral gavage administration of belusudil. The metabolite to maternal ratios ranged from 0.344 to 0.820 and 0.652 to 1.98 for KD025m1 and KD025m2, respectively. The results of the TK analysis are reported in Table 23 below. result

[0170] When berushudil was administered to pregnant rabbits at 50, 125, and 225 mg base / kg / day from gestation day 6 to 18, maternal and developmental toxicity occurred at 125 and 225 mg base / kg / day. One animal was found to abort at each of 125 and 225 mg base / kg / day, and another animal died at 225 mg base / kg / day.

[0171] The effect on body weight and food intake during the treatment period with 125 and 225 mg alkali / kg / day is considered to be unfavorable and is relevant to the treatment of berushudil. The dose-related increase of post-implantation loss (consisting of early absorption and late absorption) and the reduction of surviving fetus / litter size at 125 and 225 mg alkali / kg / day are considered to be treatment-related and bad. The effect on fetal weight only occurs at 225 mg alkali / kg / day, and fetal examination data (external and skeleton) reveal that fetal development affects only at 225 mg alkali / kg / day. In short, the dosage level of 50 mg alkali / kg / day is considered to be the NOAEL of maternal and developmental toxicity.

[0172] For the parent compound belusudil, the dose level of 50 mg base / kg / day corresponded to a parent Cmax of 437 ng / mL and a parent AUC0-24 of 1590 ng·hr / mL at the end of the dosing regimen (GD 18); for KD025m1, the parent Cmax was 569 ng / mL and the AUC0-24 was 1220 ng·hr / mL; and for KD025m2, the parent Cmax was 1120 ng / mL and the AUC0-24 was 2470 ng·hr / mL. Example 5: Combined study of fertility and early embryonic development to implantation in Sprague-Dawley rats Study objectives and design

[0173] This study was conducted to determine the effects of berushudil on the female estrous cycle, oviductal transit, embryo implantation and development, and to examine functional effects on male fertility. The study design used naive animals of both sexes, combined treatments for both sexes, and provided a recovery period for treated males based on study outcomes. The study also included a toxicokinetic evaluation to determine the exposure / toxicity relationship.

[0174] Male and female Sprague-Dawley (SD) rats were obtained from Charles River Laboratories in Raleigh, North Carolina (approximately 7 to 10 weeks old). Using standard randomization procedures by weight, 273 male and 273 female animals (weighing 229g to 497g and 169g to 242g, randomization) were assigned to control group, treatment group and toxicokinetics (TK) group. The group design of this study is shown in Table 24. The dose volume of each group is 10mL / kg, providing a dose concentration in mg / base / mL of one-tenth dose level). (In Table 24, T=treatment; U=untreated).

[0175] All animals were given a detailed clinical examination before selection, and body weights were recorded at receipt and before selection. In addition, males assigned to groups 5-8 were given detailed clinical observations weekly, and body weights were recorded weekly during the acclimatization period.

[0176] Animals were housed individually in solid-bottom cages with non-scented bedding in an environmentally controlled room, except during the pairing period. During the pairing period, rats (one male and one female from the corresponding group) were cohabited in the male's cage. During the acclimatization period, animals were observed twice daily for general health and any signs of illness. Application

[0177] Vehicle and berushedil were administered once daily to all treated animals in the morning at approximately the same time each day (±2 hours from dosing on day 1) via oral gavage at dose levels of 0, 50, 150 and 275 mg base / kg / day and a dose volume of 10 mL / kg. The high dose level (275 mg base / kg / day) provides the opportunity to have some mild toxicity and allows the evaluation of fertility and early embryonic development toxicity at an exposure level approximately 4 times higher than the expected maximum steady-state clinical exposure. The selected low dose level (50 mg base / kg / day) and medium dose level (150 mg base / kg / day) are intended to demonstrate a dose-dependent response and are expected to be clinically relevant (approximately 0.5 to 1 and 2 times the expected maximum steady-state clinical exposure, respectively).

[0178] For treated males, dosing was started at 11 weeks of age and 70 days before pairing (with untreated females), and for treated females, dosing was started 14 days before pairing (with untreated males). Dosing for males continued through the mating period and the post-mating period to euthanasia, while dosing for females continued through the mating period to GD 7. After the mating period was completed, females with no signs of mating were dosed for 7 days. Males designated for the recovery period were dosed for 70 days and then received a 77-day recovery period.

[0179] In addition, TK animals received vehicle or belusudil in the same manner as the main study group at the same dose level and volume. Male and female TK animals were dosed for 70 days and 14 days, respectively. Dosing for TK males and females was started at the same time and continued until euthanasia. Before dosing, frozen daily aliquots of the dosing formulation were placed at room temperature while stirring continuously for at least 30 minutes. The vehicle and belusudil formulations were stirred continuously before and throughout the dosing period. Individual doses were based on recent body weight. Observation and analysis

[0180] Animals were observed cage-side for detailed clinical changes, body weight, food intake, estrous cycle determination, plasma analysis, sperm analysis, toxicokinetic analysis, and anatomical pathology, including uterine and ovarian examination.

[0181] Cage observations were performed at least twice daily. All animals were observed for morbidity, mortality, injuries, and availability of food and water.

[0182] Detailed clinical observations were performed during the treatment phase: for males, twice a week during the treatment period (4 hours + / - 1 hour on the dosing day), and for females, daily during the treatment period (4 hours + / - 1 hour on the dosing day). During the non-treatment phase (males and females), detailed clinical observations were performed weekly and also on GD 13 before regular uterine examinations (females). The observations included, but were not limited to, evaluations of the skin, fur, eyes, ears, nose, mouth, chest, abdomen, external genitalia, limbs and feet, and evaluations of respiration.

