Niazoxanide for treatment of liver injury

Abstract

The present invention relates to a compound selected from the group consisting of nitazoxanide, tizoxanide, tezoxanide glucuronate, and pharmaceutically acceptable salts thereof, for use in a method of treating liver injury.

Description

Technical Field

[0001] The present invention relates to a compound selected from nitazoxanide, tizoxanide, tizoxanide glucuronide and pharmaceutically acceptable salts thereof, and the compound is used in a method for treating liver damage. Background Art

[0002] The liver is one of the important organs that plays a key role in metabolism. The functions of the liver are mainly divided into circulatory function, excretory function, metabolic function, defense and detoxification function, and blood function. When any of these functions is impaired, various characteristic symptoms of liver disease will appear, such as fatigue, weakness, anorexia, jaundice, and low fever. Long-term liver dysfunction can lead to diseases such as hepatitis, cirrhosis, and liver cancer. In addition, the liver participates in drug clearance through multiple mechanisms and pathways (e.g., cytochrome P450 [CYP] enzyme pathway, glucuronidation, biliary excretion), and liver damage / dysfunction / disease / disorder may alter drug clearance. In addition, when a subject suffers from liver damage, toxic substances that are usually cleared by the liver accumulate in the blood, thereby impairing brain function.

[0003] Therefore, it is crucial to provide therapeutic strategies to treat liver injury. Summary of the invention

[0004] The present invention relates to a compound selected from nitazoxanide (NTZ), tizoxanide (TZ), tizoxanide glucuronide (TZG) and pharmaceutically acceptable salts thereof, and the compound is used in a method for treating liver damage.

[0005] In certain embodiments, the subject has mild, moderate or severe hepatic impairment according to the Child-Pugh score.

[0006] In another specific embodiment, the subject has nonalcoholic steatohepatitis (NASH) and liver damage. Specifically, the subject may have NASH and moderate or severe liver damage.

[0007] In yet another embodiment, the compound is nitazoxanide. In another embodiment, nitazoxanide is for oral administration, particularly formulated as a tablet. In yet another embodiment, the subject is administered a tablet containing 500 mg nitazoxanide twice daily. BRIEF DESCRIPTION OF THE DRAWINGS

[0008] Figure 1 are a set of photographs of picric acid Sirius Red Fast Green stained liver sections from a bile duct ligation (BDL) rat model with LPS-induced liver injury that received NTZ or vehicle.

[0009] Figure 2is a set of graphs showing the effects of NTZ on plasma transaminase levels in a rat model of BDL+LPS-induced liver injury.

[0010] Figure 3 is a set of graphs showing the effects of NTZ on liver function markers in a rat model of BDL+LPS-induced liver injury.

[0011] Figure 4 is a graph showing the effect of NTZ on LPS-induced urea increase.

[0012] Figure 5 is a set of graphs showing the effects of NTZ on LPS-induced circulating cytokines.

[0013] Figure 6 is a graph showing the effect of NTZ on LPS-induced brain edema. DETAILED DESCRIPTION

[0014] Liver injury or liver damage is a condition in which the normal function of the liver is reduced. Liver injury and liver failure are different conditions. Liver injury refers to a condition in which the liver function is impaired but not completely lost. It can mean a partial reduction in liver function, which may manifest as elevated liver enzymes, mild jaundice, or other mild symptoms. Liver failure, such as acute liver failure and acute-on-chronic liver failure, is a more serious condition in which the liver has lost its function. Liver failure results in severe and often life-threatening derangements of liver function, with significant biochemical abnormalities and multi-organ system involvement. The prognosis for liver injury is generally more favorable, especially if the underlying cause is identified and treated promptly, whereas liver failure is a critical medical emergency with a high risk of death.

[0015] The present invention provides a therapeutic strategy for treating liver damage. More specifically, the present invention relates to a compound selected from nitazoxanide (NTZ), tizoxanide (TZ), tizoxanide glucuronide (TZG) and pharmaceutically acceptable salts thereof, for use in a method for treating liver damage.

[0016] In a specific embodiment, the compound is selected from NTZ, TZ, and pharmaceutically acceptable salts thereof. In another embodiment, the compound is selected from NTZ and pharmaceutically acceptable salts thereof. In yet another embodiment, the compound is NTZ.

