Methods and compositions for treating glaucoma and related conditions

Abstract

Provided herein are compositions and formulations for alleviating problems associated with unregulated intraocular pressure (IOP) in the eye, comprising the administration of Trabodenosone. Administration of curbodison results in reversing or blocking disease progression of glaucoma and other related conditions. The curbodison also restores the function of the pressure sensor in the eye.

Description

[0001] Related Applications This application claims the benefit of U.S. Provisional Application No. 63 / 391,303, filed on July 21, 2022, and supplemental applications filed on July 30, 2022, September 5, 2022, October 1, 2022, November 29, 2022, and March 11, 2023; and U.S. Provisional Application No. 63 / 491,070, filed on March 19, 2023, the entire contents of which are incorporated herein by reference. Technical Field

[0002] Embodiments of the present disclosure are generally directed to novel pharmaceutical compositions, formulations, dosing regimens, and to methods for making and using the same for treating glaucoma and related conditions. Provided herein are methods for regulating and treating uncontrolled intraocular pressure comprising the use of Trabodenoson. Background Art

[0003] Glaucoma is a multifactorial and slowly progressive neurodegenerative disease; it is the leading cause of irreversible blindness in the world, with an estimated 118.5 million patients worldwide by 2025. While neuroprotection of glaucomatous vision loss is a much-sought-after goal, no success has been achieved in terms of effective results. Intraocular pressure (IOP) is the only modifiable risk factor for the disease to date: controlling IOP enables slowing of disease progression and reduction of vision loss. There are more than ten FDA-approved IOP-lowering drugs (including, for example, VYZULTA®, ROCKLATAN®, RHOPRESSA®) that are effective as symptom-relieving drugs in lowering IOP in patients with early to mid-stage glaucoma. However, as glaucoma disease progresses, patients become non-responders to treatment (a condition known as refractory glaucoma), at which point high-risk invasive glaucoma drainage surgical procedures such as trabeculectomy or tube shunts become unavoidable. Unfortunately, such surgeries typically fail at a rate of 50% within 3-5 years due to various reasons such as postoperative surgical complications. Ultimately, approximately 25-30% of glaucoma patients become legally blind due to uncontrolled IOP or IOP failure in late or end-stage glaucoma.

[0004] The root cause of IOP failure or uncontrolled IOP is related to the degeneration of pressure sensors, which causes the pressure sensors to be unable to self-regulate outflow through the trabecular meshwork (TM) in patients with glaucoma or ocular hypertension (OH). In early to mid-stage glaucoma, mild damage to the TM causes functional irregularities; in late-stage glaucoma, severe damage to the TM causes engine failure. The TM is responsible for 85-90% of outflow drainage.

[0005] Traditionally, IOP-lowering eye drops have been used as the mainstay of glaucoma disease management (symptom relief). Such drops compensate for the irregularities of the pressure sensor in early to mid-stage glaucoma. Poor patient compliance (>50% failure) causes IOP instability and fluctuations, which further accelerate disease progression and eventually become irreversible. Newer generations of minimally invasive glaucoma surgery (MIGS) address poor patient compliance and thus slow disease progression, however, they do not repair the pathological processes of the pressure sensor that occur due to aging-related oxidative damage or para-inflammation.

[0006] DURYSTA® is a bimatoprost sustained-release (SR) biodegradable intracameral implant; it is the first and only FDA-approved SR drug delivery product for the long-term management of IOP stability. DURYSTA® increases the levels of matrix metalloproteinases (MMPs) in the ciliary muscle and iris, which then induces the breakdown of collagen, fibronectin and lamellae within the extracellular matrix (ECM), leading to improved uveoscleral outflow or possibly trabecular outflow. DURYSTA® enables 80% of treated patients to have a “drug holiday” of at least 8 months, and in some individuals up to 3 years. The AMERTIS-II Phase 3 clinical trial of DURYSTA® further demonstrated the benefit of visual field stability over 20 months, including an 8-month drug holiday period following 12-month API induction via three consecutive implants. DURYSTA® not only addresses the issue of poor patient compliance and saves additional medication costs, but importantly, it also halts glaucoma disease progression. However, despite the promise of DURYSTA®, its clinical use is limited by bimatoprost-triggered intraocular inflammation, which often results in corneal endothelial loss at an alarming rate (20% loss in less than 2 years, compared to 0.6% loss per year under normal circumstances). Such vision-threatening side effects are proportional to its MMP therapeutic benefits in a time- and dose-dependent manner. Given the risk of such adverse side effects, the FDA only allows a single implant and does not allow repeated applications. A single implant only allows 28% of patients to have a drug holiday of up to 20 months after a 4-month API induction (Phase 2 clinical trial results).

[0007] What is needed is a composition and method for alleviating complications caused by elevated IOP. Ideally, such compositions and methods should be easy to administer, durable, and safe. In addition, such compositions and methods should preferably be able to reverse and prevent pathological conditions associated with elevated IOP in patients suffering from glaucoma and related conditions. What is also needed is a composition that does not cause undesirable side effects. Summary of the invention

[0008] In one embodiment, the present disclosure relates to compositions and formulations comprising trebutin as an IOP therapeutic agent (rather than simply as an IOP symptom reliever) for use in patients with glaucoma, including ocular hypertension (OHT), primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), primary angle-closure glaucoma (PACG), secondary glaucoma, and congenital glaucoma. In one embodiment, trebutin restores the function of pressure sensors in the trabecular meshwork (TM) in glaucomatous human eyes.

[0009] While not wishing to be bound by the following theory, it is believed that trebutidone works by selectively binding to adenosine A1 receptors (A1R) in the TM and ciliary body (CB) at an optimal dose that triggers three independent signaling pathways to regulate IOP. The effects of trebutidone are particularly desirable in cases where the TM is damaged or pressure sensors are worn such that the pressure sensors therein show functional irregularities (outflow engine failure or dysfunction). Trebutidone regulates IOP through both a slow mode, which is through A1R activation at TM cells causing upregulation of MMPs, including potent MMP-14 and MMP-2 at the TM, and a fast mode. The MMP bioeffects improve oxygenation of the pressure sensing cell lining at the inner wall of Schlemm's canal by removing ECM debris (e.g., collagen type IV, fibronectin, lamellae) and opening the mesh of the aged stiff TM, changing the texture of the TM tissue, increasing elasticity and water conductivity (similar to MMPs in the regeneration of Bruch's membrane). Pressure sensing cells resemble the retinal pigment epithelium (RPE) monolayer with phagocytic properties, derived from the neural crest with limited self-renewal capacity after injury in the adult mammalian eye. The lifespan and health of these pressure sensing cells determine the durability of the TM regulating outflow. Activation of A1R also triggers G protein-coupled cell membrane hyperpolarization that quiescently quiescently TM endothelial cells (or pressure sensing cells), reduces calcium influx, and restores cellular homeostasis (similar to its neuroprotection in RGC cells), which is strategically important for TM health and duration.

[0010] Both MMP-induced basement membrane regeneration and adenosine-triggered neuroprotection synergistically improve the function of pressure sensors in the diseased state and thereby improve IOP performance in patients with glaucoma. The use of trebutin in the clinical setting has demonstrated sustained IOP improvements in the form of a time course: an aspect that has not been observed so far in conjunction with other IOP-lowering drugs for symptom relief. Surprisingly, such IOP pattern behavior is unique, robust and reproducible in early and late glaucoma (including PGA poor responders). The fast mode is believed to be through vascular effects, A1R-induced G protein-coupled intracellular signaling with muscarinic receptor 2 (M2) at contractile tissue in TM and CB has crosstalk (similar to the pilocarpine effect), and the pulsatile IOP is synchronized with the heart pulse, which has diurnal variations in both healthy and glaucoma-affected eyes. The fast mode of vascular effects shows a "bell"-shaped IOP dose-response curve, which requires an optimal dose or optimal point to achieve maximum IOP reduction. Stress-sensing cells are sensitive to oxidative damage and shear stress, and their function is nitric oxide (NO)-dependent or sensitive, which in turn determines the optimal dosing of trebutin.

[0011] Provided herein is a unique dosing regimen comprising administering trebutin at a clinically optimal dose. In certain embodiments, the clinically optimal dose of trebutin is determined by its complex mechanism of action (fast mode vs. slow mode). In one embodiment, a single dose of 0.6% trebutin eye drops causes maximum IOP reduction and a peak at a "bell" shape. In one embodiment, under the positive influence of MMP activation, the optimal dose of trebutin eye drops comprises approximately 0.8%-6%, 1.0-3%, 1.0%-1.5%, or 1.2%-1.5%, or 1.5%. In one embodiment, for a sustained-release product, an API loading dose and release rate that causes an API concentration similar to that of aqueous humor comprises instillation administration (1.5%). The "bell" shaped IOP lowering response curve is a guiding principle (rule) for the optimal dosing of any product associated with trebutin for the treatment of glaucoma (IOP) while attempting to achieve maximum IOP reduction.

[0012] IOP is physiologically regulated by a system of pressure-sensing cells at the TM and their accompanying underlying basement membrane (BM). Pressure-sensing cells comprise a cobblestone-shaped, monolayer lining the inner wall of Schlemm's canal, commonly referred to as the TM endothelium, similar to the RPE (retinal pigment epithelium) and corneal endothelium derived from the neural crest of the adult human eye with limited self-renewal following oxidative damage from injury or aging. The episcleral vein (EVP) acts as a valve to regulate outflow through the TM (pressure sensor).

[0013] In one embodiment of the present invention, the novel dosing regimen described herein causes a drug holiday. When the patient's TM shows a healthy state, the function of the pressure sensor is restored to the point where no drug or treatment is needed to maintain the patient's IOP at a standard target level or below 21 mmHg, a drug holiday for IOP-related diseases is achieved. The invention as described herein exceeds the efficacy of DURYSTA® (bimatoprost sustained-release intracameral implant), which causes a sustained drug holiday of 8 months to up to 3 years. Although not wishing to be bound by the following theory, trebutidone is a more effective MMP stimulator (emphasizing that MMP-14 is the most effective in the MMP family), which has anti-inflammatory activity by activating macrophages under oxidative conditions, causing a longer drug holiday than DURYSTA®. In addition, trebutidone's cytoprotection or neuroprotection of pressure-sensing cells is a unique attribute of its therapeutic effectiveness, which is superior to proinflammatory prostaglandin analogs (PGA) in SR systems such as DURYSTA®.

[0014] While not wishing to be bound by the following theory, it is believed that the drug holiday induction time and durability are determined by two key aspects: first, the stage of the glaucomatous disease, and second, the efficacy of the treatment and the duration of the treatment. With respect to the stage of the glaucomatous disease, an important consideration depends on the pressure sensor recoverability and durability or the quality of the sensor. Based on the current evidence, it is believed that in order to achieve full functional recovery and a stable drug holiday of 6-12 months or longer, it may be necessary to have at least 50-70% of the pressure sensing cells in the glaucomatous eye. Patients at the same disease stage may have different complex cell biological capabilities, and therefore, a given treatment may cause complete recovery in some patients and partial recovery in others, which may last from 3 months to up to 3 years or longer, depending on the number of remaining pressure sensing cells and their metabolic state. With respect to the second aspect (therapeutic efficacy), this aspect is generally related to MMP enzyme strength and neuroprotective efficacy. Compared to prior art drugs such as DURYSTA®, which lack neuroprotection of pressure sensing cells (and may actually increase intraocular inflammation and metabolic stress (thereby compromising the health of pressure sensing cells)), the sustained release of trebutin is significantly more effective for treating glaucoma and related conditions. As described herein, the sustained release of trebutin is more effective than administration of other prior art drugs, particularly as a drug holiday inducer. The longer the induction time given, the more stable the sustained drug holiday may be. In addition, compared to prior art drugs such as DURYSTA®, the sustained release of trebutin can induce a drug holiday for a higher percentage of patients (80-90%), including more advanced glaucoma (e.g., patients taking 3 or 4 medications), at a faster rate (e.g., 1-3 months), with a stable and longer duration. For example, with 3-5 months of sustained release of trebutin, 50-80% of patients with moderate glaucoma can achieve a drug holiday of 6-24 months (or longer), respectively. Longer term sustained release administration may result in a higher percentage of patients having a longer lasting drug holiday than shorter term sustained release forms (e.g., 6M may be superior to 3M for severe glaucoma). While not wishing to be bound by the following theory, sustained release administration may be more effective than eye drops compared to trobutisone eye drops.

[0015] In one embodiment, the invention as contemplated herein as an eye drop formulation or a sustained release formulation (e.g., as an implant) has advantages over prior art formulations because trebutin is the only drug in an eye drop formulation that can upregulate MMPs and is the only MMP therapeutic that does not increase intraocular inflammation (prostaglandin analogs are pro-inflammatory agents), making trebutin the first and best candidate for intraocular sustained release drug delivery products such as anterior chamber rods. Trebutin is also a potent vasodilator with superior therapeutic benefits for aging-related pathological processes involving glaucoma and age-related macular degeneration (AMD). BRIEF DESCRIPTION OF THE DRAWINGS

[0016] Figure 1 Table 2 is provided, showing data related to trebutazone eye drops studied in randomized controlled clinical trials that have undergone dose escalation from Phase 1 / 2 to Phase 3 in patients with POAG / OH, including a combination study of poor responders to latanoprost eye drops. A total of 819 patients or human subjects were tested for a duration of 2 weeks to 3 months, with doses ranging from 0.15% BID to 6% QD, and up to 18% single doses, which showed excellent systemic clinical safety and ocular tolerability, with low rates of conjunctival hyperemia: 2.56%, compared to 50% for Rhopressa (mild to moderate). On day 28, the maximum IOP reduction was 6-7 mmHg with 1.5% BID, and switching to QD was possible. The Phase 3 clinical trial failed to reach the IOP endpoint at 3 months, but the 6% QD group showed an incremental increase in IOP reduction (or improvement) over the course of 3 months compared to placebo, which was clinically meaningful (data source: Clinicaltrial.gov).