[0183] For each endpoint, the treatment group was compared to the control group using the analyses listed in Table 25. Data for some endpoints were transformed by arcsine square root transformation prior to the specified analysis, as indicated. Toxicokinetic analysis

[0184] A total of 402 samples of belusudil, 402 samples of KD025m1, and 402 samples of KD025m2 were analyzed using protein precipitation followed by high performance liquid chromatography followed by tandem mass spectrometry detection (LC-MS / MS).Exposure to belusudil increased as dose levels increased from 50 mg base / kg / day to 275 mg base / kg / day.

[0185] C max Value and AUC 0-24 The increase in values ​​was generally less than dose-proportional for females on Day 1 and approximately dose-proportional for males on Day 1, and approximately dose-proportional on Day 14 and Day 70 for females and males, respectively. max Value and AUC 0-24 The sex differences in values ​​were less than 2-fold, with the exception of Day 1 Group 14 (50 mg base / kg / day), where the corresponding values ​​for females were approximately 2.10- and 2.44-fold, respectively, of those for males. 0-24 The cumulative ratios for females ranged from 0.533 to 1.72 on day 14 and for males ranged from 0.859 to 1.98 on day 70. The data are summarized in Table 26.

[0186] The exposure of KD025m1 increased with increasing belusudil dose levels from 50 mg base / kg / day to 275 mg base / kg / day. At dose levels between 50 mg base / kg / day and 150 mg base / kg / day, the exposure of male C max Value and AUC 0-24 The increase in values ​​was less than dose proportional and approximately dose proportional at dose levels between 150 mg base / kg / day and 275 mg base / kg / day.

[0187] Female C max Value and AUC 0-24 The increase in values ​​was roughly proportional to the dose. max Value and AUC 0-24 The sex difference in values ​​was less than 2-fold, with the exception of Group 14 (50 mg base / kg / day), where the corresponding values ​​for males were approximately 2.10 to 2.62 times those for females. 0-24 The cumulative ratios for females ranged from 0.738 to 1.49 on day 14 and for males ranged from 0.634 to 1.24 on day 70. 0-24 The metabolite to parent ratio ranged from 0.102 to 0.520. The data are summarized in Table 27.

[0188] The exposure of KD025m2 increased with increasing belusudil dose levels from 50 mg base / kg / day to 275 mg base / kg / day. At dose levels between 50 mg base / kg / day and 150 mg base / kg / day, C max Value and AUC 0-24 The increase in values ​​was less than dose proportional and approximately dose proportional at dose levels between 150 mg base / kg / day and 275 mg base / kg / day.

[0189] Female C max Value and AUC 0-24 The increase in values ​​was generally dose-proportional on day 1 and greater than dose-proportional on day 14. KD025m2 C max Value and AUC 0-24 Sex differences in values ​​were generally less than 2-fold, with the exception of Group 14 (50 mg base / kg / day), where the corresponding values ​​for males were approximately 2.58 to 3.70 times those for females. No significant accumulation (<2-fold) of KD025m2 was observed following multiple administration of belusudil in rats. AUC 0-24 The cumulative ratios for females ranged from 0.657 to 1.80 on day 14 and for males ranged from 0.701 to 1.35 on day 70. For AUC 0-24 The metabolite to parent ratio ranged from 0.0429 to 0.270. The data are summarized in Table 28.

[0190] In this fertility and early embryonic development toxicity study with berushudil, effects were observed at 150 and 275 mg base / kg / day in treated males and females.

[0191] In treated females, adverse clinical observations of abnormal stools (little / none or discolored) and emaciated body condition were observed at 275 mg base / kg / day.

[0192] In addition, at 150 and 275 mg base / kg / day, females had lower mean body weight, mean body weight change, and reduced mean food intake throughout the treatment period and were considered to be related to belusudil and undesirable. At 50 mg base / kg / day, lower mean body weight and / or body weight change and reduced food intake were also observed in females. These differences at 50 mg base / kg / day (although possibly related to belusudil) were in fact incidental, minor, and not considered undesirable.

[0193] At 275 mg base / kg / day, in the treated females, belusudil-related increases in average post-implantation loss and average absorption number were observed, and were associated with a lower average number of viable embryos. At 50 and 150 mg base / kg / day, ovarian and uterine parameters (corpus luteum counts, implantation sites, viable embryos and absorption numbers, and pre-implantation and post-implantation losses) were not affected by belusudil treatment. The reproductive and fertility indexes of the treated females were not affected at all dose levels evaluated. In the treated females, no belusudil-related macroscopic findings or organ weight differences were observed.

[0194] In treated males, at 275 mg base / kg / day, adverse clinical observations of abnormal stools (little / none) and emaciated body condition were observed. In males, salivation was observed at 275 and 150 mg base / kg / day, and although possibly related to belusudil, this finding was not dose responsive, was in fact sporadic, and therefore was not considered adverse. In addition, at 150 and 275 mg base / kg / day, males had lower mean body weights, mean body weight changes, and reduced mean food intake throughout the treatment period, and were considered to be related to belusudil and adverse.

[0195] During the recovery period, most of these findings decreased in frequency at 150 and 275 mg base / kg / day, indicating reversibility of toxicity. Lower mean body weights and / or body weight changes and reduced food intake were also observed in males at 50 mg base / kg / day. These differences at 50 mg base / kg / day (although possibly related to belusudil) were in fact incidental, minor in degree, and not considered adverse.

[0196] At 275 mg base / kg / day, the fertility and fecundity indices of treated males were low (72% and 75%, respectively) and were considered to be belusudil related and adverse. During the recovery phase, no effects were seen in the reproductive and fecundity indices (mating, fertility and fecundity parameters) at 275 mg base / kg / day. At 50 and 150 mg base / kg / day, the reproductive and fecundity indices were not affected by belusudil treatment.