[0017] In the context of the present invention, a therapeutically effective amount of a compound is administered to a subject. "Therapeutically effective amount" refers to the amount of drug that effectively achieves the desired therapeutic result. The therapeutically effective amount of a drug may vary due to factors such as disease state, age, sex and individual weight, and the ability of the drug to cause the desired response in an individual. The therapeutically effective amount is also the amount by which any toxic or harmful effects of the drug are exceeded by the therapeutically beneficial effects. The effective dose and dosage regimen of the drug depend on the disease or condition to be treated, and can be determined by those skilled in the art. A physician with ordinary skills in the art can easily determine and prescribe the effective amount of the desired pharmaceutical composition. For example, a physician can start the drug dosage used in the pharmaceutical composition from a level lower than that required to achieve the desired therapeutic effect, and gradually increase the dosage until the desired effect is achieved. In general, the appropriate dose of the composition of the present invention is the amount of the compound at the lowest dose that effectively produces a therapeutic effect according to a specific dosage regimen. This effective dose generally depends on the above factors.

[0018] Those of ordinary skill in the art can adjust the frequency and / or dosage of administration according to the patient, pathology, form of administration, etc. Generally, the compound can be administered at a dose of between 0.01 mg / day and 4000 mg / day, such as 50 mg / day to 2000 mg / day, such as 100 mg / day to 2000 mg / day; in particular, 100 mg / day to 1000 mg / day. In a specific embodiment, the compound is administered at a dose of about 1000 mg / day, in particular 1000 mg / day. In a specific embodiment, the compound is orally administered at a dose of about 1000 mg / day, in particular 1000 mg / day, in particular as a tablet. If necessary, it can be administered daily, even several times a day. In one embodiment, the compound is administered at least once a day, for example, once a day, twice a day, or three times a day. In a specific embodiment, the compound is administered once or twice a day. Specifically, oral administration can be performed once a day during meals, such as during breakfast, lunch, or dinner, by taking a tablet containing the compound at a dose of about 1000 mg, in particular at a dose of 1000 mg. In another embodiment, the tablets are administered orally twice a day, for example a first tablet comprising the compound at a dose of about 400 mg, about 500 mg or about 600 mg, particularly at a dose of 500 mg, is administered during one meal, and a second tablet comprising the compound at a dose of about 500 mg, particularly at a dose of 500 mg, is administered during another meal of the same day.

[0019] The compounds used in the present invention can be formulated into pharmaceutical compositions, which also include one or more pharmaceutically acceptable excipients or vehicles (e.g., saline solutions, physiological solutions, isotonic solutions, etc.), which are compatible with pharmaceutical uses and are well known to those of ordinary skill in the art. These compositions can also further include one or more agents or vehicles selected from dispersants, solubilizers, stabilizers, preservatives, etc. The agents or vehicles used in these preparations (liquids and / or injections and / or solids) are particularly methylcellulose, hydroxymethylcellulose, carboxymethylcellulose, polysorbate 80, mannitol, gelatin, lactose, vegetable oils, gum arabic, liposomes, etc.

[0020] These compositions can ultimately be formulated through galenic forms or devices ensuring prolonged and / or slow release in the form of injectable suspensions, syrups, gels, oils, ointments, pills, tablets, suppositories, powders, gel caps, capsules, aerosols, etc. For such preparations, agents such as cellulose, carbonates or starches may be advantageously used.

[0021] NTZ, TZ or TZG may be in the form of a pharmaceutically acceptable salt, in particular an acid salt or base salt compatible with pharmaceutical use. Salts of NTZ, TZ and TZG include pharmaceutically acceptable acid addition salts, pharmaceutically acceptable base addition salts, pharmaceutically acceptable metal salts, ammonium salts and alkylated ammonium salts. These salts may be obtained during the final purification step of the compound, or by incorporating the salt into a previously purified compound.

[0022] The compounds used according to the invention can be administered by different routes and different forms. For example, the compounds can be administered by systemic means, oral, parenteral, inhalation, nasal spray, nasal drops or injection, such as intravenous, intramuscular routes, subcutaneous routes, transdermal routes, topical routes, intra-arterial routes, etc. Of course, the route of administration will be adapted to the form of the drug according to procedures well known to those skilled in the art.

[0023] In a specific embodiment, the compound is formulated as a tablet. In another specific embodiment, the compound is administered orally. In another specific embodiment, the compound is NTZ formulated as a tablet for oral administration. In yet another specific embodiment, the tablet contains 400 to 600 mg NTZ, more particularly 500 mg NTZ.

[0024] In a particular embodiment, the compound is used as a single active ingredient for treating liver damage. In another embodiment, the compound is used in combination with another active ingredient, for example, another compound that can be used to treat liver damage or can be used to treat at least one symptom of liver damage or can be used to treat a condition that has caused or will cause liver damage, such as a condition selected from liver infection, liver fibrosis, cirrhosis, non-alcoholic fatty liver disease or non-alcoholic steatohepatitis.