[0017] Figure 2 provides a graph showing optimal dosing and illustrates the optimal dosing of trebutadione eye drops: 1.5% versus 0.6%. The Phase 2 trebutadione dose escalation study showed a "bell" shaped IOP dose response curve with 0.6% BID that peaked at the curve (green bar), and that the dose-dependent IOP reduction with 1.5% BID was more effective than 0.6% BID in normalizing diurnal variation in patients with glaucoma at day 14 (blue bar). This is the first recognition of two components associated with the dual MOA of trebutadione given at therapeutic doses (range). Figure 2A: Shows that a single dose of 0.6% trebutadione eye drops in Dutch-beltedpigmented and normotensive rabbit eyes resulted in an immediate 25%-27% reduction in IOP from baseline at 2 hours and a return to baseline at 6 hours. This study established a trebutadione dosing schedule of twice daily at the beginning. Figure 2B: shows a 14-day phase 2 clinical trial of trebutadione in patients with POAG / OH, which shows that the "bell"-shaped dose response curve peaking at the top using 0.6% BID is superior to 0.15% BID and 0.3% BID peaking on the left and 1.5% BID peaking on the right (green bar). The green bar indicates that the IOP is reduced from the baseline IOP; the blue bar indicates that the IOP is reduced from the diurnal IOP on day -1, where the IOP response curve is time- and dose-dependent and may reach a steady state. On day 14, 1.5% BID was more effective than 0.15% BID, 0.3% BID, and 0.6% BID. In the group 1.5% BID, the average IOP reduction on day 28 was superior to the average IOP reduction on day 14. Although 0.6% peaked at a bell-shaped dose-response curve, 1.5% BID was more effective than 0.6% BID in normalizing diurnal variation in patients with glaucoma under the positive influence of trabodenosonon-derived MMP therapeutics. Figure 2 from TG Qiu. Trabodenosonon trabecular meshwork rejuvenation: a comprehensive review of clinical data. Expert Opin Investig Drugs. 2021 Mar;30(3):227-236. doi: 10.1080 / 13543784.2021.1873276. Publisher: Informa Ltd and Taylor & Francis Groups. The corresponding author reserves intellectual property and copyright 2021.

[0018] Figure 3Figures are provided showing that the clinical dosing principles of trebutin are governed by its dual mechanism of action (fast mode via vascular effects and slow mode via MMP bioeffects). The slow mode is achieved via its derived MMP therapeutics in a time, dose and disease stage dependent manner to a steady state ( Figure 3 A). Fast mode shows a "bell" shaped dose response curve, requiring an optimal point or dose to achieve maximal IOP reduction, with IOP values ​​consistent with no change over time ( Figure 3 B). The clinical readout of IOP reduction by trombopag is the sum of the IOP reductions induced by the fast and slow modes, with the maximum sum of IOP reductions varying over time as a result of improvements in MMP therapy that alter IOP values ​​( Figure 3 C).

[0019] Figure 4 provides a plot of optimal dosing (1.5% vs. 0.6%) and time course kinetics (3 scenarios) of trebutazone. Summary of Dose Selection: Under the active influence of trebutazone-derived MMP therapeutics, the previously determined optimal dose is no longer the optimal point at the beginning, 0.6%, but instead displays time course kinetics in a given disease stage. Dose selection was based on the potency of trebutazone MMP therapy to cause a drug holiday (early-mid-stage), and the need to rapidly remove ECM debris and prevent irreversible damage to pressure sensors (late or terminal stage). 1.5% was more effective than 0.6%. There are three different clinical scenarios illustrating the situation where 0.6% BID and its next dose, 1.5% BID, track each other toward the end point (steady state) where a drug holiday becomes possible. Figure 4A : The first scenario illustrates that 1.5% BID reaches steady state (drug holiday) at an early time point (e.g., 4-8 months) and 0.6% BID is still running (ramp-up), not yet reaching steady state, and in a given patient group, the sum of the IOP reductions in 1.5% BID is higher than the sum of the IOP reductions in 0.6% BID. 1.5% is more effective than 0.6% in treating patients with severe glaucoma. Figure 4B : The second scenario illustrates that 0.6% BID reaches steady state (drug holiday) at a later time point (e.g., 8-12 months) and its sum of IOP reduction may be higher than 1.5% BID (which reaches steady state earlier with stable IOP). Figure 4C: The third scenario illustrates that 1.5% BID and 0.6% BID have transition overlap, where the sum of IOP reductions in both doses is the same or similar for a very short period of time, this transition moment may be at an earlier time point (e.g. 1-4 months) before both doses reach steady state, when IOP in 1.5% is ramping up with MMP effect, and 0.6% vascular effect exceeds 1.5% with advantage. It may also be at a later time point (e.g. 6-9 months) after 1.5% BID reaches a drug holiday with stable IOP (flat curve), and IOP with 0.6% BID is still ramping up to a point where it may exceed the maximum achieved with 1.5% BID, during this dynamic period, there will be a touch point where both doses will reach the same sum of IOP reduction before 0.6% BID reaches steady state (drug holiday). It is important to note that the time points 4-8 months, 8-12 months, and 1-3 months or 6-9 months are given for illustrative purposes only and do not reflect the actual time in patients in the real world. The dosing frequency BID for both doses can be switched to QD after a certain period, but for the purpose of comparison in this description, BID will be used consistently throughout. Eye drops and SR share the same dynamic pattern: 1.5% BID is more effective than 0.6% BID in achieving steady state (or drug holiday), especially in treating severe glaucoma. The SR formulation is more effective than its eye drop formulation (at the same API concentration in aqueous humor). The time for a patient to achieve a drug holiday (steady state) depends on the formulation (SR vs. eye drops) and disease severity, and although 0.6% BID may achieve slightly higher IOP reduction (in terms of total) at a later time, 1.5% is more effective from a therapeutic point of view and will achieve a drug holiday more quickly, so 1.5% is superior to 0.6% as an IOP therapeutic for glaucoma patients, especially for severe disease that requires immediate repair before the pressure sensor reaches irreversible apoptosis (cell loss) to a point where it exceeds the threshold (unknown) to compensate for its function. Based on preclinical and clinical evidence (Figure 8), 6% is likely to be at the bottom of the bell-shaped IOP dose-response curve and 3% at half the slope shown in this figure.Trepotetin-induced neurovascular modulation is either NO-sensitive or NO-dependent.

[0020] Figure 5 provides data related to a study demonstrating a unique IOP pattern behavior of trebutin in patients with POAG / OH. This panel demonstrates a unique and effective IOP treatment improvement in patients with early to moderate POAG / OH, including PGA poor responders, and this unique pattern behavior distinguishes trebutin from current FDA-approved IOP drugs such as ROCK inhibitors, Rhopressa, PGA (latanoprost, bimatoprost, travoprost, vyzulta), beta blockers, CAIs, and brimonidine, which almost all provide symptom relief and show a flat IOP lowering curve in a time course format, with Vyzulta and Rescula showing some modest and limited treatment benefits in subset groups (NTG) or selected individuals, respectively (Figures 5E and 5F). The unique time course IOP improvement of trebutin is a result of its MMP therapeutic and neuroprotection of pressure sensing cells through TM regeneration and repair of TM pressure sensors, which is revealed for the first time by the present invention. IOP curves for latanoprost, travoprost, bimatoprost, unoprostone, and rhopressa can be found in randomized controlled clinical trials in AS Khouri et al 2019, ES Ancient et al 2005, DR Fung et al 2014, and are generally described as flat curves over the course of 6 to 12 months or longer in patients with POAG / OH. Figure 5A: In patients with mild POAG / OH with baseline IOP <= 24 mmHg, 3-stage travoprost monotherapy given at a high dose of 6% QD resulted in sustained IOP improvements over the course of 3 months that were clinically meaningful compared to placebo (Figure 5A from TG Qiu. Expert Opin Investig Drugs. 2021 Mar;30(3):227-236. Publisher: Informa Ltd and Taylor & Francis Groups. Intellectual property and copyright reserved 2021 by the corresponding author). Figure 5B provides data related to the following: A Phase 2 trobutyric acid dose escalation study in patients with POAG / OH with baseline IOP>21 mmHg showed that with 1.5% BID eye drops, incremental increases in IOP reduction (improvement) were achieved, with Day 28 performing better than Day 14 (0.9 mmHg improvement in 2 weeks), with the switch to BID dosing occurring as early as Day 29. (Figure 5B from Myers JS et al. Journal of Ocular Pharmacology and Therapeutics 2016 32:8, 555-562. https: / / www.liebertpub.com / doi / 10.1089 / jop.2015.0148 . Copyright © 2016, the author and Mary Ann Liebert, Inc. Figure 5C: In POAG / OH patients who were poor responders to latanoprost, trebutin supplementation to latanoprost also demonstrated robust and sustained IOP improvements over the course of 12 weeks, with a dosing regimen of 1.5% BID for 8 weeks followed by a switch to 3.0% QD for an additional 4 weeks. All three clinical trials (Ph2 and Ph3) demonstrated the same unique IOP pattern behavior (IOP improvement) in a time course format, with dosing likely switching from BID to QD, indicating improved TM durability in patients treated with trebutin (Figure 5C from Inotek Pharma IPO S-1 Form, 2014). Figure 5D shows the IOP reduction curve for DURYSTA®-derived MMP therapeutics in a preclinical normotensive dog model that was dose dependent, with 22ug outperforming the 12ug API loading dose, however, there was no time course improvement. In clinical trials (not shown), there was also no time course improvement, with three possible reasons, one may be related to its increased intraocular inflammation, which contains IOP manifestations, and second, DURYSTA® has no neuroprotective benefit on pressure sensing cells or TM endothelium. Third, SR rapidly reaches steady state within the first week or two. (Source: Lee SS et al. J Ocul Pharmacol Ther. 2019 Apr;35(3):138-144. doi:10.1089 / jop.2018.0095.) Figure 5E. Vyzulta (Latanoprost Bunod) IOP reduction curves over 12 months (12M) in patients with NTG shows the benefit of NO contribution in the first 12 weeks, with a slight improvement (approximately 0.6 mmHg), and then the curve flattens out for the rest of the 12M study (Figure 5E from Kawase, K. et al. Adv Ther 33, 1612–1627 (2016). Copyright 2016 by the author. https: / / link.springer.com / article / 10.1007 / s12325-016-0385-7#rightslink . ) Figure 5F shows examples of resclar eye drop-induced IOP “treatment” curves in two individual patients with refractory glaucoma, demonstrating a slow pattern and cumulative improvement over time starting from weeks or months depending on disease severity, with resclar users never reporting a drug holiday. Resclar given to patients with early or moderate glaucoma or those without “active” intraocular inflammation showed a flat curve for IOP reduction, similar to that seen with symptom-relieving medications (reference: ES Arcieri et al. Arch Ophthalmol.2005;123(2):186–192). Figure 5F from Qiu TG (2015) J Clin Exp Ophthalmol 6: 473 (copyright © 2015 author).

[0021] Figure 6 provides data related to a study showing the effectiveness of trebutin treatment in favor of severe glaucoma and pathologies. As shown herein, trebutin is more effective for patients with more severe glaucoma than for patients with less severe pathologies, and more effective for POAG than OH. The IOP of both mild and advanced POAH / OH improves over time with treatment. Figure 6A: Phase 2 clinical trial shows that in the early cohort, administration of 1.5% BID of trebutin eye drops resulted in a greater reduction in IOP in patients with POAG than in patients with OH. (Figure 6A from Qiu TG. Expert Opin InvestigDrugs. 2021 Mar;30(3):227-236, copyright author of 2021) Figure 6B: Ph2 clinical trial showed that administration of trebutin eye drops at 1.5% BID resulted in a greater IOP reduction at day 14 in patients with baseline IOP>25 mmHg than in patients with baseline IOP>21 mmHg (>7 mmHg vs. 6.5 mmHg), and IOP improved over time with better day 28 than day 14 (data source: Inotek Pharma OIS 2012). Figure 6C: Phase 2 clinical trial of patients with trebutin supplementation for poor responders to latanoprost showed robust and incremental IOP improvements over a 12-week treatment time course, with dosing switching from 1.5% BID * 8 weeks to 3% QD * 4 weeks. Furthermore, among latanoprost poor responders, trebutazone was more effective in patients with POAG than in those with OH (data source: Inotek Pharma 2014 Form S-1).

[0022] Figure 7 provides data related to trebutadione treatment of pressure sensors via neuroprotection and ECM regeneration at the TM. As shown herein, trebutadione treatment provides neuroprotection to pressure sensing cells (neuronal lineage cells) while removing ECM debris through upregulation of potent MMP-14, followed by degradation of collagen IV and fibronectin at the ECM leading to thickening of the trabecular meshwork in glaucomatous eyes, these two mechanisms of action synergistically lead to regeneration and repair of pressure sensors, which was not previously understood or reported. Figure 7A: In a preclinical NAION mouse model, trebutadione was administered as 6% eye drops BID for a period of time, and EM morphological assessment of cross-sections of the optic nerve tract demonstrated a significant reduction in axonal loss and myelination impairment observed in treated eyes compared to placebo controls. The TM endothelium is similar to the RPE in that it is a cobblestone-like, self-contact-inhibited monolayer in cell culture systems; both are derived from the neural crest of the adult mammalian eye and have lost their ability to self-renew (WD Stamer et al., Exp. Eye. Res. 2017 May;158:112-123). Neuromodulation induced by A1R activation is inhibitory in nature, and through its G protein-coupled cell membrane hyperpolarization, neurons are forced into a quiescent state by increasing K-ATP conductance, inhibiting calcium influx and release of excitatory neurotransmitters such as glutamate and dopamine. The evidence for trebutazone neuroprotection in RGCs can be transferred to its cytoprotection of TM pressure-sensing cells; placing these cells into a quiescent state is essential for replenishing the cellular metabolic capacity (regeneration) (Figure 7A from Yan Guo et al.; Trans. Vis. Sci. Tech.2019;8(6):47, doi: https: / / doi.org / 10.1167 / tvst.8.6.47. Copyright © 2019 by the author(s), published by ARVO Journal). Figure 7B / C: In an in vitro cultured human TM cell model, trebutin showed its biological activity by upregulating the expression of MMP-14, which subsequently caused the downregulation of collagen IV and fibronectin. Figure 7D: In a preclinical aging mouse model, 6% trabodenoson treatment resulted in TM mesh opening and ECM remodeling with enlarged ECM space compared to placebo-treated eyes (Figure 7B / C / D Source: Li G, Stamer WD, et al. "Trabodenoson, an Adenosine Mimetic With A1 Receptor Selectivity Lowers Intraocular Pressure by Increasing Conventional Outflow Facility in Mice". Invest Ophthalmol VisSci. 2018 Jan 1;59(1):383-392. https: / / doi.org / 10.1167 / iovs.17-23212 . Copyright © 2018 by the author, published by ARVO Journal). The TM is a spongy tissue composed of ECM, with outflow resistance located at the transition of the JCT to the basement membrane (BM) beneath the endothelial monolayer that forms the inner wall of Schlemm’s canal. In healthy eyes, the BM is composed of fibronectin, lamellae, and collagen IV, and in glaucomatous eyes, pathological ECM material is present, with deformed proteoglycans deposited on the BM and coagulating the TM mesh. Treatment with trebutazone-derived MMP-14 removed ECM debris, opened the mesh, and resulted in changes in ECM texture, increased elasticity, and hydraulic conductance, similar to the effects of MMP-9 treatment on Bruch’s membrane in the retina (Figure 9). Dr. Qiu first discovered the therapeutic effect of CHA(A1R)-derived MMPs on TM regeneration in 2015. Trebutazone is a more potent MMP stimulator, with MMP-14 being the most potent MMP in the family. Its therapeutic efficacy in aged mice is consistent with that in patients with severe disease.