[0197] At 275mg alkali / kg / day, in untreated females (25 untreated females mated with treated males), there are 6 unpregnant untreated females, and the average number of implantation sites and the average number of viable embryos are reduced. These differences in pregnancy outcomes and uterine parameters at 275mg alkali / kg / day are considered to be related to the abnormal sperm evaluation (low motility, low average sperm count and increased abnormal sperm percentage) observed in the males treated, and are considered to be related to belusudil and bad. In the males treated with 275mg / kg / day, during the recovery period, reproduction, fertility and sperm parameters were not affected. Male reproduction and fertility parameters were not affected at 50 and 150mg alkali / kg / day.

[0198] At 275 mg / kg / dose, berushedil-related macroscopic observations of small testes (left and right) and epididymis (left, right and right tail) were observed at terminal and recovery necropsy, and correlated with reduced mean organ weights (absolute). In addition, at 275 mg / kg / day, testes (minimal to severe degeneration / atrophy) and epididymis (minimal to mild luminal cell debris) were noted in approximately 64% and 68% of terminal males, respectively; while at recovery necropsy, the percentages of treated males in which these findings were observed were approximately 30% and 40%, respectively. Macroscopic findings, organ weights, and microscopic findings were not affected by treatment at 50 and 150 mg base / kg / day.

[0199] Exposure as assessed by berushudil and its metabolites KD025m1 and KD025m2 max Value and AUC 0-24 The values ​​increased as the belusudil dose level increased from 50 mg base / kg / day to 275 mg base / kg / day. max Value and AUC 0-24 The increase in values ​​was generally less than dose proportional on Day 1 for females and approximately dose proportional on Day 1 for males, and approximately dose proportional on Days 14 and 70 for both males and females.

[0200] At dose levels between 50 mg base / kg / day and 150 mg base / kg / day, KD025m1 and KD025m2C in males max Value and AUC 0-24 The increase in values ​​was less than dose proportional and was approximately dose proportional at dose levels between 150 mg base / kg / day and 275 mg base / kg / day. KD025m1 and KD025m2 C in females max Value and AUC 0-24 The increase in values ​​was roughly dose proportional, with the following exception: KD025m2 on Day 14, where the increase was greater than dose proportional.

[0201] Belushudil C max Value and AUC 0-24 The sex differences in values ​​were less than 2-fold, with the exception of Day 1 Group 14 (50 mg base / kg / day), where the corresponding values ​​for females were approximately 2.10 and 2.44 times those for males, respectively.

[0202] KD025m1 and KD025m2 C max Value and AUC 0-24 Sex differences in values ​​were generally less than 2-fold, with the exception of Group 14 (50 mg base / kg / day), where the corresponding values ​​for males were approximately 2.10 to 3.70 times those for females.

[0203] For AUC of KD025m1 0-24 The metabolite to parent ratio ranged from 0.102 to 0.520. For KD025m2, the AUC 0-24 , metabolite-to-parent ratios ranged from 0.0429 to 0.270.

[0204] Based on these results, the NOAEL for the general toxicity endpoint was considered to be 50 mg base / kg / day [AUC 0-24 21600 ng·hr / mL (male) and 26200 ng·hr / mL (female) and C max 2480ng / mL (male) and 3200ng / mL (female)].

[0205] For male and female reproductive performance and fertility, the NOAEL is considered to be 150 mg base / kg / day and 275 mg base / kg / day, respectively [AUC 0-24 is 70100ng·hr / mL and C max is 10100 ng / mL (male), and AUC 0-24 is 209000ng·hr / mL and C max is 14900ng / mL (female)].

[0206] In treated females, the NOAEL for ovarian and uterine parameters was considered to be 150 mg base / kg / day (AUC 0-24 is 99500ng·hr / mL and C max is 9860ng / mL). Example 6: US REZUROCK TM (Berushudil) FDA label

[0207] ---------------------------Indications and Usage--------------------------

[0208] REZUROCK is a kinase inhibitor indicated for the treatment of adult and pediatric patients 12 years of age and older with chronic graft-versus-host disease (chronic GVHD) after failure of at least two prior lines of systemic therapy.(1)

[0209] -----------------------Dosage and Administration----------------------

[0210] Recommended dose: 200 mg orally once daily with food. (2.1)

[0211] ---------------------Dosage form and strength--------------------

[0212] Tablet: 200 mg. (3)

[0213] ------------------------------Contraindications----------------------------

[0214] None. (4)

[0215] ------------------------------------Warnings and precautions----------------------

[0216] Embryo-Fetal Toxicity: May cause fetal harm. Inform females of reproductive potential of the potential risk to a fetus and use effective contraception. (5.1, 8.1, 8.3)

[0217] ---------------------------Drug Interactions------------------------------

[0218] Strong CYP3A inducers: Increase REZUROCK dose to 200 mg twice daily. (7.1)

[0219] Proton Pump Inhibitors: Increase the dose of REZUROCK to 200 mg twice daily. (7.1)

[0220] ------------------------------Adverse Reactions-----------------------------

[0221] The most common (≥20%) adverse reactions (including laboratory abnormalities) were infections, asthenia, nausea, diarrhea, dyspnea, cough, edema, hemorrhage, abdominal pain, musculoskeletal pain, headache, decreased phosphate, increased gamma-glutamyl transferase, lymphocytopenia, and hypertension. (6.1)

[0222] -----------------------Medication for special groups-----------------------

[0223] Lactation: Breastfeeding is not recommended. (8.2)

[0224] See 17 for patient counseling information and FDA-approved patient labeling. Full Prescribing Information 1 Indications and Usage

[0225] REZUROCK is indicated for the treatment of adult and pediatric patients 12 years of age and older with chronic graft-versus-host disease (chronic GVHD) after failure of at least two prior lines of systemic therapy. 2 Dosage and administration 2.1 Recommended Dosage

[0226] The recommended dose of REZUROCK is 200 mg, given orally once daily until chronic GVHD progresses requiring new systemic therapy.