[0025] The compounds used according to the present invention are administered to treat liver damage in a subject in need thereof. As used herein, the term "subject" refers to a mammal, preferably a human subject.

[0026] The Child-Pugh classification is the most widely used and is a method of classifying liver function. Using this classification, subjects are grouped according to two clinical features (encephalopathy and ascites) and three laboratory parameters (S-albumin, S-bilirubin and prothrombin time). Liver dysfunction is divided into groups A, B and C, or "mild", "moderate" and "severe", corresponding to 5-6, 7-9 and 10-15 points, respectively. In a specific embodiment, the subject suffers from mild, moderate or severe liver damage as assessed by the Child-Pugh scoring system well known in the art. In another specific embodiment, the subject suffers from moderate or severe liver damage, more particularly severe liver damage. In another specific embodiment, the subject suffers from non-alcoholic steatohepatitis (NASH) and liver damage. In yet another embodiment, the subject suffers from NASH and moderate or severe liver damage. In another embodiment, the subject suffers from non-alcoholic steatohepatitis and severe liver damage.

[0027] The term "treatment" as used herein refers to both therapeutic measures and preventive treatment or preventive measures, wherein the goal is to prevent or slow down (mitigate) undesirable physiological changes or disorders. Beneficial or desired clinical results include, but are not limited to, relieving symptoms, stabilizing the pathological state (specifically, not worsening), slowing or stopping the progression of the disease, and improving or alleviating the pathological state. Specifically, for the purposes of the present invention, treatment is intended to slow the progression of liver damage and reduce the risk of further complications. It may also include prolonging survival compared to the expected survival without treatment.

[0028] In a specific embodiment, the compound is used to reduce the mortality rate associated with liver damage. The compound can also be used to slow or stop the progression of liver damage. In particular, the compound can be used to prevent, slow or stop the progression of liver damage, especially to prevent, slow or stop a subject with mild or moderate liver damage (especially moderate liver damage) from progressing to severe liver damage. In particular, the compound can be used to reverse liver damage from severe to moderate or mild liver damage. In another specific embodiment, the compound can be used to reverse liver damage from moderate to mild liver damage.

[0029] Example

[0030] Example 1: Evaluation of the efficacy of NTZ on BDL+LPS-induced liver injury in rats

[0031] Materials and methods:

[0032] The aim of the study was to evaluate the efficacy of NTZ in preventing LPS-induced inflammation, liver dysfunction, and brain edema in fibrotic rats undergoing BDL surgery.

[0033] Thirty Sprague Dawley rats (Janvier) underwent BDL surgery. After anesthesia, a median laparotomy was performed to expose the liver and duodenum. The main bile duct was identified and dissected. Afterwards, the bile duct was ligated in two parts: the first ligation was in the middle of the bile duct and the second ligation was above the entrance of the pancreatic duct. The bile duct was then cut from the middle to avoid recanalization. Blood samples were collected from the sublingual vein 14 days after surgery to measure markers of liver damage (serum aspartate aminotransferase (AST), total bile acid, and bilirubin), and the animals were stratified into treatment groups. At the end of the study, two BDL rats were excluded due to abnormal blood parameters (a 10-20% surgical failure rate is expected in this model). Two non-operated animals were included in the study as healthy controls.

[0034] Liver injury was induced by intraperitoneal administration of 1 µg / kg LPS (Escherichia coli O111:B4) 20 / 21 days after BDL surgery. Nine BDL rats received phosphate-buffered saline (PBS, Fisher Scientific, USA) instead of LPS as BDL controls.

[0035] Body weight and food intake were monitored twice weekly throughout the study.

[0036] During the fibrosis induction phase, observe each animal once daily to monitor clinical signs. Observations include changes in the skin, hair, eyes, the occurrence of secretions and excretions, and locomotor activity (lacrimation, piloerection, abnormal breathing patterns). Changes in gait, posture, stereotypic behaviors (e.g., excessive grooming, repetitive circling), or bizarre behaviors (self-mutilation, walking backwards) are also monitored. Animals were euthanized if they lost more than 25% of their body weight for more than 3 consecutive days, did not eat, had a deterioration in general condition, or vocalized.

[0037] After LPS administration, each animal was observed continuously for 7 h (animal appearance - hair, skin color changes - activity level, alertness - response to stimulation, eyelid opening, activity, gait and behavior) to assess the severity of inflammatory response and pain.

[0038] Treatments with NTZ 100 mg / kg or vehicle (1% carboxymethylcellulose (C4888, Sigma-Aldrich), 0.1% Tween 80 (P8074, Sigma-Aldrich)) were given by gavage 1 hour before LPS injection.

[0039]

[0040] NTZ is light sensitive, so store it away from light.