[0023] Figure 8: Trebutazone 3% QD outperforms 6% QD in a “bell” shaped IOP dose reduction curve, a fast mode through vascular effects. The vascular effects of A1R are through Gi protein-coupled muscarinic M2 neurovascular modulation (through increased nitric oxide (NO) effects), similar to the effects of acetylcholine (Ach) on increased NO-induced muscle relaxation, A1R is coupled to cAMP production through Gi protein activation, which causes vascular relaxation (dilation) as well as A1R-mediated NO production. The targeted receptor may be through M2 parasympathetic innervation on blood vessels or contractile tissues such as TM smooth muscle cells and TM endothelial cells that are most sensitive to NO. Figure 8A / B: Trebutazone eye drops were given for 7 consecutive days at 3% QD and 6% QD in young and aged C57 mice, respectively. On day 1 of the study, Trebutazone 6% QD appeared to be more effective in aged mice than young mice given 3% QD, which is consistent with clinical studies in patients as a result of MMP effects. It is also noteworthy that the IOP reduction of 3% QD lasted for 7 days, while its IOP-lowering effect in 6% QD aged mice slowly diminished by day 7, perhaps with 6% QD falling at the bottom of the bell-shaped IOP dose-response curve. The mouse eye has a very thin sclera, which increases the efficiency of drug delivery to the pars plana and vitreous cavity (small), resulting in cumulative cAMP levels (high) and exceeding optimal NO levels. The vascular effects of trebutin are dose sensitive. This study result has not been properly interpreted in previous publications, and this is the first time that trebutin administration has been noted to be associated with a NO effect in terms of IOP reduction. In a mouse model, 3% is superior to 6% in terms of IOP reduction. Similar findings were found in patients (Figure 8A / B from Li G, WD Stamer et al. Invest Ophthalmol VisSci. 2018 Jan 1;59(1):383-392, doi: 10.1167 / iovs.17-23212. Copyright 2018 by ARVO Journals). Figure 8C: In a phase 2 trial of fixed-dose trebutin combined with latanoprost, 3% QD trebutin also worked better than 6% QD combined with 0.005% QD latanoprost, but neither seemed as effective as 0.005% QD latanoprost alone, likely due to conflicting vascular effects of PGA and A1R, i.e., one is a vasodilator and the other is a vasoconstrictor (Source: Inotek Pharmaceuticals, Clinical Trial Identifier: NCT02829996).

[0024] Fig. 9 provides the proof of MMP to Bruch's membrane regeneration. Fig. 9A / B shows that MMP-2 increases the hydraulic conductivity of the aging Bruch's membrane from human donor eyes. MMP-9 is more effective than MMP-2, and its treatment changes the curve of the hydraulic conductivity of the Bruch's membrane in the 60-year-old donor tissue, to regain the hydraulic conductivity of the Bruch's membrane of 40 years old, with increased elasticity (Fig. 9A / B from Ahir A, Guo L, Hussain AA, Marshall J. Expression of metalloproteinasesfrom human retinal pigment epithelial cells and their effects on thehydraulic conductivity of Bruch's membrane. Invest Ophthalmol Vis Sci. 2002 February; 43(2):458-65. Copyright ARVO publisher in 2002). Fig. 9C shows that nano-pulse laser stimulates host RPE cell regeneration (limited), and the production of MMP at Bruch's membrane increases, which causes the subretinal fluid dissolution of the patient with DME, and the clinical efficacy is shown as a slow accumulation mode, with a sustained therapeutic benefit (visual gain). This is a retinal MMP treatment pattern behavior similar to what is seen in trombopagine-derived MMP treatment outcomes (slow accumulation pattern) with IOP improvement. MMPs and the basement membrane (BM) are key common links from the retina to the junction of glaucoma. Bruch's membrane is a type of BM. (Figure 9C from Qiu TG. Expert Opin Investig Drugs. 2021 Mar;30(3):227-236. Copyright 2021 author).

[0025] Figure 10 demonstrates that DURYSTA®-derived MMPs induce a drug holiday in patients with mild to moderate glaucoma, where pressure sensor function is restored, however the holiday period is erratic, likely due to increased intraocular inflammation, driven in proportion by high levels of SR API released in the AC. Figure 10A: Ph2 clinical trial: DURYSTA® with 4.2 months API release resulted in 68%, 40%, and 28% of patients with mild to moderate POAG / OH with a drug holiday of 2 months, 8 months, and 20 months, respectively, with the MOA believed to be ECM remodeling and TM regeneration towards full functional restoration of pressure sensors through upregulation of MMPs (such as MMP-9) triggered by high concentrations of bimatoprost (Figure 10A from Craven ER et al. Drugs. 2020 Feb;80(2):167-179; https: / / link.springer.com / article / 10.1007 / s40265-019-01248-0# rightslink. Copyright 2019 by Springer Nature). Figure 10B: In an in vitro human TM cell culture model, high concentrations (10ug / mL) of bimatoprost and latanoprost upregulated MMP-9 expression (Figure 10B from Li X et al. PLoS One. 2016 Mar 24;11(3):e0151644, doi: 10.1371 / journal.pone.0151644. Copyright 2016 by Springer Nature). Figure 10C: Elevated cytokines and pro-inflammatory molecules (e.g., TNFa, interleukins) in the aqueous humor of patients with uveitis, diabetic retinopathy, etc. lead to corneal endothelial loss (CEL), which is clinically significant and shows a dose-dependent or disease severity-dependent linear manner. (Figure 10C from Yagi-Yaguchi, Y. et al. Sci Rep 7, 13603 (2017). https: / / doi.org / 10.1038 / s41598-017-14131-3 . Copyright 2017 by the authors, published by Springer Nature).

[0026] Figures 11 and 12: Effect of trebutin on estimated drug holiday parameters. Scientific basis: The drug holiday reflects the full functional restoration of TM health and pressure sensors in the glaucomatous eye. It reflects the complex biological capacity of pressure sensing cells that can self-regulate IOP without the additional help of symptom-relieving IOP drugs. The drug holiday parameters are determined by two key aspects: one is related to the glaucoma disease stage, which defines the pressure sensor recoverability (estimated: to achieve full functional recovery and a stable drug holiday of 6-12 months or more, at least 50-70% of pressure sensing cells need to remain in the glaucomatous eye). The parameters should include the percentage of patients: for example 50%-80%, the time of initiation (1-3 months or 3-6 months induction), and the durability of the holiday period (3-6M or 12-24M or 3-5 years). The other is related to the efficacy of the treatment and the duration of treatment. Efficacy includes MMP efficacy and neuroprotective efficacy, Durysta has no neuroprotective effect on pressure sensing cells, and it increases inflammation and metabolic stress on pressure sensing cells. Therefore, trebutazone is far more effective in SR (such as Durysta) than PGA. The therapeutic benefit of trebutazone increases with treatment duration, so its SR is more effective as a drug holiday inducer than eye drops. High concentration eye drops are more effective than low concentration eye drops, for example, 1.5% is more effective than 0.6% as a drug holiday inducer. 3% is more therapeutically effective than 1.5% as a drug holiday stabilizer, without the need for maximal target of IOP lowering.

[0027] In principle, the Trabo-SR (extended-release trabodisone) form could induce a drug holiday in a higher percentage of patients, including those with more advanced glaucoma (e.g., patients taking 3-4 medications or glaucomatous eyes that have undergone trabeculectomy or IDose implantation but failed), at a faster rate compared to Durysta, with a longer duration. In addition, for trabodisone, a longer SR induction would put a higher percentage of patients on a longer-lasting drug holiday compared to a shorter-duration SR form (e.g., 6M is better than 3M for severe glaucoma). However, Durysta MMP treatment benefit increases in proportion to its vision-threatening side effects on corneal and TM health, and therefore, its MMP benefit is compromised.

[0028] Clinical Evidence: Figure 11-12A: Durability of drug holiday with single-dose implant of Durysta SR (10ug and 15ug of 4.2M API loading) resulted in an estimated 68%, 47% (estimated), 40% and 28% of patients on drug holiday at 6M, 9M, 12M and 2M, respectively. Figure 11-12B: Durysta API time course induction of drug holiday: Durysta SR single implant of 4.2M API loading of 10ug and 15ug resulted in 40% on drug holiday at 12M, and 3 consecutive implants of 10ug of 12-month API resulted in 80% of patients on drug holiday. By 8-month API (1 or 2 implants of trebutinol), it is estimated that approximately 60% of patients are on drug holiday. Figure 11-12C: In mild-moderate POAG / OH, trebutin given as a low-dose eye drop (1.5% BID) can induce a unique dosing switch from BID to QD as early as 29 days and 8 weeks in latanoprost poor responders. Dosing switch is a clinical biomarker of TM durability and a precursor to a drug holiday.

[0029] Real World Possibility: Figure 11D provides an estimate showing the durability of drug holidays with administration of trebutadione eye drops: Estimated drug holidays for patients with glaucoma when trebutadione eye drops are used in combination with SR MMP as a loading dose (e.g., DURYSTA®): 50% of patients at 12 months or 80% at 24 months can achieve a durable drug holiday of at least 6 months and up to 3 years. Trebutadione eye drops can also stabilize and extend drug holidays in patients induced by Durysta SR MMP up to 12 months or longer (Durysta induced 67% of holidays, but 27% had holidays shorter than 2 months). Figure 12D shows the estimated drug holiday of trebutadione SR (AC rod) as a holiday inducer with 3-5 months API in patients with glaucoma, with an estimated 50-80% of patients taking 1-2 medications can achieve a stable drug holiday with holiday durability of 6-24 months, respectively. In newly diagnosed early glaucoma, 2-3M API can induce drug holidays.

[0030] Figure 13A shows that the trabecular meshwork is a spongy tissue composed of contractile tissue that forms an outflow drainage system with the outlet of Schlemm's canal, with the water flowing toward the episcleral vein, and the episcleral vein (EVP) acts as a valve for IOP regulator, which is innervated by the pressure sensor (Figure 13A from Kay Lam et al. Anatomy of the Aqueous Outflow Drainage Pathways. Book Title: Minimally Invasive Glaucoma Surgery (Page 11-19). January 2021. Copyright: Author @ CCA Sng, K. Barton). Figure 13B: Shows the pressure sensing cells that form a monolayer lining at the inner wall of the SC and its underlying BM, which functionally and anatomically forms an integral part of the pressure sensor. The ECM in the JCT, together with the BM, also plays a key role in maintaining and supporting the metabolic health and function of the pressure sensing cells. The outflow resistance in the TM is believed to be located in the JCT region. MMP therapeutics help clear ECM debris and pathological proteoglycans at dense JCT areas, improve elasticity and hydraulic conductivity, and subsequently increase oxygenation of pressure-sensing cells, which regenerates their metabolic capacity and thus helps the survival of the sensor. Trabeculin induces neuroprotection of pressure-sensing cells by placing the cells in a quiescent period, which is unique and important for preventing cells from apoptosis or necrosis under oxidative stress or metabolic inflammation. (Figure 13B from Keller KE, Peters DM. Pathogenesis of glaucoma: Extracellular matrixdysfunction in the trabecular meshwork-A review. Clin Exp Ophthalmol. 2022 Mar;50(2):163- 182).

[0031] All cited figures are published in open access journals and are licensed under a Creative Commons Non-Commercial No Derivatives 4.0 International License ( http: / / creativecommons.org / licenses / by-nc / 4.0 / ) protection, copyright is granted free of charge by the corresponding author or publisher. DETAILED DESCRIPTION

[0032] The following specific embodiments are exemplary and explanatory, and are intended to provide further explanation of the disclosure described herein. Through the following specific embodiments of the present disclosure, other advantages and novel features will be apparent to those skilled in the art. The text and references mentioned herein are incorporated herein in their entirety, including U.S. Provisional Patent Application Nos. 63 / 491,070 and 63 / 391,303.

[0033] U.S. Patent Nos. 7,423,144, 8,501,708, 9,522,160, 9,370,530, and U.S. Patent Application Serial No. US2016 / 0158268 are also incorporated herein in their entireties.

[0034] As used herein, the term "subject" should be interpreted to include subjects, for example, medical or surgical subjects, such as humans and other animals in need of therapeutic intervention.