[0227] Instruct patients as follows: Swallow REZUROCK tablets whole. Do not cut, crush, or chew the tablets. Take REZUROCK with food at approximately the same time each day [see Clinical Pharmacology (12.3)]. If a dose of REZUROCK is missed, instruct patients not to take an additional dose to make up for the missed dose.

[0228] Treatment with REZUROCK has not been studied in patients with pre-existing severe renal or hepatic impairment. For patients with pre-existing severe renal or hepatic impairment, consider the risks and potential benefits before initiating treatment with REZUROCK [see Clinical Pharmacology (12.3)]. 2.2 Dose Modification for Adverse Reactions

[0229] Monitor total bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) at least monthly.Modify the dose of REZUROCK for adverse reactions according to Table 29.

[0230] Table 29: Recommended Dose Modifications of REZUROCK for Adverse Reactions *Based on CTCAE v 4.03 2.3 Dose Modifications Due to Drug Interactions

[0231] Strong CYP3A inducers

[0232] When coadministered with strong CYP3A inducers, increase the dose of REZUROCK to 200 mg twice daily [see Drug Interactions (7.1)].

[0233] Proton pump inhibitors

[0234] When co-administered with a proton pump inhibitor, increase the dose of REZUROCK to 200 mg twice daily [see Drug Interactions (7.1)]. 3 Dosage forms and specifications

[0235] Each 200 mg tablet is a light yellow film-coated oval tablet with "KDM" debossed on one side and "200" debossed on the other side. 4 Contraindications

[0236] none. 5 Warnings and Precautions 5.1 Embryo-Fetal Toxicity

[0237] Based on findings in animals and its mechanism of action, REZUROCK may cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of berushedil to pregnant rats and rabbits during the period of organogenesis produced adverse developmental outcomes, including embryo-fetal mortality and malformations at maternal exposures (AUC) lower than those in patients at the recommended dose. Inform pregnant women of the potential risk to a fetus. Advise females of reproductive potential and males with female partners of reproductive potential to use effective contraception during treatment with REZUROCK and for at least one week after the last dose [see Use in Specific Populations (8.1, 8.3), Nonclinical Toxicology (13.1)]. 6 Adverse Reactions 6.1 Clinical Trial Experience

[0238] Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

[0239] Chronic graft-versus-host disease

[0240] In two clinical trials (Study KD025-213 and Study KD025-208), 83 adult patients with chronic GVHD were treated with REZUROCK 200 mg once daily [see Clinical Studies (14.1)]. The median duration of treatment was 9.2 months (range, 0.5 to 44.7 months).

[0241] One patient reported fatal adverse reactions, including severe nausea, vomiting, diarrhea, and multi-organ failure.

[0242] Permanent discontinuation of REZUROCK due to adverse reactions occurred in 18% of patients. Adverse reactions leading to permanent discontinuation of REZUROCK in >3% of patients included nausea (4%). Adverse reactions leading to dose interruptions occurred in 29% of patients. Adverse reactions leading to dose interruptions in ≥2% were infections (11%), diarrhea (4%), and asthenia, dyspnea, hemorrhage, hypotension, abnormal liver function tests, nausea, pyrexia, edema, and renal failure (2% each).

[0243] The most common (≥20%) adverse reactions (including laboratory abnormalities) were infections, asthenia, nausea, diarrhea, dyspnea, cough, edema, hemorrhage, abdominal pain, musculoskeletal pain, headache, decreased phosphate, increased gamma-glutamyl transferase, lymphocytopenia, and hypertension.

[0244] Table 30 summarizes the non-laboratory adverse reactions.

[0245] Table 30: Non-Laboratory Adverse Reactions in ≥10% of Patients with Chronic GVHD Treated with REZUROCK aInfection by unspecified pathogens, including acute sinusitis, device-related infection, ear infection, folliculitis, gastroenteritis, gastrointestinal infection, hordeolum, infectious colitis, lung infection, skin infection, dental infection, urinary tract infection, wound infection, upper respiratory tract infection, pneumonia, conjunctivitis, sinusitis, respiratory tract infection, bronchitis, sepsis, and septic shock. bIncludes influenza, rhinovirus infection, gastroenteritis virus, viral upper respiratory tract infection, bronchitis virus, Epstein-Barr viremia, Epstein-Barr virus infection, parainfluenza virus infection, varicella-zoster virus infection, and viral infection. c Includes cellulitis, Helicobacter infection, Staphylococcal bacteremia, catheter site cellulitis, Clostridium difficile colitis, Escherichia coli urinary tract infection, Escherichia coli gastroenteritis, Pseudomonas infection, and bacterial urinary tract infection. dIncludes fatigue, weakness, and asthenia. eIncludes peripheral edema, systemic edema, facial edema, local edema, and edema. fIncluding nausea and vomiting. gIncludes abdominal pain, upper abdominal pain, and lower abdominal pain. hIncludes dyspnea, dyspnea on exertion, apnea, orthopnea, and sleep apnea syndrome. iIncluding cough and wet cough. jIncludes contusions, hematomas, epistaxis, increased tendency to bruise, conjunctival hemorrhage, hematochezia, oral hemorrhage, catheter site bleeding, hematuria, hemothorax, and purpura. kIncludes extremity pain, back pain, flank pain, extremity discomfort, musculoskeletal chest pain, neck pain, musculoskeletal pain. lIncluding headaches and migraines. mIncludes rash, maculopapular rash, erythematous rash, systemic rash, and exfoliative dermatitis. nIncluding itching and itching all over the body.

[0246] Laboratory abnormalities for REZUROCK are summarized in Table 31.

[0247] Table 31: Selected Laboratory Abnormalities in Patients with Chronic GVHD Treated with REZUROCK 7. Drug Interactions 7.1 Effects of Other Drugs on REZUROCK

[0248] Strong CYP3A inducers

[0249] Coadministration of REZUROCK with strong CYP3A inducers decreases berushedil exposure [see Clinical Pharmacology (12.3)], which may reduce the efficacy of REZUROCK. Increase the dose of REZUROCK when coadministered with strong CYP3A inducers [see Dosage and Administration (2.3)].