[0041] For oral gavage, NTZ powder was dissolved at a concentration of 10 mg / ml in 1% CMC, 0.1% Tween 80 in a brown glass bottle, homogenized with a polytron, and sonicated at 10% power for 10 seconds. NTZ was kept under magnetic stirring until administration to rats at 10 ml / kg.

[0042] LPS solution was prepared under a microbiological safety cabinet to obtain a sterile solution for injection into rats. LPS solution was dissolved in phosphate buffered saline (PBS) at 0.5 µg / ml, aliquoted and frozen until the day of the experiment. LPS was administered to rats at 2 ml / kg.

[0043] All surviving animals were euthanized 3 h after LPS injection for plasma and tissue analysis. At the end of the study, plasma levels of liver function markers and cytokines as well as brain edema were assessed.

[0044] result:

[0045] Assessment of fibrosis level

[0046] Periductal fibrosis was observed in the liver of rats that underwent BDL surgery, as shown by Sirius red staining ( Figure 1 ).

[0047] Neither LPS nor NTZ treatment affected the percentage of liver fibrosis (data not shown), which was expected for such brief treatments.

[0048] Plasma levels of liver and kidney function markers

[0049] BDL surgery induced severe liver damage and alterations in liver function, and LPS injection further exacerbated these changes. The effects of NTZ on plasma levels of liver and renal function markers were evaluated.

[0050] Plasma transaminases ALAT and ASAT (markers of hepatocellular damage) were increased in the BDL group compared with the non-pathological group. LPS further increased the plasma levels of ASAT and ALAT by 5.7-fold and 3.9-fold, respectively. NTZ treatment significantly reduced ALAT by 101% (p=0.03) and ASAT by 100% (p=0.01) compared with ACLF-vehicle conditions ( Figure 2 ).

[0051] In BDL rats, LPS administration also altered the plasma levels of liver function markers total bile acid, total bilirubin, albumin, and GGT ( Figure 3 ). NTZ treatment tended to reduce the LPS-induced changes in these markers.

[0052] LPS injection also altered renal function, as indicated by increased urea concentrations ( Figure 4 ), confirming that organs other than the liver are affected in this model. NTZ treatment also prevented LPS-induced renal injury by reducing plasma urea by 84%, p=0.007 ( Figure 4 ).

[0053] Plasma levels of circulating cytokines

[0054] Circulating cytokine levels were measured in the blood of animals collected 3 hours after LPS injection. Although LPS injection induced a robust increase in cytokines, with IL-6 increasing 228-fold, TNFα increasing 91-fold, and IL-1β increasing 143-fold, NTZ reduced circulating IL-6 levels by 93%, TNFα by 94%, and IL-1β by 91% ( Figure 5 ).

[0055] Brain edema

[0056] Finally, LPS injection induced brain edema (water content +0.78%), whereas NTZ completely restored the water content to the levels of BDL and healthy animals (-111% compared to BDL conditions, p = 0.006) ( Figure 6 ).

[0057] in conclusion:

[0058] BDL surgery induced severe liver damage and altered liver function, as manifested by increased levels of AST (3.8-fold), total bile acid (3.8-fold), total bilirubin (165-fold), γ-glutamyltransferase (GGT) (4-fold), and urea (1.3-fold) compared with healthy controls.

[0059] LPS injection in BDL rats further elevated AST (5.7-fold) and urea (1.4-fold) levels, while also inducing an increase in ALT (3.9-fold) and a decrease in albumin concentration (-11%) compared with BDL rats.

[0060] NTZ treatment blocked LPS-induced increases in AST (-100%), ALT (-101%), and urea (-84%). These effects were associated with a significant impact on systemic inflammation: while LPS injection induced a strong increase in cytokines (228-fold increase in IL6, 91-fold increase in TNFα, and 143-fold increase in IL-1β), NTZ reduced circulating levels of IL-6 by 93%, TNFα by 94%, and IL-1β by 91%. Brain edema (water content +0.78%) was also induced in these animals, whereas NTZ completely restored water content to levels seen in BDL and healthy rats.

[0061] In conclusion, these results demonstrate that NTZ can rapidly counteract LPS-induced systemic inflammation and liver and brain damage in rats with liver injury.

[0062] Example 2: Design of a study to evaluate nitazoxanide in the treatment of liver injury

[0063] To evaluate the efficacy and safety of nitazoxanide in patients with hepatic impairment.

[0064] There are multiple methods for classifying the severity of liver injury. In this study, the Child-Pugh classification (hereinafter referred to as the “CP system”) was selected because it is the most widely used and an acceptable method supported by regulatory agencies, including the US FDA and the European Medicines Evaluation Agency.