[0035] Abbreviations: A1R: Adenosine A1 receptor AAV: adeno-associated virus AC: Anterior chamber Ach: Acetylcholine (Ach) ADON: autosomal dominant optic neuropathy AMD: Age-related macular degeneration ARTEMIS 1: A Phase 3, Randomized, 20-Month Study of Bimatoprost Implant in Open-Angle Glaucoma and Ocular Hypertension ARTEMIS 2: A phase 3, randomized, 20-month study of the efficacy and safety of the bimatoprost implant in patients with open-angle glaucoma and ocular hypertension API: Active Pharmaceutical Ingredient ARVO: Association for Research in Vision and Ophthalmology BID: twice a day BM: Bruch membrane BM: basement membrane C3: complement factor 3 CB: Ciliary body CEL: Corneal endothelial loss CHA: Cyclohexyl adenosine CFTR: Cystic Fibrosis Transmembrane Conductance Regulator CM: Cornea-Sclera Mesh DME: diabetic macular edema ECD: endothelial cell density ECM: Extracellular Matrix ERK: Extracellular signal-regulated kinase EVP: episcleral venous pressure GA: Geographic atrophy IND: Investigational New Drug IOP: Intraocular Pressure IVT: intravitreal JCT: Paratubular tissue LBN: Latanoprost Buno LCA: Leber's congenital amaurosis LHON: Leber's hereditary optic neuropathy MATrX-1: A study of trobutyricone in adults with ocular hypertension or primary open-angle glaucoma MIGS: Minimally Invasive Glaucoma Surgery MMP: matrix metalloproteinase MOA: Mechanism of Action 6M: 6 months or 6-month MS: Multiple Sclerosis mTOR: mechanistic target of rapamycin NAION: non-arteritic anterior ischemic optic neuropathy NO: Nitric Oxide NTG: Normal Tension Glaucoma OH: high intraocular pressure PACG: primary angle-closure glaucoma PGA: prostaglandin analog POAG: primary open-angle glaucoma POC: Proof of Concept PXF: Pseudoexfoliation QD: Once a day RD: Retinal detachment RGC: retinal ganglion cell ROCKi: Rho kinase inhibitor RP: Retinitis pigmentosa RPE: retinal pigment epithelium 2RT Laser: Retinal Regeneration (2RT) Laser, SC: Schlemm's canal SLT: Selective Laser Trabeculoplasty SR: sustained release TID: three times a day TM: Trabecular meshwork TNF: Tumor necrosis factor UM: Uveoscleral Mesh VEGF: vascular endothelial growth factor.

[0036] In one embodiment, provided herein are novel methods and dosing regimens for improving intraocular pressure, comprising administering a composition comprising trebutin. Trebutin (formerly known as INO-8775) is provided in the form of:

[0037] While not wishing to be bound by the following theory, it is believed that trebutadione works by binding to adenosine A1 receptors. A1 receptors are distributed in ocular tissues as follows: Table 1: Distribution of adenosine A1 receptors in ocular tissues

[0038] like Figure 1 As demonstrated, trobutisone ophthalmic solution was previously studied in a randomized controlled clinical trial that underwent a phase 1 / 2 dose escalation through phase 3 in patients with POAG / OH, including a combination study in poor responders to latanoprost ophthalmic solution. Figure 1 Table 2 shown provides a summary of the clinical trials for trobutisone (INO-8775) eye drops in glaucoma. This clinical trial series validated the therapeutic benefit of trobutisone-derived MMPs in patients with mild to moderate or advanced glaucoma, including PGA poor responders. Unlike Rhopress, neither trobutisone therapeutic nor IOP had an upper limit of baseline IOP <= 24 mmHg. Trobutisone was more effective in patients with high baseline IOP or more severe pathology. The time course of IOP improvement is a key mode of behavior for trobutisone therapeutics in glaucoma.

[0039] Figure 2 and Figure 3 Details are provided on proprietary findings demonstrating optimal dosing of 1.5% versus 0.6%. The Phase 2 trebutadione dose escalation study showed a "bell" shaped IOP dose response curve with 0.6% BID peaking at the curve (0.15%, 0.3%, 0.6%, 1.5%, 3%, 4.5%, and 6%) and that at Day 14, dose-dependent IOP reduction with 1.5% BID was more effective than 0.6% BID in normalizing diurnal variation in patients with glaucoma (0.15%, 0.3%, 0.6%, and 1.5%). For IOP reduction, 3% was superior to 6%. This is the first time that two components have been recognized associated with dual MOA given at therapeutic doses (range).

[0040] The present disclosure shows for the first time that although trebutin is associated with IOP reduction, the mechanism has been unknown until now. As discovered by the current inventors, trebutin has a significant impact, producing a vascular effect that is the main driver of IOP reduction (the largest), while the MMP effect improves IOP, has no direct effect on the contractile tissue or blood vessels (opening the mesh and increasing outflow facilities), on the contrary, it removes debris and changes the tissue texture of the TM, which improves the compliance of the contractile tissue in reducing IOP. With MMP therapeutics, the dual effect of a fast mode with a vascular effect (contraction) works in synergy with its slow mode of action.

[0041] The novel findings of the present invention include demonstrating that trebutadione is dose sensitive for vascular effects: 3% is superior to 6% for IOP reduction, and 0.6% is superior to 1.5% at the beginning before its MMP therapeutic effect ramps up. The present invention also demonstrates that trebutadione induces a fast mode IOP reduction through vascular effects (which may be NO dependent), so an optimal dose (bell shape) is required. 3% performs better than 6% for IOP reduction (preclinical and clinical evidence). See Figure 8, which shows that trebutadione 3% is superior to 6% on a "bell" shaped IOP dose reduction curve, which is a fast mode through vascular effects (Figures 8A and 8B).

[0042] Some blood vessels in the body are innervated by parasympathetic nerve fibers (e.g., coronary vessels). These nerves release Ach, which binds to muscarinic receptors on smooth muscle and / or endothelium. The vascular effect of A1R is vasomodulation (increased nitric oxide (NO) effect) via Gi protein coupling to muscarinic M2 nerves, similar to the effects of Ach on increased NO-induced muscle relaxation, A1R activation is coupled to cAMP production via Gi protein activation, which causes vascular relaxation (dilation) as well as A1R-mediated NO production. The targeted receptor is likely to be M2 parasympathetic innervation on vessels or contractile tissues such as TM smooth muscle cells and TM endothelial cells, which are most sensitive to NO. Brimonidine has the opposite effect, causing vasoconstriction via norepinephrine (NE)-mediated vasoconstriction where sympathetic innervation is present in vascular endothelium and / or smooth muscle cells. Preclinical studies have demonstrated that trebutin is more effective at rescuing and protecting RGCs and outer photoreceptors from apoptosis in a rodent model of ischemia-reperfusion compared to brimonidine, which lacks effects on outer photoreceptor cells (W McVicar 2015 ARVO).

[0043] Professor John Marshall's discovery of the impact of MMPs on Bruch's membrane regeneration and the clinical application of his 2RT in retinal specialist care provide additional understanding of the role of trepone-derived MMPs in TM basement membrane regeneration: both Bruch's membrane and the BM at the TM share common molecular structures and glycoprotein components: fibronectin, collagen IV, and laminin. 2RT and SLT also share similar effects by recruiting or regenerating new cells at adjacent areas (RPE or TM endothelium) that upregulate MMPs, which results in long-term therapeutic benefits of up to many years in a one-time treatment of early POAG / OH.

[0044] Prior art drugs such as the bimatoprost SR intracameral implant (DURYSTA®) upregulate MMPs with high concentrations of API released at target tissues (iris and CB), resulting in a drug holiday in 68% of patients with a single implant, however more than half of induced patients required rescue medication within 12-24 months (instability), likely due to increased rates of intraocular inflammation caused by high levels of SR API. Bimatoprost, like other prostaglandin analog drugs, is inherently proinflammatory (all commercially available PGA eye drops, including newer generation VYZULTA and ROCKLATAN, have FDA label warnings as they are associated with increased risk of cystoid macular edema (CME) and intraocular inflammation when given in low-dose eye drop formulations). DURYSTA® releases 4400 times more API to target tissues compared to bimatoprost eye drops (0.03% QD) administered on day 7. Three consecutive DURYSTA® implants allowed 80% of patients to maintain a drug holiday of 8 months or more, however such repeated treatments resulted in an alarming rate of corneal endothelial cell (CEL) loss, 20% in 20 months compared to 1% per year in normal aging (Reference: DURYSTA® Pivotal Ph3 clinicaltrials: ARMERTIS-1 and ARMERTIS-2). (See Figure 10).

[0045] The drug holiday reflects the full functional restoration of TM health and pressure sensors in the glaucomatous eye. It reflects the complex biological capabilities of pressure sensing cells that can self-regulate IOP without the need for additional assistance from symptom-relieving IOP drugs. The drug holiday parameters are determined based on two key aspects. First: Glaucoma disease stage defines pressure sensor recoverability (estimated: at least 50-70% of pressure sensing cells need to remain in glaucomatous eyes to achieve full functional recovery and a stable drug holiday of 6-12 months or longer. This parameter includes the percentage of patients: 50%-80%, the start time (1-3 months or 3-6 months induction), and the durability of the holiday period (3-6M or 12-24M or 3-5 years). Second: treatment efficacy and treatment duration. Efficacy includes MMP efficacy and neuroprotective efficacy. DURYSTA® has no neuroprotective effect on pressure sensing cells, and it increases inflammation and metabolic stress in pressure sensing cells. Therefore, trebutin is far more effective in SR (such as DURYSTA®) than PGA. The therapeutic benefit of trebutin increases with the treatment time, so its SR is more effective as a drug holiday inducer than eye drops.

[0046] In principle, extended-release trebutazone could induce a drug holiday in a higher percentage of patients at a faster rate, including those with more advanced glaucoma (e.g., patients taking 3 medications), with a longer duration, compared to DURYSTA®. In addition, extended-release trebutazone would induce a higher percentage of patients with a longer-lasting drug holiday compared to the shorter-release forms (e.g., 6M is better than 3M for severe glaucoma). However, the MMP benefit of DURYSTA® MMP treatment increases in proportion to its vision-threatening side effects on corneal and TM health (which was not previously recognized), compromising its MMP benefit.

[0047] Based on previous studies, as shown in Figure 11A, the durability of the drug holiday with a single-dose implant of DURYSTA® SR (10ug and 15ug of 4.2M API loading) resulted in 68%, 47% (estimated), 40%, and 28% of patients on a drug holiday of 6M, 9M, 12M, and 24M, respectively. Figure 11B provides the DURYSTA® API time course induction of drug holiday: a single implant of DURYSTA® SR at 4.2M API, loaded with 10ug and 15ug, resulted in 40% on drug holiday at 12M, and 3 consecutive implants of 10ug of 12-month API resulted in 80% of patients on drug holiday. By 8-month API (1 or 2 consecutive implants), approximately 60% of patients were estimated to be on drug holiday. In contrast, Figure 11C shows that in mild-moderate POAG / OH, administration of trebutinol as a low-dose eye drop (1.5% BID) can induce a unique dosing switch from BID to QD as early as 29 days, and 8 weeks in latanoprost poor responders. Dosing switching is a clinical biomarker of TM durability and a precursor to drug holidays.

[0048] In one embodiment, provided herein is a novel method and dosing regimen for improving intraocular pressure, comprising administering to a subject in need thereof a composition comprising 1.0-3.0%, 1.0-2.0%, or 1.2-1.5%, 1.5% of trebutin. The optimal dose (range) causes a peak IOP reduction in a "bell" shaped dose response curve, wherein 0.6% peaks at the beginning and 1.5% (or 1.0%-1.5%) catches up at a later time. In one embodiment, administration of the trebutin composition enables a unique IOP pattern to be achieved, with sustained IOP improvement toward a steady state. The pattern behavior comprises a slow-acting pattern in a time, dose, and disease stage dependent manner. In one embodiment, the invention as described herein is beneficial to subjects with early POAG / OH or late POAG / OH, including poor or non-responders to PGA. In one embodiment, the claimed invention is based on therapeutic improvement, not limited to symptom relief, wherein the therapeutic improvement includes but is not limited to improving or restoring trabecular meshwork function through the dual effects of neuroprotection and BM regeneration of stress sensing cell metabolic capacity, thereby benefiting its duration.

[0049] In one embodiment, the claimed invention normalizes diurnal IOP irregularity, with 1.5% BID eye drops being more effective than 0.6% BID eye drops for patients with glaucoma. In one embodiment, the invention effectively reverses mild to moderate dysfunction of sensing cell metabolic activity in early-mid stage glaucoma with mild to moderate TM pathology, and in another embodiment, the invention is more effective in arresting disease progression and treating advanced glaucoma with moderate to severe damage to the TM, further preventing the need for high risk glaucoma drainage surgery.

[0050] While not wishing to be bound by the following theory, it is believed that the invention as claimed herein is effective because trebutadione simultaneously activates three independent signaling pathways through A1R specific binding affinity, which triggers G protein-coupled muscarinic M2 receptor activation at the TM and CB, cell hyperpolarization at the TM endothelium, and MMP14 / MMP2 upregulation at the TM. In addition, it is believed that within the optimal dose range, trebutadione induces A1R activation, resulting in a neuroprotective or cytoprotective effect on pressure sensing cells at the TM in glaucomatous eyes. Such neuroprotection or cytoprotection is inhibition of calcium influx through G protein-coupled cell membrane hyperpolarization and restoration of cellular homeostasis of TM endothelial cells (or pressure sensing cells). Cell hyperpolarization represents a metabolic resting state of sensing cells with cytoprotective benefits. It is the M2 receptor activation that leads to IOP reduction through the contractile tissue in motion, rather than its source MMP biological effect, which has been previously misunderstood. Its MMP enzymatic degradation helps improve the compliance of the contractile tissue in response to the primary IOP regulation of the pressure sensor. The present invention reveals for the first time such an integral functional relationship between MMP upregulation and M2 activation at the TM / CB.