[0250] Proton pump inhibitors

[0251] Coadministration of REZUROCK with proton pump inhibitors decreases berushedil exposure [see Clinical Pharmacology (12.3)], which may reduce the efficacy of REZUROCK. Increase the dose of REZUROCK when coadministered with proton pump inhibitors [see Dosage and Administration (2.3)]. 8 Medication for special groups 8.1 Pregnancy

[0252] Risk Overview

[0253] Based on findings from animal studies and the mechanism of action [see Clinical Pharmacology (12.1)], REZUROCK may cause fetal harm when administered to a pregnant woman. There are no available human data on the use of REZUROCK in pregnant women to evaluate the drug-associated risk. In animal reproduction studies, administration of berushedil to pregnant rats and rabbits during the period of organogenesis produced adverse developmental outcomes, including growth alterations, embryo-fetal mortality, and embryo-fetal malformations at maternal exposures (AUC) that were approximately ≥3 times (rats) and ≥0.07 times (rabbits) the human exposure (AUC) at the recommended dose (see Animal Data). Inform pregnant women and females of reproductive potential of the potential risk to a fetus.

[0254] In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies are 2% to 4% and 15% to 20%, respectively.

[0255] data

[0256] Animal data

[0257] Embryo-fetal development studies were conducted in rats, where belusudil was administered to pregnant animals at oral doses of 25, 50, 150 and 300 mg / kg / day during the organogenesis period in preliminary studies, and belusudil was administered to pregnant animals at doses of 15, 50 and 150 mg / kg / day in key studies. In preliminary studies, maternal toxicity and embryo-fetal development effects were observed. Maternal toxicity (reduced weight gain) occurred at doses of 150 and 300 mg / kg / day. Post-implantation loss increased at 50 and 300 mg / kg / day. Fetal malformations were observed at ≥50 mg / kg / day, including the absence of anus and tail, umbilical hernia and dome-shaped head. The exposure (AUC) of rats at 50 mg / kg / day was approximately 3 times that of humans at the recommended dose of 200 mg.

[0258] In the embryo-fetal development study of rabbits, oral doses of berushudil were administered to pregnant animals at 50, 125 and 225 mg / kg / day during the organogenesis period, resulting in maternal toxicity and embryo-fetal development effects. Maternal toxicity (weight loss and death) was observed at a dose of ≥125 mg / kg / day. Embryo-fetal effects, including spontaneous abortion, increased post-implantation loss, reduced percentage of live fetuses, malformations and fetal weight loss, were observed at a dose of ≥50 mg / kg / day. Malformations included the following malformations: tail (short), ribs (branched, fused or deformed), sternum (fused) and neural arches (fused, dislocated and deformed). The exposure (AUC) of rabbits at 50 mg / kg / day was approximately 0.07 times that of humans at the recommended dose of 200 mg. 8.2 Lactation

[0259] Risk Overview

[0260] There are no data on the presence of berushudil or its metabolites in human milk or on the effects on the breastfed child or milk production. Because berushudil may cause serious adverse reactions in the breastfed child, advise lactating women not to breastfeed during treatment with REZUROCK and for at least one week after the last dose.

[0261] 8.3 Females and Males of Reproductive Potential

[0262] REZUROCK may cause fetal harm when administered to a pregnant woman [see Use in Specific Populations (8.1)].

[0263] Pregnancy test

[0264] Verify the pregnancy status of females of reproductive potential prior to initiating treatment with REZUROCK.

[0265] contraception

[0266] female

[0267] Advise females of reproductive potential to use effective contraception during treatment with REZUROCK and for at least one week after the last dose of REZUROCK. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus.

[0268] male

[0269] Advise males with female partners of reproductive potential to use effective contraception during treatment with REZUROCK and for at least one week after the last dose of REZUROCK.

[0270] Infertility

[0271] female

[0272] Based on findings in rats, REZUROCK may impair female fertility. The effects on fertility were reversible [see Nonclinical Toxicology (13.1)].

[0273] male

[0274] Based on findings in rats and dogs, REZUROCK may impair male fertility. The effects on fertility were reversible [see Nonclinical Toxicology (13.1)]. 8.4 Pediatric Use

[0275] The safety and effectiveness of REZUROCK have been established in pediatric patients older than 12 years. The use of REZUROCK in this age group is supported by evidence from adequate and rigorously controlled studies of REZUROCK in adults, in which additional population pharmacokinetic data demonstrated that age and body weight have no clinically meaningful effects on the pharmacokinetics of the drug substance, that exposure to the drug substance is expected to be similar between adults and pediatric patients older than 12 years, and that the course of disease is sufficiently similar in adults and pediatric patients to allow extrapolation of adult data to pediatric patients.

[0276] The safety and effectiveness of REZUROCK have not been established in pediatric patients less than 12 years of age. 8.5 Elderly Use

[0277] Of the 186 patients with chronic GVHD in the REZUROCK clinical study, 26% were 65 years of age or older. No clinically meaningful differences in the safety or effectiveness of REZUROCK were observed compared to younger patients. 11. Description

[0278] Belushudil is a kinase inhibitor. The active pharmaceutical ingredient is belushudil mesylate, with a molecular formula of C27H28N6O5S and a molecular weight of 548.62 g / mol. The chemical name of belushudil mesylate is 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide mesylate (1:1). The chemical structure is as follows:

[0279] Berushudil mesylate is a yellow powder that is practically insoluble in water, slightly soluble in methanol and DMF, and soluble in DMSO.

[0280] REZUROCK tablets are for oral administration. Each tablet contains 200 mg of free base, equivalent to 242.5 mg of berushudil mesylate. The tablets also contain the following inactive ingredients: microcrystalline cellulose, hypromellose, croscarmellose sodium, colloidal silicon dioxide, and magnesium stearate.