[0065] Hepatic impairment was classified as moderate or severe using the CP system. Parameters to determine the CP grade for each subject with hepatic impairment were collected at Screening.

[0066]

[0067] Chronic liver damage is classified into Child-Pugh (CP) grades A to C, using the sum of the five parameters in the table above: mild damage (CP-A): 5 or 6 points; moderate damage (CP-B): 7 to 9 points; severe damage (CP-C): 10 to 15 points.

[0068] a In this study, HE was graded according to the following criteria:

[0069] • Grade 0: normal consciousness, personality, neurological examination or normal EEG;

[0070] Grade 1: restlessness, sleep disturbance, irritability / agitation, tremor, dysgraphia, or waves of 5 cycles per second (cps);

[0071] • Grade 2: lethargy, time disorientation, abnormal behavior, asterixis, ataxia, or slow triphasic waves;

[0072] • Grade 3: lethargy, stupor, positional disorientation, hyperreflexia, rigidity, or slower waves;

[0073] • Grade 4: Unawakenable coma, no personality / behavior, loss of brain function, or slow 2 to 3 cps delta activity.

[0074] b Ascites is graded according to the following criteria:

[0075] • None: no ascites detected by manual inspection or ultrasonography (if ultrasound was performed);

[0076] • Mild: Ascites suspicious on palpation but measurable on ultrasonography (if performed);

[0077] • Moderate: Ascites detectable by palpation and ultrasonography (if performed);

[0078] • Severe: Needs paracentesis and drainage; no response to medical treatment;

[0079] • Subjects with a history of severe ascites who are receiving diuretics (eg, furosemide) to prevent recurrence should obtain a score of the original extent of ascites.

[0080] c Subjects with Grade 3 or 4 hepatic encephalopathy will not be allowed to participate in the study. However, subjects with a history of Grade 3 or 4 who are receiving medication (lactulose, neomycin, or rifaximin) to prevent recurrence of encephalopathy may enter the study and will be scored for Grade 3 or 4 encephalopathy.

[0081] Each enrolled patient was administered a tablet containing 500 mg of nitazoxanide twice daily.

[0082] Example 3: Safety of Nitazoxanide in Patients with Hepatic Impairment

[0083] The study design was an open-label, non-randomized, two-center, multiple-dose, parallel-group study to evaluate the PK, safety, and tolerability of NTZ 500 mg BID for 7 days in male and female patients with moderate and severe hepatic impairment compared with matched healthy male and female patients with normal hepatic function.

[0084] The objective was to evaluate the effect of hepatic impairment on the PK of tizoxanide (TZ; the active metabolite of NTZ) in subjects with moderate or severe hepatic impairment and in subjects with normal hepatic function following repeated oral administration of NTZ 500 mg BID for 7 days.

[0085] When evaluating the effect of the degree of liver impairment on NTZ PK, the following parameters for measuring liver function were considered: Child-Pugh (CP) score (*), serum albumin, serum total bilirubin, international normalized ratio (INR), aspartate aminotransferase (AST), alanine aminotransferase (ALT).

[0086] (*) CP score was not calculated for the control-matched healthy subject group and the analysis was restricted to patients with liver injury.

[0087] Based on the CP score at screening, subjects were divided into the following groups:

[0088] - Group 1: Normal liver function

[0089] - Group 2: Moderate hepatic impairment (CP grade B)

[0090] - Group 3: Severe hepatic impairment (CP grade C)

[0091] A total of 25 subjects were included in the study and received at least one dose of NTZ, including 10 healthy subjects assigned to the control group, 9 subjects assigned to the moderate hepatic impairment group, and 6 subjects assigned to the hepatorenal impairment group.

[0092] On Day 1, study subjects took 500 mg NTZ (1 tablet) with 240 mL (8 fluid ounces) of water 30 minutes after starting a standard breakfast. No food was allowed for at least 4 hours after each dose. Blood PK samples were collected at the following time points: pre-dose (completed on an empty stomach before starting a standard breakfast), T1h, T2h, T3h, T4h, T5h, T6h, T7h, T8h, T10h, and T12h post-dose.

[0093] From Day 2 to Day 6, subjects took 500 mg of nitazoxanide (1 tablet) in the morning and evening for 6 consecutive days, with the last dose taken in the morning on Day 7. Pre-dose blood PK samples were collected every morning on an empty stomach before starting a standard breakfast from Day 2 to Day 6.

[0094] On day 7, blood PK samples were collected at the following time points: before medication (completed on an empty stomach before a standard breakfast), T1h, T2h, T3h, T4h, T5h, T6h, T7h, T8h, T10h, T12h, T14h, and T16h after medication. PK samples were collected at T18h, T24h, and T48h after medication on days 8 and 9, respectively.