[0051] Again, without wishing to be bound by the following theory, it is believed that at optimal dosing, trebutin causes maximal IOP reduction via M2 receptor activation. Its vascular effects are sensitive to NO, also requiring an optimal dose (e.g., 0.6%-1.5%, 1.0-1.5%). Trebutin-derived MMP14 / MMP2 upregulation causes changes in basement membrane (BM) texture with increased elasticity and water conductance (similar to the MMPs in Bruch's membrane regeneration). It is also believed that increased TM water conductance increases oxygenation and metabolic waste discharge of pressure sensing cells at the patient's pathological TM.

[0052] In one embodiment, a composition comprising trebutadione is administered, for example, in the form of (eye drops) once a day, twice a day, three times a day, four times a day, once a week, twice a week, three times a week. In one embodiment, 1.5% (or 1.0-1.5%, 1.5-3%) trebutadione eye drops are administered twice a day as a loading dose during the initial period, and then may be switched to once a day. In certain embodiments, the loading dose period may be determined based on the disease state of early to late stage glaucoma, and in some cases, the loading dose period may include 1-12 weeks, 2-10 weeks, 4 weeks to 8 weeks, and increments therein. The dose switch from BID to QD is a precursor to a drug holiday, which is unique due to its powerful therapeutic benefits.

[0053] As a drug holiday stabilizer or maintenance agent, tropolamine ophthalmic solution administration does not require maximum IOP reduction or strict compliance, for example, the dose range can be 1.5%-3% QD, 3% QD, 1.5% BID, or 3% (at a frequency of QD), every other day or 3 times per week. Evening dosing is better than morning dosing.

[0054] In one embodiment, the composition comprising trebutin is administered as a sustained release (SR) formulation for the prevention and treatment of IOP failure in glaucoma. In order to achieve the maximum IOP treatment effect with clinically significant IOP reduction, the sustained release product should ideally produce an API concentration in the aqueous humor equivalent to the same API concentration (range) achieved by eye drops at a given optimal dose (range). In one embodiment, the optimal dose (range) of trebutin eye drops determines the API loading dose and release rate. In one embodiment, the sustained release formulation of the present invention can be made using polymer-based PLGA and / or PEG biodegradable or non-biodegradable materials.

[0055] In one embodiment, the sustained release formulation is provided in a form in which the shape, size and dimensions are minimally invasive, and / or is administered by an office-based procedure. The form can be an injectable rod, disc, ring, stent, and other comparable forms known to those skilled in the art. In one embodiment, a form of the "rod" in the anterior chamber can be made of biodegradable material to fit a 27G-30G needle with a length of 0.5-1.0 mm. The API life or sustained drug release can include a duration between 3-6 months, 6-12 months, or 12-24 months, or 1-3 months for a single implant. In one embodiment, the sustained release formulation can be delivered by various routes in a minimally invasive manner, such as in the anterior chamber, in the vitreous, on the choroid, under the Tenon's fascia capsule, around the eye, on the surface of the eye, and on the punctum plug. The sustained release formulation can also be made by medical coating technology, such as drug eluting stents, drug eluting contact lenses, and drug eluting intraocular lenses.

[0056] To minimize clinical side effects associated with SR formulations, the biodegradable polymer degradation rate and API release rate should be guided by the time when both are eliminated from the aqueous system simultaneously or within a 2-3 day or up to 7 day difference. Care should be taken to avoid API precipitation or long retention of empty implants without API in the AC as seen with Durysta (Ph3 trial). The superior advantage of the Trebutazone SR AC rod is its repeated dosing without stimulating intraocular inflammation, however, dosing intervals must be based on the duration of the drug holiday in the individual eye and the visibility of the implant, which will ensure the desired and targeted pharmacokinetic API release profile.

[0057] The novel methods and dosing regimens for improving intraocular pressure as described herein can solve the problems caused by intraocular pressure associated with glaucoma. Glaucoma can be early, intermediate or late, terminal glaucoma. In certain embodiments, glaucoma is POAG / OH, refractory POAG / OH, late POAG / OH, terminal POAG / OH, primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG), normal tension glaucoma, angle-closure glaucoma, such as uveitis glaucoma or pseudo-exfoliation glaucoma, steroid-induced IOP increase or glaucoma or congenital glaucoma.

[0058] In certain embodiments, administration of a composition comprising trebutin is combined with an additional therapeutic intervention. The additional therapeutic intervention may comprise surgical intervention or laser treatment. In certain embodiments, the additional intervention comprises administering an agent selected from the group consisting of Xalatan® latanoprost, Lumigan®, bimatoprost, Travatan Z®, travoprost, Zioptan™, tafluprost, Vyzulta™ (latanoprost brune), beta blockers, timolol, alpha agonists, Alphagan® P, brimonidine, lopidine®, carbonic anhydrase inhibitors, Trusopt®, dorzolamide, Azopt®, brinzolamide, Diamox, acetazolamide, Neptazane® (methazolamide), rho kinase inhibitors, Rhopressa®, Rocklatan®, netarsudil, or Cosopt®, Omlonti, or Ripasudil. In certain embodiments, trebutazone improves the IOP performance of Rhopressa®, Rocklatan®, omiretinib, or ripasidine in advanced or end-stage glaucoma. In certain embodiments, administration of a composition comprising trebutazone occurs after trabeculectomy or tube shunt in advanced stage glaucoma, after administration of SLT, Ellios laser, or transscleral laser. In certain embodiments, administration of a composition comprising trebutazone occurs after MIGS implantation, with / without cataract removal, and the MIGS device may comprise stent, Hydrus, microshunt, trabeculectomy, isent infinity, iDose in early moderate and refractory glaucoma, respectively. Trebutazone eye drops are a desired solution for stabilizing and extending the drug holiday of patients with unstable holidays (e.g., less than 2 months) receiving Durysta.

[0059] In one embodiment, the invention herein comprises a method for repairing a pressure sensor in the eye, comprising administering to a subject in need thereof a composition comprising 1.0-2.0%, 1.0-1.5%, or 1.5% or 3% of trebutadione. In one embodiment, administration of the composition causes upregulation of MMP14, cytoprotection of pressure sensing cells, anti-inflammatory effects on the trabecular meshwork / repair of the trabecular meshwork, vasodilation, or neuromodulation. In one embodiment, repair of TM comprises reducing inflammation, reducing extracellular matrix, restoring trabecular meshwork elasticity, and / or reducing mesh clogging. Regeneration and repair of TM restores the function of the pressure sensor in the glaucomatous eye and causes a drug holiday state, thereby allowing for prolonged suspension of IOP lowering therapy.

[0060] In one embodiment, a drug holiday in glaucoma patients can be induced by trebutin eye drops and / or its sustained release formulation products. In one embodiment, trebutin is provided by a sustained release biodegradable AC rod, which can be used as a loading dose delivery of MMP-14 therapeutic agents to rapidly induce a drug holiday. In early glaucoma, drug holidays may be as early as 3 months and last up to 3 years. Such trebutin AC rods can induce drug holidays in treated patients or refractory glaucoma, estimated to have 1-3 months, 3-6 months, or 6-12 months of API presence (preferably 2-4 months).

[0061] In certain embodiments, depending on the disease stage and the duration of API sustained release, the Trepotizon AC rod can be inserted into a given eye periodically, for example, every 3-6 months or 6-9 months, 9-12 months or annually, or every two years, or every three years or less frequently. In addition, the Trepotizon eye drops can be used as a drug holiday inducer with a fixed BID dosing regimen as a monotherapy or in combination with current standard of care eye drops or MIGS. In certain embodiments, the Trepotizon eye drops are used as a "relay" for drug holiday inducers after a MMP loading dose delivered by the Trepotizon AC rod or DURYSTA®. The eye drops can be used as a drug holiday inducer with a fixed BID dosing regimen as a monotherapy or in combination with MIGS or current standard of care eye drops. Once a patient achieves a drug holiday with SR MMP or MMP eye drops, IOP control or reduction is not required, at which point the Trepotizon dosing and regimen can be more flexible, for example 3% QD may be preferred. In one embodiment, a higher dose (e.g., 1.5%-3%) of tropolamine eye drops can be used as a drug holiday maintenance agent or stabilizer with a flexible dosing schedule (BID, QD, or every other day, or 3 times a week, without strict compliance).

[0062] Trebutazone eye drops (1.5% or 1.0-1.5%) have the advantage of being superior for the treatment of previously untreatable or refractory IOP elevation in patients with conditions involving severe intraocular inflammation such as uveitic glaucoma, pseudoexfoliation glaucoma, steroid-induced IOP elevation, or glaucoma with intraocular extended-release steroid implants such as Iluvein or Ozurdex implants or YUTIQ®. These patients have vision-threatening ocular complications such as diabetic retinopathy or diabetic macular edema, retinal vein occlusion, panuveitis, etc.

[0063] The Tribolium SR AC Rod has superior advantages in treating advanced to end-stage glaucoma, including but not limited to POAG / OH patients, due to its superior therapeutic efficacy and excellent clinical safety, which are inadequate in Durysta or other PGA-related SR intraocular implants. The Tribolium SR AC Rod can provide 24 / 7 MMP therapeutic restoration of pathological TM before pressure sensing cell death reaches its cell loss threshold towards irreversibility (e.g., >50% loss). Speed ​​of restoration without compromising safety is of the essence for this group of glaucoma patients.

[0064] Optimal tropol dosing, unique molecular signature, and distinct IOP pattern behavior in patients with glaucoma.

[0065] Trebutin is an adenosine mimetic and binds specifically to the A1 receptor (A1R). It is the first IOP "therapeutic" agent with the potential to repair and restore the pressure sensor function in patients with glaucoma. At the same time, it can effectively reduce IOP by 6-7 mmHg at day 28 in patients with early POAG / OH, possibly increasing their IOP reduction incrementally over time (unique pattern). Given at an optimal dose or dose range (specifically optimal API concentration in the aqueous humor), trebutin can simultaneously stimulate three independent signaling pathways through G protein-coupled cell membrane hyperpolarization (resting phase), MMP14 and MMP-2 upregulation in the TM endothelium, and muscarinic receptor 2 activation in the ciliary body and TM (similar to pilocarpine for M3 activation, but without miosis).

[0066] Specifically, the bioeffects of trebutadione-derived MMP-14 induce changes in TM texture with increased tissue elasticity and water conductance, similar to MMP-2-driven Bruch's membrane regeneration in the retina. Bruch's membrane is a basement membrane (BM) and shares a similar molecular structure with the BM formed by collagen IV, laminin, and fibronectin. BM health depends on continuous ECM remodeling by appropriate ratios of MMPs and TIMPs (tissue inhibitors of metalloproteinases), and with aging, MMPs are downregulated, ECM degradation slows, causing BM thickening and solidifying the mesh, so that TM tissue becomes rigid and loses elasticity and water conductance. Trebutadione triggers MMP-14 upregulation, which accelerates ECM turnover, cleans the mesh and increases water conductance of the BM, further improving oxygenation through the BM / ECM to pressure-sensing cells. In addition to its cytoprotective properties and neuroprotection of pressure-sensing cells, trebutadione can synergistically enhance patients' response to other IOP drugs such as ROCK inhibitors, especially in the advanced stages of glaucoma. Due to its dual effects of cytoprotection and BM regeneration, trebutin is a more effective therapeutic agent than prior art therapeutics such as DURYSTA®, which require very high API concentrations to trigger MMP upregulation (but no MMP14 and MMP2 release). Commercially available PGA eye drops do not upregulate MMPs in the aqueous humor (JY Heo, YH Ooi, DJ Rhee, 2020).

[0067] Treponema pallidum-derived MMP-14 is a member of the membrane-type MMP subfamily with a MW of approximately 66 kDa; it is one of the most potent MMP enzymes and removes various types of ECM debris at thickened and stiff BM, such as glycoproteins (fibronectin, vitronectin, laminin, and tenascin), proteoglycans and GAGs (decorin, versican, hyaluronic acid [HA]), collagens (types I, III, IV, V, and VI), elastic fiber components (MAGP-1, fibrillin), and glaucoma-associated proteins, (actin, which is common in human glaucomatous eyes). Its downregulation or deficiency is associated with premature aging. Upregulation of MMP-14 is associated with macrophage activation and anti-inflammatory activity in aged tissues from which it is derived, which distinguishes it from proinflammatory PGAs. Bimatoprost and travoprost SR induced MMP upregulation in proportion to the increase in intraocular inflammation, and even with a single implant, clinically visible or measurable intraocular inflammation was observed in the AC, such as AC flare, adhesions, or depigmentation changes around the implant (Ocular Therapeutics and Allergan study reports). PGA requires high concentrations to stimulate MMP upregulation, and MMP1, MMP3, and MMP-9 are the most reported MMP phenotypes in in vitro cultured TM models. PGA eye drops did not upregulate MMPs. DURYSTA® did not upregulate MMP-14 and MMP-2, even at high doses.

[0068] Unique pattern behaviors induce dosing switches, which are precursors to drug holidays.

[0069] Low doses of trebutazone eye drops (1.5%) contain therapeutic potency that improves the durability of the pressure sensor, demonstrating the ability to switch from BID dosing to QD as early as around day 29, which is unique to trebutazone. Such dosing switches are seen in both early and advanced glaucoma, including PGA poor responders. Its derived MMP therapeutics and cytoprotection enable sustained IOP reduction (or improvement) in a time, dose and disease stage dependent manner. This is a unique IOP lowering pattern of behavior that is unique to trebutazone as an IOP drug and is driven by its unique MOA and molecular features, unlike Vyzulta and Resclara or Rhopressa, which have very limited therapeutic benefit to patients. This IOP pattern of behavior is robust, reproducible and repeatable in both early and advanced stages of glaucoma. Such sustained IOP improvements enable dosing switches, which are the first reported precursors to drug holidays, seen in the therapeutic benefit of DURYSTA® sustained-release (SR) MMP in patients with glaucoma.