[0281] The tablet film consists of polyvinyl alcohol, polyethylene glycol, talc, titanium dioxide and yellow iron oxide. 12 Clinical Pharmacology 12.1 Mechanism of Action

[0282] Berushudil is an inhibitor of rho-associated coiled-coil-containing protein kinase (ROCK), which inhibits ROCK2 and ROCK1 with IC50 values ​​of approximately 100 nM and 3 μM, respectively. Berushudil downregulates proinflammatory responses in ex vivo or in vitro human T cell assays by modulating STAT3 / STAT5 phosphorylation and altering the Th17 / Treg balance. In vitro, berushudil also inhibits aberrant profibrotic signaling. In vivo, berushudil exhibits activity in animal models of chronic GVHD. 12.2 Pharmacodynamics

[0283] The exposure-response relationship and time course of the pharmacodynamic response to berushudil have not been determined. 12.3 Pharmacokinetics

[0284] Unless otherwise specified, the following pharmacokinetic parameters are presented for chronic GVHD patients administered 200 mg of belusudil once daily. Mean (coefficient of variation, CV%) steady-state AUC and C max They were 22700 (48%) h·ng / mL and 2390 (44%) ng / mL respectively. max The AUC and AUC increased in a roughly proportional manner over the dose range of 200 and 400 mg (1 to 2 times daily recommended doses). The accumulation ratio of berushedil was 1.4.

[0285] absorb

[0286] The median T of berushudil at steady state was 2.3 % after once-daily or twice-daily administration of 200 mg in patients. max The mean (CV%) bioavailability of belusudil after a single dose in healthy subjects was 64% (17%).

[0287] Effects of food

[0288] In healthy subjects, belushudil C increased significantly after administration of a single belushudil dose with a high-fat and high-calorie meal (800 to 1,000 calories, with approximately 50% of the total meal calories coming from fat) compared to the fasting state. max The AUC and AUC increased by 2.2-fold and 2-fold, respectively. The median Tmax was delayed by 0.5 hours.

[0289] distributed

[0290] Following administration of a single dose of berushudil in healthy subjects, the geometric mean volume of distribution was 184 L (geoCV% 67.7%).

[0291] In vitro, berushudil binds to human serum albumin and human α1-acid glycoprotein at 99.9% and 98.6%, respectively.

[0292] eliminate

[0293] In patients, the mean (CV%) elimination half-life of berushudil was 19 hours (39%) and the clearance was 9.83 L / hour (46%).

[0294] metabolism

[0295] In vitro, berushudil is metabolized primarily by CYP3A4 and, to a lesser extent, by CYP2C8, CYP2D6, and UGT1A9.

[0296] excretion

[0297] Following a single oral dose of radiolabeled berushedil in healthy subjects, 85% of the radioactivity was recovered in the feces (30% unchanged) and less than 5% in the urine.

[0298] Special groups

[0299] The age (18 to 77 years), sex, weight (38.6 to 143 kg), or mild to moderate renal impairment (eGFR ≥ 60 and < 90 mL / min / 1.72 m 2 To eGFR ≥ 30 and < 60 mL / min / 1.72 m 2 ), no clinically significant differences in the pharmacokinetics of belushudil were observed. The effect of severe renal impairment on the pharmacokinetics of belushudil has not been studied.

[0300] Drug interaction studies

[0301] The impact of other drugs on clinical studies of berushudil and model-guided approaches

[0302] Strong Cytochrome P450 (CYP) 3A Inhibitors: There were no clinically meaningful effects on berushedil exposure when co-administered with itraconazole in healthy subjects.

[0303] Strong CYP3A inducers: In healthy subjects, co-administration of rifampin increased the risk of berushudil C max The decrease was 59% and the AUC was reduced by 72%.

[0304] Moderate CYP3A inducers: In healthy subjects, co-administration of efavirenz is expected to increase the risk of berushedil C max The decrease was 32% and the AUC was reduced by 35%.

[0305] Proton pump inhibitors: In healthy subjects, co-administration of rabeprazole increased the max The C of belushudil was decreased by 87% and AUC by 80%, and omeprazole decreased the max The decrease was 68% and the AUC was reduced by 47%.

[0306] Effects of Berushudil on other drugs

[0307] CYP3A Substrates: Coadministration of berushudil is expected to increase the sensitivity of midazolam, a sensitive CYP3A substrate, to C max and AUC increased by approximately 1.3-fold and 1.5-fold, respectively.

[0308] CYP2C9 Substrates: Co-administration of berushudil is not expected to have a clinically meaningful effect on the exposure of CYP2C9 substrates, such as warfarin.

[0309] CYP2C8 Substrates: Co-administration of berushudil is not expected to have a clinically meaningful effect on the exposure of CYP2C8 substrates that are not OATP1B1 substrates.

[0310] In vitro studies

[0311] Transporter systems: Berushudil is a substrate of P-gp. Berushudil inhibits BCRP, P-gp, and OATP1B1 at clinically relevant concentrations.

[0312] Enzyme systems: Berushudil is an inhibitor of CYP1A2, CYP2C19, CYP2D6, UGT1A1, and UGT1A9. 13 Nonclinical Toxicology 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

[0313] Carcinogenicity studies have not been conducted with berushudil.

[0314] Berushudil was not genotoxic in the in vitro bacterial mutagenicity (Ames) assay, the in vitro chromosome aberration assay in human peripheral blood lymphocytes (HPBL), or the in vivo rat bone marrow micronucleus assay.