[0095] Table 3 presents the preliminary analysis of the geometric means of total TZ in the impaired and control groups and the geometric mean ratios (GMRs) to the control group in the steady state (90% CI).

[0096]

[0097] The primary analysis was to evaluate the PK parameters of total TZ (C max , AUC 0-12 and AUC 0-t ) in subjects with moderate or severe hepatic impairment and those with normal hepatic function.

[0098] For subjects with moderate hepatic impairment, AUC and C max There were no statistically significant differences from the control group. Given that the GMR was between 0.80 and 1.00, it is unlikely that there would be differences in subjects with moderate hepatic impairment, even if this was not formally demonstrated due to the limited sample size.

[0099] For subjects with severe hepatic impairment, the AUC was statistically significantly different from the control group. The GMR was between 1.64 and 1.79, with a 90% CI excluding 1.00. max The GMR was estimated to be 1.19, which was not statistically different from the control group.

[0100] Total TZ parameters between subjects with moderate hepatic impairment and control subjects and C in subjects with severe hepatic impairment max There was no difference. However, there was a moderate increase in AUC in subjects with severe hepatic impairment. This increase was statistically significant.

[0101] The secondary analysis of total TZ accumulation ratios is shown in Table 4 .

[0102]

[0103] Secondary analyses were performed to determine the AUC measured after single (day 1) and 7-day repeated (BID) oral dosing. 0-12 and C max The cumulative ratio.

[0104] No interaction between day and group was found for any parameter. Therefore, accumulation was assumed to be independent of the degree of liver injury and was assessed for all groups.

[0105] For the total TZ, C max and AUC 0-12 There was a statistically significant accumulation, but the magnitude was limited. The GMR between day 7 and day 1 was significantly higher for C max is about 1.4, for AUC 0-12 It is about 1.6.

[0106] Sensitivity analysis confirmed that moderate hepatic impairment may have no effect on total TZ PK. Severe hepatic impairment also did not appear to have an effect on C max has an impact, but may increase the AUC by about 1.5 times.

[0107] The association of liver function markers (serum albumin, serum total bilirubin, INR, AST, and ALT (obtained at screening)) with the PK parameters of TZ and TZGlu (total and unbound) (C max and AUC 0-12 )’s relationship.

[0108] Pearson (support for linear trends) and Spearman correlation (support for monotonic trends) coefficients were calculated. The correlation coefficient (ρ) was used to appropriately measure the association of the most likely relationship, and only strong correlations (i.e., ρ ≥ 0.75) supported further modeling.

[0109] The relationship between liver function and PK parameters is summarized in Table 5.

[0110]

[0111] The results showed that for most liver function markers, the correlations with TZ or TZGlu (total or unbound) PK parameters were poor (ρ < 0.25) or weak (0.25 ≤ ρ < 0.5). max A separate moderate linear (ρ = 0.51) correlation was found between β-catenin and bilirubin, but the correlation was too weak (ρ < 0.75) to support further modeling.

[0112] For tizoxanide, the time to maximum concentration was consistent across groups and days (t max The median was between 3.5 and 5.0 hours. The total TZ exposure on days 1 and 7 was higher in the severe hepatic injury group than in the other groups, with moderate to high variability among individuals (C max , AUC 0-12 and AUC 0-∞ The GM ratio between the heavy and control groups was about 0.8 to 1.0 times, and the GM ratio between the heavy and control groups was about 1.1 to 1.8 times). In all subjects, regardless of day, AUC 0-∞ The extrapolation percentages were all below 20%.

[0113] Elimination was comparable between groups on day 1, but appeared to be slower on day 7 in subjects with severe hepatic impairment (GM t 1 / 2 was about 2 hours, while the GM t on the 7th day 1 / 2 4 hours). Overall, trough concentrations appear to increase with the degree of liver damage.

[0114] In the urine, the fraction of the dose recovered within 12 hours was less than 1% on days 1 and 7, regardless of group, with wide inter-individual variability. Renal clearance was also low in all groups, with values ​​ranging from 0.002 to 0.030 L / h, regardless of day, with wide inter-individual variability.

[0115] For peak exposure (C max ), the area under the curve from time zero to 12 hours (AUC 0-12 ) and the time from time zero to the last quantifiable concentration (AUC 0-t ) statistical analysis (primary analysis) could not find differences between subjects with moderate hepatic impairment and control subjects, with GMR ranging from 0.80 to 1.25, indicating no relevant differences. In the severe hepatic impairment group, only AUC showed a statistically significant difference, with GMR between 1.64 and 1.79.