[0070] IOP lowering curves differ between trobutyric acid therapy and symptom-relieving drugs The unique IOP pattern behavior of trebutazone with time course improvement is based on a treatment curve that is the result of a perfect match between the drug's MoA and the underlying cause of disease pathology associated with elevated or uncontrolled IOP or IOP failure. Such treatment pattern behavior is driven by its unique molecular characteristics and dosing regimen. In contrast, most therapeutic agents available for the treatment of glaucoma, including RHOPRESSA®, VYZULTA®, and other IOP lowering drugs, are targeted at IOP symptomatic relief, showing a flat IOP lowering curve in a time course manner, e.g., IOP reductions at Week 1 and Week 12 are the same and consistent for patients in the same group or period. Vyzulta has a NO contributing group that showed mild improvement (less than 1.0 mmHg) during the first 12 weeks and then plateaued in a 12-month study of normal tension glaucoma (NTG) in a Japanese population. NTG is considered a subset of POAG with risk factors independent of IOP.

[0071] Trebotoxon is particularly desirable due to its therapeutic effects: it not only removes ECM debris through MMP bioeffects, but also has a unique cytoprotective effect by restoring TM endothelial homeostasis, which synergistically improves the survival of pressure sensors. It is suitable for all stages of glaucoma (early, mid-stage, end-stage or advanced), all types of glaucoma and pathologies involving ECM thickening and stiffness at the TM, such as POAG, NTG, PACG, secondary glaucoma, uveitic glaucoma, steroid-induced IOP elevation or glaucoma, refractory glaucoma, congenital glaucoma, etc.

[0072] The dosing principles and optimal dose of trebutinib were confirmed: 1.5% versus 0.6%.

[0073] The administration principle of the trebutadione combination is dominated by a fast-acting mode and a slow-acting mode. The fast-acting mode produces a "bell"-shaped dose-response curve, and an optimal dose is required to achieve maximum IOP reduction ( Figure 3 ). A single dose infusion of 0.6% trebutadione reached a peak at the "bell" shaped IOP dose response curve.

[0074] This rapid mode of action has vascular effects, inducing activation of G protein-coupled M2 receptors at contractile tissues of the CB or TM via A1R activation, similar to the effect of pilocarpine on M3 receptor activation, causing IOP reduction but without miosis. As with most IOP-lowering drugs with symptomatic relief, the rapid mode of action is synchronized with the pulsatile heartbeat, and similar to blood pressure, IOP also pulsates with circadian rhythms and diurnal variations or fluctuations. Trebutazone or INO-8775 reduces heart rate in rats by rapidly increasing potassium conductance in the atrioventricular (AV) node (at rest). Reference: Mor, Michal E. et al. 2013.

[0075] In glaucoma, patients suffer from greater diurnal variations than normal healthy individuals without glaucoma or OH. Such diurnal IOP irregularities in glaucomatous eyes are caused by irregularities in pressure sensor function; as glaucoma disease progresses from early to mid-stages and toward end-stages, the functional performance of the pressure sensor deteriorates over time if a threshold (unknown, e.g., 70% loss around the annulus) of sensing cell loss is reached, at which point the patient becomes a non-responder and invasive drainage surgery becomes inevitable. Similar to the corneal endothelial loss that reaches a threshold (500-1000 cells / mm2) that causes corneal edema or decompensation and blurred vision, in the TM, there is a threshold of pressure sensing cell loss (edema or cavitation) before the outflow engine shuts down completely (irreversible damage) and the patient becomes a drug non-responder. During normal aging, TM endothelial loss is 0.58% per year per eye (similar to the 0.6% per year corneal endothelial loss under normal physiological conditions). In glaucomatous eyes, this process is accelerated, with intraocular inflammation and metabolic stress causing accelerated apoptosis. At age 20, there are approximately 750,000 cells, and at age 80, there are approximately 400,000 cells. For example, for a 60-year-old patient with glaucoma, it is estimated that 70% of the TM cells at his age may be needed to achieve full recovery or a drug holiday.

[0076] The slow-acting mode is the treatment group of trebutin that showed steady state in a time-, dose-, and disease stage-dependent manner ( Figure 3 A). In clinical studies, it took more than 3 months for tropol to reach steady state in early POAG / OH with very mild damage. 0.6% had previously been identified as the optimal point to peak at the "bell" shaped dose response curve at the beginning. However, it was surprisingly found that higher doses such as 1.5% BID (or 1.0-1.5%) were more effective than 0.6% in normalizing diurnal IOP irregularity and producing a drug holiday at an earlier time point, given its MMP therapeutics and its positive effects on neuroprotection of pressure sensors. The higher dose (1.5% BID) was also more effective in treating severe disease conditions that require timely repair to avoid massive irreversible damage (apoptosis) to pressure sensors. Figure 4A / B / C show three different scenarios of the interaction of 0.6% BID and 1.5% BID (an example of a higher dose) that track the end point (steady state).

[0077] The optimal dose not only ensures IOP lowering at the peak of the “bell”-shaped dose-response curve, but also requires achieving maximum or optimal “therapeutic” benefit via G protein-coupled vasodilation or muscle relaxation via release of nitric oxide (NO).

[0078] Dosing and regimen of trobutyric acid eye drops As claimed herein, the present invention comprises administering trebutinol in an optimal dosage range of about 0.15%-6%, 0.6%-6% or 3-6%, 1.0-2.0%, 1.5-3% or preferably 1.0-1.5%, 1.2-1.5% or specifically, 1.2% or 1.5%.

[0079] In one embodiment, the dosing regimen at the beginning of monotherapy is BID, which can be switched to QD at 2-4 weeks, 4-8 weeks, 8-12 weeks, or 3-6 months, or 6-9 months, or 12-24 months, depending on the need and stage of the disease (e.g., drug holiday inducer). The regimen requires a BID fixed dose regimen at the beginning. It is recommended to continue to administer the drug until the drug holiday is achieved, but it can also be switched to QD at the time points mentioned above. For drug holiday maintenance agents or as a supplement to MIGS or other glaucoma surgery or laser treatment for patients whose IOP is controlled, the trebutazone eye drop dosing regimen can be used flexibly at BID or QD, or can be three to five times a week without compliance. Depending on its clinical utility or purpose, for drug holiday stabilizers or maintainers, the clinically effective dose range of trebutazone can be extended from 1.5% QD to 3% QD, depending on the circumstances.

[0080] In one embodiment, for at least one trebutin eye drop formulation: the concentration of trebutin will be the same at all stages of preclinical and clinical trials, with the optimal concentration being 1.5% (or 1.2%, or 1.0-1.5%, or 1.0-.02%, or 1.5%-3.0% or 3-6%). The eye drops may be prepared in the form of nanoparticle eye drops, microparticle suspensions or emulsions. The formulation may further comprise dextran or fluorinated or other lipid materials. The eye drops may be prepared as water-based solutions, lipid-based emulsions or other suspension formulations. The eye drops may or may not contain a preservative.

[0081] Effects of tropodisone on the duration and TM health of the IOP pressure sensor in glaucoma.

[0082] Components of the TM pressure sensor: The trabecular meshwork is a porous, spongy, avascular tissue formed by ECM contractile tissue that terminates at the basement membrane and endothelial cells on top of it that form a monolayer lining at the inner wall of Schlemm's canal. For decades, the most advanced pharmacological research and drug development has been focused on the paratubular (JCT) zone where outflow resistance is located. Rho kinase inhibitors (ROCK inhibitors) such as Rhopressa are drugs that relax the JCT by modulating the dynamics of the actin fibers (cytoskeleton) of the contractile tissue at the TM, which relaxes the ECM space at the JCT zone and causes increased outflow through the TM. Few people are aware of such contractile activities that are governed by pressure sensors (the first level of command). If the pressure sensing cells are under extreme oxidative stress 24 / 7, Rhopressa will not work, even without significant cell loss, and the patient will become a non-responder. Trebuta has the ability to repair and regenerate these metabolically damaged cells before they undergo irreversible apoptosis. For example, in patients with the Hydrus intraocular stent implant, in which a quarter of the pressure-sensing cells are metabolically impaired or die, Trebutazone has the ability to protect and prevent the remaining ¾ of the cells from apoptosis as the disease progresses toward more advanced stages, whereas current IOP agents lack the appropriate MOA to regenerate, repair and restore function to these sensing cells.

[0083] The inventors herein are the first to demonstrate IOP regulation at a pressure sensor located at the distal end of the TM, consisting of the TM endothelium as well as its underlying BM, based on the trepone A1R target site of action (causing IOP improvement in patients). Just as blood pressure has a pressure sensor at the heart, IOP also has a pressure sensor at the TM. It consists of two components; one is the pressure sensing cell, which is a cobblestone-shaped neuronal lineage cell that forms a monolayer lining at the inner wall of Schlemm's canal (sometimes referred to as the TM endothelium or Schlemm's canal endothelial cells). It is a shear stress sensor for maintaining IOP homeostasis in response to oxidative stress, sensitive to NO levels (Fiona McDonnel et al. 2021). The second component is the basement membrane (BM) beneath the TM endothelium, which consists of collagen IV, lamellae, and fibronectin in the healthy TM, providing essential support for the health and persistence of the sensing cells that lack self-renewal after injury in the adult human eye, similar to RPE cell health, which depends on the elastic water conduction of the Bruch's membrane beneath it. MMP2 and MMP-14 are the major MMPs involved in regulating IOP homeostasis in TM cells in response to mechanical stretch via the mTOR pathway (Reference: J Bradley et al. 2003).

[0084] MMP-14 is a potent enzyme that helps clean the meshwork and remove ECM debris from the BM through proteolytic degradation of fibronectin, laminae, and collagen IV, as well as other pathological proteoglycans deposited in the glaucomatous eye, such as glycoproteins (fibronectin, vitronectin, laminin, and tenascin), proteoglycans and GAGs (decorin, versican, hyaluronic acid [HA]), collagens (types I, III, IV, V, and VI), elastic fiber components (MAGP-1, fibrillin), and glaucoma-associated proteins (myocilin deposited at the TM sheaths and trabeculae, which are common in human glaucomatous eyes).

[0085] Root causes of elevated or uncontrolled IOP in glaucoma: The present invention also reveals for the first time that pressure sensor dysfunction, wear or failure is the rate limiting and primary root cause associated with elevated or uncontrolled IOP in patients with glaucoma, which further informs future therapeutic developments for the clinical management of IOP in glaucoma. Pressure sensor dysfunction in glaucoma is a result of TM endothelial cell senescence and apoptosis (with underlying BM thickening and stiffness caused by age-related oxidative stress, metabolic inflammation or parainflammation), similar to RPE loss and Bruch's membrane senescence (thickening or atrophy) as rate limiting in dry AMD. In glaucomatous vision loss, neurovascular inflammation involves both the anterior and posterior of the eye. At the anterior of the eye, it causes functional irregularities in the early stages of the disease, either apoptosis (late stage) of pressure sensing cells or early stages of the disease. Pressure sensing cells are neural lineage cells that share commonalities with neuronal cell biology. At the posterior of the eye, neuroinflammation affects RGC health, causing apoptosis. Oxidative stress and metabolic inflammation lead to glutamate excitotoxicity in both neuronal cells. Trebutazone exerts its neuroprotective effects through G protein-coupled cell hyperpolarization, restoring cellular homeostasis, thereby reducing oxidative stress or damage to RGCs and pressure sensing cells. Trebutazone demonstrated its neuroprotective effects against RGC apoptosis in two preclinical models (through enhancement of multiple direct RGC protection and indirect neurovascular modulation involving Muller glial cells, astrocytes and microglia, and more importantly, a powerful vascular effect (dilation)).

[0086] Trebuthidrosisone and refractory glaucoma Refractory glaucoma represents a clinical state in which glaucoma patients do not respond well to current symptom-relieving medications, which may be the result of advanced or terminal POAG / OH and PACG, or the result of uveitis or PXF-related or steroid-induced, or congenital glaucoma. The trebutilone therapeutic agent dosing regimen of the present invention provides a superior advantage to this group of patients with severe ECM coagulation or fibrosis and dysfunctional or damaged pressure sensors (no effective treatment is currently available). In POAG / OH, approximately 25-30% of patients suffer from inflammatory susceptibility, with increased pro-inflammatory molecules (such as TNFa, NF-κB, interleukins, bradykinin) circulating in the bloodstream, and some patients have genetic susceptibility, such as mutations in the optic nerve protein gene (reference: G Qiu 2015). These pro-inflammatory molecules or cytokines enter the anterior chamber from the bloodstream exposing the TM pressure sensors to ongoing metabolic damage or parainflammation (subthreshold inflammation) along with aging-related oxidative stress, risk factors that accelerate apoptosis of the sensing cells and thickening of the underlying BM, as well as fibrotic coagulation of the TM meshwork, collectively leading to rupture of the TM outflow engine in end-stage glaucoma. Such inflamed aqueous humor is often the root cause associated with failure of filtration surgery as a result of fibrosis of the filtering bleb. Both CYPASS® and DURYSTA® kill the corneal endothelium at an alarming rate in the same subset of “inflamed” glaucomatous eyes, which may have been barely noticed previously.

[0087] Uveitic glaucoma involves more severe intraocular inflammation than advanced POAG / OH and causes severe damage to the pressure sensor, especially during acute episodes of disease recurrence. Steroids have been the mainstay of treatment for uveitis, however, steroids further exacerbate the TM pathology. Most uveitic glaucoma is refractory and no effective treatment is currently available.

[0088] Pseudoexfoliation syndrome is a systemic condition in which abnormally high concentrations of fibrillar proteinaceous material are produced within the tissues of the eye. It is the most common cause of secondary glaucoma worldwide and the most common cause of unilateral glaucoma. The resulting pseudoexfoliation glaucoma responds less well to medical therapy than other types of glaucoma and can lead to rapid progression of optic nerve damage. The prevalence can be as high as 5% in people aged 75 years or older and 0.6% in people aged 52-62 years.

[0089] Steroid-induced IOP elevation is the result of ECM accumulation at the TM causing BM thickening and dysfunctional pressure sensors, which is usually a transition that can be treated with standard of care IOP-lowering medications in most patients, but approximately 4-5% of patients may become drug non-responders with recurrent IOP spikes and eventually develop refractory glaucoma requiring high-risk glaucoma drainage surgery, which is common in Iluvein and repeat Odisra users. For steroid-induced IOP spikes, MMP therapeutic eye drops are a better option than MMP-based gene therapy.