[0315] In a combined male and female rat fertility study, male animals treated with belusudil were mated with untreated female animals, or untreated male animals were mated with female animals treated with belusudil. Belusudil was orally administered to male rats at a dosage of 50, 150 or 275 mg / kg / day 70 days before mating and throughout the mating period, and was orally administered to female rats 14 days before mating and until the 7th day of gestation. At a dosage of 275 mg / kg / day, adverse findings in female rats (treated or untreated with belusudil but mated with treated males) included increased loss before or after implantation and reduced number of surviving embryos. Belusudil was administered to male rats at a dosage of 275 mg / kg / day, resulting in the discovery of sperm abnormalities (reduced motility, decreased counts, and increased percentages of abnormal sperm) and testicular / epididymal organ changes (weight loss and degeneration).

[0316] At a dose of 275 mg / kg / day, fertility was reduced in both treated males and females, and statistical significance was achieved in males. Adverse changes in male and female reproductive organs also occurred in general toxicology studies; findings included sperm degeneration in dogs at a dose of 35 mg / kg / day of berushedil, and reduced follicular development in the ovaries of rats at a dose of 275 mg / kg / day. Changes were partially or completely reversed during recovery. The exposure (AUC) in dogs at a dose of 35 mg / kg / day and in rats at a dose of 275 mg / kg / day was 0.5 times and 8-9 times the clinical exposure at the recommended dose of 200 mg per day, respectively. 14Clinical Research 14.1 Chronic Graft-Versus-Host Disease

[0317] Study KD025-213 (NCT03640481) is a randomized, open-label, multicenter study of REZUROCK for the treatment of patients with chronic GVHD who have received 2 to 5 prior lines of systemic therapy and require additional treatment. Patients were excluded from the study if they had: platelets <50×10 9 / L; absolute neutrophil count <1.5×10 9 / L; AST or ALT>3×ULN; total bilirubin>1.5×ULN; QTc(F)>480ms; eGFR<30mL / min / 1.73m 2; or FEV1 ≤ 39%. 66 patients were treated with REZUROCK 200 mg orally once daily. Concomitant treatment for chronic GVHD with supportive care therapy was allowed. Concomitant treatment with GVHD prophylaxis and standard of care systemic chronic GVHD therapy was allowed, as long as the subject had been taking a stable dose for at least 2 weeks prior to the study. No new systemic chronic GVHD therapy was allowed to be started during the study.

[0318] Demographics and baseline characteristics are summarized in Table 32.

[0319] Table 32: Demographics and Baseline Characteristics of Patients with Chronic GVHD a The denominator excludes patients whose status is unknown b Prednisone equivalent / kg

[0320] The efficacy of REZUROCK is based on the overall response rate (ORR) by day 1 of cycle 7, where an overall response includes a complete response or a partial response according to the 2014 NIH response criteria. The ORR results are presented in Table 33. The ORR was 75% (95% CI: 63, 85). The median duration of response, calculated from the first response to progression, death, or the start of new systemic therapy for chronic GVHD, was 1.9 months (95% CI: 1.2, 2.9). The median time to first response was 1.8 months (95% CI: 1.0, 1.9). Among patients who achieved a response, 62% (95% CI: 46, 74) of patients did not die or start new systemic therapy for at least 12 months after the response.

[0321] Table 33: Overall Response Rates by Cycle 7 Day 1 in Patients with Chronic GVHD in Study KD025-213 a Estimate using the Clopper-Pearson method

[0322] The ORR results were supported by an exploratory analysis of patient-reported symptom bother, which showed that 52% (95% CI: 40, 65) of patients had a reduction of at least 7 points in the Lee Symptom Scale total score by Day 1 of Cycle 7. 16 How to supply / Storage and handling

[0323] REZUROCK 200 mg tablets are supplied as light yellow film-coated oval tablets containing 200 mg of belusudil (equivalent to 242.5 mg of belusudil mesylate). Each tablet has a debossed design "KDM" on one side and a debossed design "200" on the other side, and is packaged as follows:

[0324] 30 200 mg tablets per bottle: NDC 79802-200-30

[0325] Store at room temperature 20°C to 25°C (68°F to 77°F); short-term travel permitted at 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature].

[0326] Dispense to patients only in original container. Store in original container to protect from moisture. Close cap tightly after each opening. Do not discard desiccant. 17 Patient Counseling Information

[0327] Advise patients to read the FDA-approved patient labeling (Patient Information). Embryo-fetal toxicity :

[0328] Inform pregnant women and females of reproductive potential of the potential risk to a fetus. Advise females of reproductive potential to inform their healthcare provider of a known or suspected pregnancy [see Warnings and Precautions (5.1), Use in Specific Populations (8.1, 8.3)].

[0329] Advise females of reproductive potential to use effective contraception during treatment with REZUROCK and for at least one week after the last dose [see Warnings and Precautions (5.1)].

[0330] Advise males with female partners of reproductive potential to use effective contraception during treatment with REZUROCK and for at least one week after the last dose [see Use in Specific Populations (8.3)].

[0331] Lactation

[0332] Advise women not to breastfeed during treatment with REZUROCK and for at least one week after the last dose [see Use in Specific Populations (8.2)].

[0333] Infertility

[0334] Inform males and females of reproductive potential that REZUROCK may impair fertility [see Use in Specific Populations (8.3)].

[0335] Application

[0336] Inform patients to take REZUROCK orally once daily with food as directed by their physician and that the oral dose (tablet) should be swallowed whole with a glass of water at approximately the same time each day and the tablet should not be cut, crushed, or chewed [see Dosage and Administration (2.1)].

[0337] Advise patients that if they miss a daily dose of REZUROCK, they should take it as soon as possible on the same day and resume their normal schedule the next day. Patients should not take an additional dose to make up for the missed dose [see Dosage and Administration (2.1)].

[0338] Drug interactions

[0339] Advise patients to inform their healthcare provider of all concomitant medications, including prescription and over-the-counter medicines, vitamins, and herbal products [see Drug Interactions (7)].