[0116] The sensitivity analysis of total TZ was consistent with the primary analysis. The trends observed in the PK parameters were consistent and they confirmed that moderate hepatic impairment may have no effect on the PK of total TZ. However, severely impaired subjects appeared to be sensitive to C max There was no effect, but it may increase the AUC by about 1.5 times. Secondary analysis showed that C max and AUC 0-12 There was a statistically significant cumulative difference between day 7 and day 1 for C max is about 1.4, for AUC 0-12 is 1.6.

[0117] This clinical trial showed that nitazoxanide is safe and metabolized to its active metabolite.

[0118] Example 4: Efficacy of Nitazoxanide in Patients with Hepatic Impairment

[0119] This study was conducted to evaluate the efficacy of nitazoxanide 500 mg twice daily in patients with hepatic impairment. Based on the results reported in Example 1, it is expected that this treatment improves the condition of the subjects.

[0120] This is an interventional, proof-of-concept, phase 2a, randomized, open-label, controlled, parallel-group clinical study to evaluate the safety, pharmacokinetics, and efficacy of nitazoxanide (NTZ) 500 mg orally administered twice daily (BID) in the context of standard of care (SOC) versus SOC alone in patients with acute-on-chronic liver failure (ACLF).

[0121] The study consisted of 3 phases: a 72-hour screening period, followed by a 7-day treatment period, and a safety follow-up period of up to 90 days from the start of treatment.

[0122] Patients were randomized to receive nitazoxanide 500 mg orally twice daily (BID) on a background of SOC or SOC alone for 7 days.

[0123] Standard of care (SOC) is defined as standard medical management of patients with ACLF according to local practice at participating clinical sites. On-site medical care should be directed by the treating physician, taking into account their overall clinical assessment of the patient, the precipitating events, and the nature and severity of organ dysfunction. Interventions may include (but are not limited to) supportive care with fluid therapy, including albumin infusion (if indicated), antibiotics (for suspected or confirmed infection), nutrition, bowel management, thromboprophylaxis, and organ system support, including cardiovascular support, oxygen and non-invasive or invasive respiratory support, laxatives and non-absorbable antibiotics for hepatic encephalopathy, and dialysis for renal failure. The SOC may also include liver transplantation, depending on the individual patient’s clinical status and local institutional practice.

[0124] The primary objective was to evaluate the safety of nitazoxanide (NTZ) in ACLF patients with hepatic impairment.

[0125] Secondary objectives are:

[0126] - To evaluate the pharmacokinetics of the major metabolites of NTZ (tizoxanide and tizoxanide glucuronide) in patients with ACLF

[0127] - Evaluate the effect of NTZ on clinical disease progression using applicable prognostic criteria in ACLF patients

[0128] - To assess the effect of NTZ on clinical outcomes including liver transplantation, 28-day and 90-day mortality

[0129] Additional goals are to evaluate the effects of NTZ therapy on inflammatory markers in these patients and to assess the effects of NTZ on the gut microbiota.

[0130] Approximately 30 patients in this study will be randomized in a 2:1 ratio (NTZ+SOC: SOC) as follows:

[0131] • • Group A: NTZ+ SOC

[0132] • • Group B: SOC

[0133] Safety information, clinical prognostic scores, markers of renal and liver function, gut microbiota characteristics, and inflammatory markers were assessed as described at screening, days 1 to 7 (active treatment period), days 8, 14, 21, 28, and 90 (follow-up).

[0134] PK measurements of NTZ and metabolites were assessed on days 1, 7, and 8 (NTZ+SOC group only).

[0135] Clinical outcomes, including liver transplantation and mortality, will be monitored throughout the study and through Day 97.

[0136] Exclusion criteria:

[0137] Patients who met any of the following exclusion criteria were not included in the trial:

[0138] 1) Patients with cirrhosis who have decompensated liver function at any time after partial hepatectomy or major non-hepatic surgery

[0139] 2) Patients with uncontrolled infection or sepsis. Patients with infection can participate in the study, provided that they have been given antimicrobial drugs for at least 48 hours and have observed an appropriate response that is considered acceptable by the principal investigator before randomization.