[0090] Trebutazone eye drops delivering MMP are the best choice for steroid-induced IOP spikes or glaucoma in a broad target population, including patients in need due to cataract surgery and retinal gene therapy who require short-term steroid therapy, as well as patients with DME or uveitis who require long-term steroid therapy. In contrast, other extended-release products such as DURYSTA® may cause complications such as severely inflamed aqueous humor in patients with DME or uveitis who require long-term steroid therapy (e.g., patients taking Odisra or Iluvein).

[0091] Primary angle closure glaucoma (PACG) typically presents acutely, causing adhesions or microfibrosis around the TM, resulting in scattered or punctate pattern damage to the pressure sensor around the clock. For patients undergoing trabeculectomy or tube shunts or under standard care with laser or eye drop therapy, protecting the health and longevity of the remaining pressure sensor becomes extremely important. The prevalence of PACG is approximately 1 / 3 of the POAG population and 74% of the glaucoma population, yet it causes 50% of glaucomatous blindness, typically seen in small Asian eyes with shallow AC. The DURYSTA® implant (27G. 1.0mm) may be too large to fit into small eyes with PACG. In contrast, trebutazone offers a more effective MMP intervention with neuroprotection, allowing for a smaller “rod” size with an equivalent slow release duration, which may be an advantage for patients with PACG.

[0092] Normal Tension Glaucoma (NTG): NTG is a subset of POAG, but patients have an IOP below 21 mmHg. Vision loss in patients with NTG involves both pressure-independent risk factors such as neurovascular abnormalities, with the former being the primary causative factor and no effective treatment available. Compared to the current standard of care medication (symptom-relieving eye drops), Trebotoxon offers superior benefits and overall therapeutic potential to address the root causes associated with both the front and back of the eye.

[0093] Trebutin treatment in combination with current standard of care. For advanced glaucoma, trebutin (eye drops or SR) can be combined with first-line PGA drugs (such as Vyzulta, ROCKLATAN, latanoprost, travoprost, bimatoprost) and second-line IOP-lowering drugs (such as Rhopressa, timolol, brimonidine, CAI) as a "triple" or with a combination of 2 drugs to manage difficult and refractory cases. Preferably, trebutin combined with a ROCK inhibitor (such as Rhopressa) may improve or enhance the IOP-lowering efficacy of Rhopressa by repairing or improving the function of the pressure sensor in this end-stage group (otherwise drug non-responders). For patients who require 2 to 4 drugs, trebutin treatment may reverse the disease stage to the point where fewer drugs are needed, or prevent the disease from progressing toward a stage where all drugs have failed and high-risk surgery is inevitable. For advanced or refractory glaucoma, tropolamine (eye drops or SR) may also be an effective addition to patients with MIGS such as microshunts and trabeculectomy or tube shunts.

[0094] Trebutazone treatment as a drug holiday inducer or stabilizer The term "drug holiday" was originally used for cancer patients undergoing chemotherapy, during which periods of remission did not require treatment. In glaucoma IOP management, a drug holiday reflects the healthy state of the TM in the glaucomatous eye, indicating that the function of the pressure sensor has been restored to the point where medication is not required to maintain IOP at normal or target levels. It also reflects the complex metabolic capabilities of the pressure sensor, which can self-regulate IOP in response to shear-stretch in patients with glaucoma.

[0095] The discovery of a possible drug holiday caused by trepone-derived MMPs is based on the common thread of key enzyme proteins upregulation by the following shared MMPs in specialized care for retina and glaucoma: 1) DURYSTA®-derived MMP therapeutics cause patients to be in a sustained drug holiday, a clinical phenomenon that was previously not fully understood, 2) Retinal regeneration laser (2RT) induces MMP-2 upregulation in patients with dry AMD, and subretinal fluid resolution in patients with DME, demonstrating sustained clinical benefit that can last for 6-12 months or longer. 3) SLT lasers for glaucoma may also produce long-term clinical IOP control through a similar mechanism as 2RT lasers, where MMPs are upregulated. Leading experts in the field describe DURYSTA®-derived MMP bioeffects as a one-time anatomical change that causes ECM remodeling, however few realize that MMP-induced ECM remodeling causes TM regeneration, with changes in the texture of the BM, and MMP therapy has the ability to turn a 60-year-old Bruch's membrane into a 40-year-old Bruch's membrane, increase hydraulic conductance, and help regain its elastic youth, ultimately resulting in better tissue oxygenation and metabolic exchange.

[0096] Whether and how long glaucoma patients can achieve a drug holiday depends on TM restorability, which is essentially dependent on the number and quality of pressure-sensing cells (rate limiting) as well as treatment potency and duration. For example, for a given disease stage, trebutazone SR is more effective than DURYSTA® SR, and the trebutazone SR formulation is also more effective than its eye drops in driving patients toward a drug holiday and repairing severe TM damage (such as refractory glaucoma). Single implantation of DURYSTA® SR may be more effective than trebutazone eye drops (pulsatile delivery), and repeated implantation may impair pressure sensor function due to increased intraocular inflammation (ARMETIS-1 and 2 Ph3 clinical trials).

[0097] The timing and duration of drug holiday induction is directly related to the recoverability of the pressure sensors, which is determined by the disease stage or severity and extent of damage: for example, a loss (apoptosis) of 25%, 50%, 75%, or 80% of the pressure sensing cells around the Schlemm's canal ring. The therapeutic potency of the agent and its duration of treatment is another important parameter in determining the timing and durability of drug holiday induction. Cell loss and recoverability (unknown): For example, it is unclear what percentage of remaining pressure sensing cells is required in a patient with glaucoma to achieve a stable drug holiday of 3 or 6 months or longer. Pressure sensors appear to be metabolically very robust. For example, 15% of patients with a Hydrus implant may suffer severe damage to one quarter (1 / 4) of the pressure sensing cells in the ring, where the remaining ¾ of the cells can compensate for the loss of ¼ of the cells, and some individuals appear to still be functioning well at year 2 without the need for additional medication. Although it is unclear whether 75% of the remaining cells without Hydrus contact would be sufficient to self-regulate if fully restored by trepothione MMP treatment, it is estimated that 70% of functional sensing cells should be sufficient to compensate for damage in a glaucomatous eye within a given time if pressure is controlled.

[0098] The number and quality of sensing cells are rate limiting for disease pathology associated with elevated or uncontrolled IOP, and the effect of trebutazone on TM recoverability is determined by the minimum number of sensing cells that can compensate for loss in chronic and long-term glaucoma disease progression. Similar to the corneal endothelium, there is a threshold of cell loss when the cornea decompensates due to edematous changes, blurring vision. During normal aging, the TM endothelium is lost at a rate of 0.58% per year per eye. In the glaucomatous eye, this process is accelerated, with intraocular inflammation and metabolic stress causing cell apoptosis to accelerate. At the age of 20 years, there are approximately 750,000 cells, and at the age of 80 years, there are approximately 400,000 cells. Although there is no established information on the threshold, it is estimated that for a 60-year-old patient with glaucoma, it is estimated that 70% of the TM cells at his age may be required to achieve full recovery or a drug holiday.

[0099] For the same group of patients with POAG / OH taking 1-2 medications, as the DURYSTA® treated population, it is expected that at least 80% or more of this group of patients can achieve a stable medication holiday of 6 months or more with a single trebutin SR implant. Specifically, for the same group of patients with POAG / OH taking 1-2 medications, it is expected that 3 months of MMP induction (single implant) can enable more than 28% of patients (e.g., 50%) to achieve a stable medication holiday of more than 20 months duration. Specifically, with a single implant of trebutin (SR API duration of 3-5 months), it is estimated that 60-70% of patients taking 1-2 medications can achieve a stable medication holiday of 6 months to up to 3 years. With a single implant of trebutin (SR API duration of 1-3 months (for smaller eyes)), it is estimated that 50% of patients taking 1-2 medications can achieve a stable medication holiday of 6 months to up to 3 years in some individuals. In patients with advanced disease on 2-3 medications, a single implant of Trebutazone (SR API duration of 3-5 months), MMP induction may result in 50% or more of patients being on a drug holiday of 6 months or more. In patients with more advanced glaucoma on 2-3 medications, 3-4 medications, or requiring high-risk drainage surgeries such as tube shunts or trabeculectomies, the Trebutazone SR Implant (AC Rod) may reduce medications from 3-4 to 2-3 medications, or from 2-3 to 1-2 medications, or replace such invasive risky surgeries that typically have a >50% failure rate within 3-5 years. The Trebutazone SR Implant (like the AC Rod) is more effective than its eye drop formulation in this advanced glaucoma or refractory glaucoma. The Trebutazone SR Implant (like the AC Rod) has superior advantages over DURYSTA® in advanced glaucoma (2-4 medications) through its anti-inflammatory and vasodilatory benefits. Trebutazone can be manufactured in a smaller SR size, which could fill a gap in the market for primary angle-closure glaucoma where DURYSTA® is not recommended. DURYSTA® significantly increases intraocular inflammation at an alarming rate, causes vision-threatening side effects, and is only allowed for a single implant (restricted) for clinical safety purposes. It may need to be used with caution in patients with advanced glaucoma.

[0100] Target curve of tropodisone sustained-release product In one embodiment, the sustained-release device containing trebutadione comprises a biodegradable material (e.g., PLGA or PEG) in a shape suitable for use in the eye, including but not limited to a "rod" shape and preferably a size suitable for a 30G needle (or 27G-30G) and a length of 0.5-1.0 mm, via intracameral injection in an office-based procedure. In one embodiment, the device should be capable of re-dosing or repeated dosing at the end of the drug holiday. In one embodiment, the API loading dose and daily release rate or speed are designed to enable API SR duration of 3-6 months, which may enable 80% of treated patients to achieve a stable drug holiday of at least 5-6 months and up to 3 years depending on the disease stage (early versus advanced). In one embodiment, for SR products, the API daily release rate (speed) is optimized based on the optimal API concentration in the aqueous humor, determined by optimal eye drop dosing (1.5% BID) preferably in week 4 (between week 1 and week 4). The optimal API concentration in the aqueous humor delivered by trebutadione SR or eye drops should be the same, with a small range of variation. The optimal concentration of such API in the AC or aqueous humor should be the same in preclinical animal models (rabbit, dog, monkey) and human patients. At such optimal API in the aqueous humor in the AC, trebutinol causes the maximum IOP reduction (6-7 mmHg or more) with maximum therapeutic effectiveness.

[0101] In certain embodiments, the sustained-release trebutadione devices contemplated herein comprise devices and forms that can be delivered, administered, implanted, or otherwise applied to a patient via anterior chamber, intravitreal, suprachoroidal, periocular, sub-Tenon's capsule, sub-conjunctival, posterior to the eyeball, or on the surface of the eye, via a drug eluting contact lens or ring or punctal plug. The SR form can be of various shapes and sizes, such as rods, discs, stents, rectangles. In one embodiment, the size of the SR anterior chamber implant can be made 27-30G, with a length of 0.5-1.0mm. 30G is preferred. The SR form can be made by medical coating technology, for example, iDose drug eluting stent, drug eluting contact lens, drug eluting intraocular lens (Spyware), etc.

[0102] According to certain embodiments, the IOP profile induced by trebutadione eye drops has a slow onset of action, a ramp-up time of approximately 4 weeks to achieve 6-7 mmHg, and may take 3 months or longer to reach its steady state, where maximum IOP reduction is achieved in early-mid glaucoma. The IOP profile induced by trebutadione SR AC rod is estimated to have a rapid onset of action, with a ramp-up time of less than 4 weeks, because MMP exposure is continuous and its eye drops are required. Compared to DURYSTA® MMP and trebutadione SRAC rod, which deliver MMP continuously, trebutadione eye drops deliver MMP twice daily, and it will take longer to induce a drug holiday for the same group of patients. Although there is no direct reference to the eye drop MMP induction time to achieve a drug holiday, based on the trebutadione eye drop MMP potency, the dosing switch from BID to QD occurred as early as 29 days. If a loading dose of MMP delivered by DURYSTA® (currently available) is used, it is estimated that 50-80% of patients taking 1-2 medications may achieve a stable drug holiday of 4-6 months or more within 12-24 months after BID dosing. Trebutazone Ophthalmic Solution is best used as a drug holiday inducer or stabilizer (in combination with SR MMP delivery via DURYSTA® or Trebutazone AC Rod), patients who have not achieved a drug holiday state can be induced with Trebutazone Ophthalmic Solution, and for patients who have achieved a drug holiday, Trebutazone Ophthalmic Solution can be used as a maintenance agent or stabilizer, with an estimated total of 50% to 80% of patients achieving a stable drug holiday of 6 months or more within 12-24 months.

[0103] Trebutazone is a more potent stimulator of MMPs, with MMP-14 being the most potent MMP in the family, which also has direct cytoprotective effects on stress-sensing cells, and therefore, Trebutazone "treatment" achieves a longer drug holiday in patients with more severe or end-stage glaucoma with equivalent API induction times. Trebutazone has an excellent clinical safety profile and is the only drug holiday inducer that does not increase intraocular inflammation.

[0104] The sustained release (SR) derived API dose concentration in aqueous humor within the first 30 seconds after instillation after 4-6 weeks of multiple dose BID treatment should be the same as the API concentration delivered by its eye drops, regardless of the delivery route and product prototype material or SR duration. The API loading dose and release rate (daily) are determined by the API concentration at its site of action in the aqueous humor in the AC tissues (TM and CB). The optimal dose ensures maximal therapeutic outcome with IOP reduction reaching its maximum steady state in 3-12 months or 6-12 months or 3-6 months or 1-3 months.

[0105] Effects of tropodisone treatment on the back of the eye - Tropodisone and wet age-related macular degeneration (AMD): Study of bordisone in reducing atrophic lesions in patients with wet AMD following long-term anti-VEGF therapy.