[0340] Table 34: Patient Information Patient InformationREZUROCK(REZ-ur-ok)

[0341] Although the present invention has been described in considerable detail by way of illustration and example for purposes of clarity and understanding, the description and example should not be construed as limiting the scope of the invention. The disclosures of all patents and scientific literature cited herein are expressly incorporated herein by reference in their entirety.

Claims

1. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating chronic graft-versus-host disease (cGVHD) in female patients of reproductive potential, comprising the step of advising the patient to use effective contraception during treatment and for at least one week after the last dose of the compound.

2. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating chronic graft-versus-host disease (cGVHD) in a female patient who is pregnant or becomes pregnant when taking the compound, including informing the female patient of the potential risks to the fetus of receiving treatment with the compound during pregnancy.

3. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating chronic graft-versus-host disease (cGVHD) in female patients of reproductive potential, comprising the step of verifying the pregnancy status of the patient prior to initiating treatment with the compound.

4. The use according to claim 1 or 2, further comprising the step of verifying the pregnancy status of the patient before starting treatment with the compound.

5. The use according to claim 2, wherein the patient is pregnant while receiving treatment with the compound.

6. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating chronic graft-versus-host disease (cGVHD) in male patients whose female partners have reproductive potential, comprising the step of advising the male patients to use effective contraception during treatment with the compound and for at least one week after the last dose of the compound.

7. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating chronic graft-versus-host disease (cGVHD) in patients of reproductive potential who use effective contraception during treatment with the compound.

8. The use according to claim 7, wherein the patient uses effective contraception during treatment with the compound and for at least one week after the last dose of the compound.

9. The use according to claim 7, wherein the patient is a female of reproductive potential.

10. The use according to claim 7, wherein the patient is a male of reproductive potential.

11. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for treating chronic graft-versus-host disease (cGVHD) in a lactating patient, comprising the step of advising the patient not to breastfeed during treatment with the compound and for at least one week after the last dose of the compound.

12. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating chronic graft-versus-host disease (cGVHD) in non-lactated patients.

13. Use according to any one of claims 1 to 11, wherein the compound is the methanesulfonate salt of 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide.

14. The use according to any one of claims 1 to 12, wherein the compound is administered to the patient at a dose of 200 mg per day.

15. The use according to any one of claims 1 to 13, wherein the patient suffers from chronic graft-versus-host disease and has failed at least two previous lines of systemic therapy for the chronic graft-versus-host disease.

16. The use according to claim 14, wherein the previous line of systemic therapy is selected from prednisone, tacrolimus, ECP, sirolimus, ibrutinib, ruxolitinib, MMF, rituximab, MTX, cyclosporine, imatinib, ixazomib and ofatumumab.

17. 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) for use in treating chronic graft-versus-host disease (cGVHD) in patients at risk of pregnancy, comprising the step of informing the patient of the reproductive risks associated with treatment with the compound.

18. The use according to claim 16, wherein the patient is a female patient of reproductive potential.

19. The use according to claim 17, further comprising the step of verifying the pregnancy status of the patient before starting treatment.

20. The use according to claim 16, wherein the patient is a male patient.

21. The use according to any one of claims 16 to 19, comprising the step of advising the patient to use effective contraception during treatment with the compound and for at least one week after receiving the last dose of the compound.

22. Use according to any one of claims 16 to 19, comprising the step of informing the patient of the fertility risks associated with treatment with the compound.

23. Use according to any one of claims 16 to 21, wherein the compound is the methanesulfonate salt of 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide.

24. The use according to any one of claims 16 to 22, wherein the compound is administered to the patient at a dose of 200 mg per day.

25. The use according to any one of claims 16 to 23, wherein the patient suffers from chronic graft-versus-host disease and has failed at least two prior lines of systemic therapy for the chronic graft-versus-host disease.

26. Use of 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) in treating graft-versus-host disease in female patients, comprising the following steps: (a) verifying the pregnancy status of the patient prior to initiating treatment with the compound; (b) if the patient is treated with the compound while pregnant, inform the patient of the potential risk to the fetus; as well as (c) Advise the patient to use contraception during treatment with the Compound and for at least one week after receiving the last dose of the Compound.

27. Use of 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide or a pharmaceutically acceptable salt thereof (compound) in treating graft-versus-host disease in male patients whose female partners have reproductive potential, comprising the following steps: (a) informing the patient of the potential risk to the fetus if the patient becomes pregnant while receiving treatment with the compound; as well as (b) Advise the patient to use contraception during treatment with the Compound and for at least one week after receiving the last dose of the Compound.

28. A method for treating chronic graft-versus-host disease (cGVHD) in a patient using 2-{3-[4-(1H-indazol-5-ylamino)-2-quinazolinyl]phenoxy}-N-(propan-2-yl)acetamide methanesulfonate (berushudil), comprising the steps of: (a) verifying whether the patient is a reproductive risk patient; as well as (b)(i) If it is verified that the patient is not a reproductive risk patient, then berushudil is administered to the patient, or (ii) if the patient is identified as a reproductive risk patient, the patient is informed of the potential reproductive risks of treatment with berushudil.

29. The method of claim 27, wherein in step (a) it is verified that the patient is a patient of reproductive potential, the method further comprising the step of advising the patient to use effective contraception during treatment with berushudil and for at least one week after receiving the last dose thereof.

30. The method of claim 27, wherein in step (a) it is verified that the patient is a lactating patient, the method further comprising the step of advising the patient not to breastfeed a child during treatment with berushudil and for at least one week after receiving her last dose.

31. A method of treating chronic graft-versus-host disease (cGVHD) in a patient, comprising the steps of: (a) verifying whether the patient is a reproductive risk patient; as well as (b)(i) If it is verified that the patient is not a reproductive risk patient, then berushudil is administered to the patient, or (ii) if the patient is identified as a reproductive risk patient, the patient uses effective contraception during treatment with berushudil and for at least one week after receiving the last dose.

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