[0106] Trebutazone was originally developed for the treatment of cardiovascular disease, pain and inflammation, and diabetes, and there are a number of clinical trials for the treatment of cardiovascular and diabetes based on this adenosine A1R-related drug in Ph1-3 clinical trials. Adenosine A1R-targeted therapies have also been studied in models of stroke and in models of ischemia-reperfusion in the eye (elevated IOP models). A1Rs are most abundant in neurons in the brain and retina, and are also present in microglia, astrocytes, oligodendrocytes, and Muller cells. A1Rs have a high density distribution in the inner retina (RGC cells and nerve bundles), but a lower density in the photoreceptor layer. In at least one model of optic nerve crush, trebutazone eye drops showed neuroprotection in both the inner RGC layer of neurons and the outer layer of neurons (photoreceptors) in an ischemia-reperfusion model, while brimonidine did not protect against photoreceptor loss. Trebutazone has been observed as an effective neuroprotectant for RGC cell rescue in the NAION mouse model, which involves ischemia-reperfusion pathology. In a light-damaged rat model that mimics one aspect of AMD disease progression (oxidative damage), trebutazone has also demonstrated its role in rescuing photoreceptor cell loss through indirect targets, likely involving Müller glial cell-driven anti-inflammatory pathways and choroidal vasomodulation or vasodilation, where its neurovascular modulation is important for removing outer segment detachment during bright light damage. Based on such studies, trebutazone is a therapeutic candidate for atrophic lesions in wet AMD. The key pathology in wet AMD that is overkill with ranibizumab (Lucentis) is choroidal ischemia surrounding macular lesions. Eye drops with formulations that can carry the API to the choroid and outer layers of the retina should be effective in reducing such atrophic lesions, as shown by evidence from the Rescue clinical study report in this indication, and both eye drops share a commonality of being neurovascular modulators with high penetration into scleral tissue.

[0107] Example Example 1 Trepotex treatment for patients with early-mid POAG / OH. The Trepotex extended-release (SR) AC rod will be used as a loading dose followed by Trepotex eye drops as a drug holiday maintenance agent for patients who have achieved drug holiday, or as a drug holiday induction agent for those who have not achieved drug holiday with the loading dose and require additional MMP to drive repair and recovery of the pressure transducer toward full restoration. The endpoint will be the percentage of patients who achieve drug holiday within 3-6 months (or 1-3 months) using the Trepotex AC rod alone. Due to its therapeutic potency, its IOP ramp-up time in SR will be faster than its 1.5% BID eye drops, which require 4 weeks to achieve a 6-7 mmHg reduction; moreover, for example, with a 3-6 month SR duration of trebutazone, it is estimated that 80% or more of treated patients may achieve a stable drug holiday of 6 months or more, and its IOP reduction curve will be equivalent to 2-line IOP drugs (such as Rhopressa or latanoprost) with a daytime IOP baseline of 7 mmHg or more starting at week 2, followed by weeks 6 and 12 as clinical IOP endpoints (primary endpoint). The remaining 20% ​​of patients who receive a SR loading dose of trebutazone and progress toward a drug holiday can be supplemented with trebutazone eye drops (1.5% BID), and it is estimated that within 6-12 months, these patients can achieve a stable drug holiday of 6 months or more.

[0108] Duration of Trebuta SR: Based on preclinical studies with Durysta in a normal dog model, one month of MMPSR treatment appears to produce a stable state. Trebuta SR given for 1-3 months (or 3-5 months) may be sufficient to induce a stable drug holiday of 3-6 months or longer in 60-70% of patients. For patients with advanced glaucoma with more severe TM damage, longer duration of MMP induction and more than one implant (such as two consecutive implants, each lasting 1-3 months, or one implant with 3-5 months API release) may be required to repeat this situation.

[0109] If the Trebutazone AC rod is not available, DURYSTA® could be used as an alternative to the MMP loading dose to study Trebutazone eye drops as a drug holiday inducer. The clinical endpoints and study design would be similar to those described above using the Trebutazone SR AC rod.

[0110] A: Clinical endpoints for the Trepotex SR AC rod clinical trial: The primary endpoint will be the percentage of patients who achieve a stable drug holiday (at least 3-6 months) after a single implant (with a 3-6 month SR duration). Rhopressa eye drops will be used as a positive control. The co-primary endpoint will be the 3-month IOP reduction curve at all time points at 8am, 10am and 2pm at Week 2, Week 6, Week 12, equivalent to current 2nd line eye drops such as Rhopressa or timolol eye drops.

[0111] B: Clinical trial endpoints for Trebutazone as a drug holiday induction agent: Study drug holiday parameters using Durysta or Trebutazone SR (if available) as MMP loading dose followed by Trebutazone (1.5% BID). This will be a superiority study compared to 2-line IOP eye drops such as Rhopressa or Timolol. The primary endpoint will be the percentage of patients who achieve a stable drug holiday at the 12-month endpoint after 4 months of Durysta MMP treatment with a SR loading dose. Secondary endpoints: During the drug holiday induction period with Trebutazone, IOP will be measured at weeks 2, 4, 8, 12, and monthly until drug holiday is achieved or the 12-month endpoint, all IOP reduction points need to be maintained (except week 2 given the slow onset of action of Trebutazone) or comparable to Timolol or Rhopressa (2-line IOP eye drops), whichever is applicable.

[0112] Example 2 Trepotizon Therapy for Refractory Glaucoma (End-stage POAG / OH). Trepotizon (SR or eye drops) will be used as a "triple" combination in patients with end-stage POAG / OH or refractory glaucoma, for example, the triple combination would be Trepotizon (SR or eye drops) + Rhopressa + Brimonidine versus Bimatoprost (SR or eye drops) + Rhopressa + Brimonidine (positive control).

[0113] Tribolium SR AC Rod as a Triple Combination Clinical Endpoints Relative to Durysta: 12-month Tribolium-derived MMP therapeutic-induced IOP improvement will be the primary endpoint, measured by the percentage of patients who can improve or maintain corresponding IOP and visual field stability without the need to add a 4th medication or invasive glaucoma surgery due to disease progression. Secondary endpoints: Percentage of patients requiring less medication at the 12-month endpoint following SR implantation of MMP therapeutic. Secondary endpoints: IOP reduction at Weeks 2, 4, 8, 12 compared to active control (equivalence).

[0114] A clinical trial of trebutazone eye drops + Rhopressa + brimonidine vs. bimatoprost + Rhopressa + brimonidine for patients with refractory glaucoma who require 3 medications at admission. The primary endpoint will be extended to 24 months at 12 months to compare the percentage of patients in the two treatment groups who require the addition of a 4th medication or who inevitably require a trabeculectomy or tube shunt due to their worsening VF or change in target IOP. The IOP reduction during treatment must meet the criteria for the target IOP defined for each study eye or individual at the start of the study, which may vary. Specifically, IOP will be measured at Weeks 2, 4, 8, and 12, followed by monthly measurements until the study endpoint at Months 12 or 24.

[0115] Expected Results: Trebutazone SR is more effective than Durysta in repairing pressure sensor failure and dysfunction in this end-stage group, and therefore, the SR formulation should achieve a significant difference in IOP improvement in a higher percentage of the patient population at 12 months compared to Durysta SR. In the Trebutazone triple combination therapy study, Trebutazone is expected to perform better than the active control group without Trebutazone or MMP therapeutics, as it is a historically known fact that IOP in the latter patients will worsen over time. Within 12-24 months, some individuals will progress faster than others to the point where their corresponding target IOP will need to be lowered further by adding a 4th medication or giving surgical options. In principle, IOP improvement will be faster with Trebutazone SR than with Trebutazone.

Claims

1. A method for preventing or treating intraocular pressure (IOP) failure or uncontrolled IOP of an eye, the method comprising administering a composition comprising Trabodenoson at a dosage in the range of 1.0-1.5%, 3-6%, 1.0-3.0%, 1.5%, 1.2%.

2. The method of claim 1, wherein a given optimal dose (range) causes a peak IOP reduction in a "bell" shaped dose response curve, wherein 0.6% peaks at the beginning and 1.5% (or 1.0%-1.5%) catches up at a later time, which is therapeutically more effective.

3. The method of claim 1, wherein administration of the composition results in sustained IOP improvement toward a steady state.

4. The method of claim 1, wherein administration of the composition results in upregulation of MMP14, cytoprotection of stress-sensing cells, anti-inflammatory effects on the trabecular meshwork, vasodilation, or neuromodulation.

5. The method of claim 1, wherein administration of the composition results in reversal and / or arrest of glaucoma disease progression by repairing and regenerating pressure sensors.

6. The method of claim 1, wherein the glaucoma is early glaucoma, intermediate glaucoma or end-stage glaucoma, refractory POAG / OH, advanced POAG / OH, end-stage POAG / OH, mild to moderate POAG / OH, primary angle-closure glaucoma (PACG), normal-tension glaucoma, congenital glaucoma, secondary glaucoma such as uveitic glaucoma or pseudo-exfoliation glaucoma, steroid-induced IOP elevation or glaucoma, uncontrolled IOP elevation or IOP failure associated with other known or unknown pathological root causes.

7. The method of claim 1, wherein administration of the composition comprising trebutadione results in repair of the trabecular meshwork in the eye, and wherein the repair of the trabecular meshwork comprises restoration and enhancement of the metabolic capacity of the master IOP regulators, pressure sensing cells, which allows regaining their complex self-regulation of the IOP in response to shear force stretch, with the clinical benefit of reducing dosing frequency, such as switching from BID to QD or reducing the need for multiple medications or replacing high-risk invasive surgical procedures with an ideal scenario of a drug holiday, reflecting the metabolic health state of the aging pressure sensors in glaucomatous eyes or patients with uncontrolled IOP.

8. The method of claim 1, wherein the composition comprising trebutinol is administered as eye drops once a day, twice a day, three times a day, four times a day, once a week, twice a week, three times a week.

9. The method of claim 1, wherein administration of the composition results in sustained IOP improvement toward a steady state, and wherein the IOP improvement is therapeutic and not limited to symptomatic relief.

10. The method of claim 1, wherein administration of the composition comprising trebutin normalizes diurnal IOP irregularities more effectively than 0.6% BID eye drops in patients with glaucoma.

11. The method of claim 1, wherein administration of the composition at an optimal dose simultaneously activates three independent signaling pathways through A1R specific binding affinity, which triggers G protein-coupled muscarinic M2 receptor activation at TM and CB, which mediates the fast mode of maximal (6-7 mmHg or greater) IOP reduction through contractile tissue and cellular hyperpolarization (resting state) at the pressure sensing cells and MMP14 / MMP2 upregulation at the TM, which synergistically promotes its unique IOP pattern behavior with superior therapeutic efficacy.

12. The method of claim 1, wherein administration of the composition upregulates MMP14 / MMP2, thereby causing basement membrane (BM) texture changes through a slow cumulative pattern (from weeks to months) of increased water conduction and oxygenation to sensing cells to achieve long-term functional improvement or restoration of aged TM.

13. A method for improving intraocular pressure of an eye, the method comprising administering to a subject in need thereof a dose of 1.5% 、 1.2% or a range of 1.0-1.5% or 1.0-3.0% of a composition comprising trebutinol, wherein the composition is administered in the form of a sustained release formulation that releases an API concentration per day at the aqueous humor or target tissue equivalent to the level delivered by its eye drop formulation administered at an optimal therapeutic concentration (e.g., 1.2%-1.5%); and wherein the sustained release formulation is provided in the form of an implantable device, and wherein the implantable device comprises a rod, a stent, a micro-shunt, or a microsurgical glaucoma drainage device, and wherein the implantable device is made of a polymer-based PLGA and / or PEG biodegradable or non-biodegradable material.

14. The method of claim 13, wherein the implantable device is delivered in a minimally invasive manner, such as intracameral, intravitreal, suprachoroidal, sub-Tenon's capsule, periocular, ocular surface or punctal plug, preferably a biodegradable AC rod, which has the great advantage of regular (once a year or every 2 or 3 years) and safe repeated administration without causing undesirable side effects such as CEL.

15. The method according to claim 13, wherein the implantable device containing the sustained-release formulation is made by medical coating technology, such as drug eluting stents, drug eluting contact lenses, and drug eluting intraocular lenses.

16. The method of claim 13, wherein the sustained release of the composition comprising trebutin causes a drug holiday that is more stable across a wider spectrum of diseases and lasts longer with a shorter induction time.

17. The method of claim 13, wherein said administration of said composition comprising trebutinol is combined with an additional therapeutic intervention, wherein the additional therapeutic intervention comprises surgical intervention or laser therapy or pharmacological drugs; And wherein the pharmacological agent is selected from the group consisting of: Xalatan® latanoprost, Lumigan®, bimatoprost, Travatan Z®, Travoprost and Zioptan™, tafluprost, Vyzulta™ (latanoprostene bunod), beta blockers, timolol, alpha agonists, Alphagan® P, brimonidine, Iopidine®, carbonic anhydrase inhibitors, Trusopt®, dorzolamide, Azopt®, brinzolamide, Diamox, acetazolamide, Neptazane® (methazolamide), rho kinase inhibitors, Rhopressa®, Rocklatan, netarsudil or Cosopt®.

18. The method of claim 1, wherein the administration of the composition comprising trebutin induces a drug holiday or stabilizes and prolongs a drug holiday for subjects with glaucoma at a dose within the range of 1.0-1.5%, 1.0-3.0%, 1.5%, 1.2% or 3-6% in a flexible dosing regimen that does not require strict adherence during the drug holiday period.

19. The method according to claims 13 and 19, wherein said composition is administered by implantation of an AC rod, preferably using a biodegradable formulation, and wherein said implantation of said AC rod induces a drug holiday in 80% or more of treated patients, including refractory glaucoma, within 3-6 months, and wherein said drug holiday lasts for 3 years.

20. A method for treating macular atrophy caused by choroidal ischemia in wet age-related macular degeneration following long-term anti-VEGF therapy, inherited retinal degenerations including but not limited to retinitis pigmentosa and NAION, and glaucomatous neuropathy, the method comprising administering a composition comprising trebutinol in an eye drop formulation, preferably nanoparticle or lipid-based ocular surface delivery, or sustained release intravitreal or suprachoroidal delivery.

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