[0140] 3) Patients with ACLF grade 3

[0141] 4) Patients with MELD-Na score > 25

[0142] 5) Hepatic encephalopathy grade III (stupor) or grade IV (coma) according to West Haven criteria

[0143] 6) Patients with clinical evidence of disseminated intravascular coagulation

[0144] 7) Patients who require inotropic support due to cardiovascular dysfunction

[0145] 8) Patients with evidence of significant and / or uncontrolled bleeding as judged by the principal investigator

[0146] 9) Patients receiving mechanical ventilation or expected to require mechanical ventilation

[0147] 10) Patients with active malignancy (expected survival less than one year) or with malignancy other than hepatocellular carcinoma (HCC) as defined in the Milan criteria or curatively treated skin cancer (basal cell carcinoma or squamous cell carcinoma) unless adequately treated or in complete remission for five years or more

[0148] 11) Known allergy to nitazoxanide, or use of nitazoxanide within 30 days before screening

[0149] 12) Hemoglobin <9 g / dl

[0150] 13) All patients receiving dialysis treatment

[0151] 14) Patients currently using warfarin. Previous use of warfarin is allowed, provided that it has not been used within 5 days before the start of screening.

[0152] 15) Receiving systemic corticosteroids within 30 days prior to screening

[0153] 16) Participation in another interventional trial (drug or device) or use of other investigational products within 30 days prior to screening

[0154] 17) Pre-existing gastrointestinal diseases that alter intestinal absorption (such as celiac disease, inflammatory bowel disease, etc.)

[0155] 18) Serious systemic or major diseases other than liver disease, including coronary artery disease, cerebrovascular disease, lung disease, renal failure, and severe mental illness, which the investigators believe will prevent the patient from participating in and completing the study.

[0156] 19) Pregnant or breastfeeding women or women who plan to become pregnant during the study

[0157] 20) Positive for anti-human immunodeficiency virus (HIV) antibodies

[0158] 21) Individuals whom the researcher deems unsafe to participate in the research

[0159] 22) Patients on the UNOS liver transplant list

[0160] 23) Test positive for illegal drugs (except marijuana), unless the subject is using any of these drugs as a prescription medication and approved by the investigator

[0161] 24) Positive alcohol test, except for patients with alcoholic hepatitis

[0162] 25) History of serious drug abuse within 1 year before screening or recreational use of soft drugs (except marijuana) within 1 month before screening or recreational use of hard drugs (such as cocaine, phencyclidine [PCP], opioid derivatives including heroin, and amphetamine derivatives) within 3 months before screening.

[0163] Evaluation criteria:

[0164] Primary endpoint:

[0165] The primary endpoints were treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), and treatment discontinuations within 90 days due to safety-related reasons.

[0166] Secondary endpoints:

[0167] Safety endpoints:

[0168] a. Laboratory measurements (chemistry, hematology, and coagulation)

[0169] b. Physical examination, vital signs, and electrocardiogram (ECG)

[0170] Pharmacokinetic endpoints:

[0171] After a single oral dose (day 1) and at steady state (steady state is expected to be achieved on day 7), determine the following PK parameters expressed as unbound and total concentrations for TZ and TZ-glucuronide, when applicable:

[0172] • Maximum observed plasma concentration (C max ),

[0173] • The area under the plasma concentration-time curve (AUC) from time zero to 12 hours (AUC 0-12 ),

[0174] • AUC from time zero to the last quantifiable concentration (AUC 0-t ),

[0175] • Time of maximum observed plasma concentration (T max ),

[0176] • Apparent plasma terminal elimination half-life (t 1 / 2 ).

[0177] Secondary efficacy endpoints:

[0178] • Changes from baseline: MELD-Na, CLIF-C ACLF score, CLIF-C organ failure score, ACLF grade, Child-Turcotte-Pugh (CTP) score, West Haven criteria

[0179] • Clinical outcomes – Any other hepatic clinical events such as ascites, GI bleeding, liver transplantation, 28-day and 90-day mortality.

Claims

1. A compound selected from nitazoxanide (NTZ), tizoxanide (TZ), tizoxanide glucuronide (TZG) and pharmaceutically acceptable salts thereof, for use in a method for treating liver damage.

2. The compound for use according to claim 1, wherein the subject suffers from mild liver impairment according to the Child-Pugh score.

3. The compound for use according to claim 1, wherein the subject has moderate liver impairment according to Child-Pugh score.

4. The compound for use according to claim 1, wherein the subject suffers from severe liver damage according to the Child-Pugh score.

5. The compound for use according to any one of claims 1 to 4, wherein the subject suffers from non-alcoholic steatohepatitis and liver damage.

6. The compound for use according to claim 5, wherein the subject suffers from NASH and moderate liver damage.

7. The compound for use according to claim 5, wherein the subject suffers from NASH and severe liver damage.

8. The compound for use according to any one of claims 1 to 7, wherein the compound is nitazoxanide.

9. The compound for use according to claim 8, wherein nitazoxanide is for oral administration.

10. The compound for use according to claim 9, wherein nitazoxanide is formulated as a tablet.

11. The compound for use according to claim 10, wherein the subject is administered a tablet containing 500 mg of nitazoxanide twice daily.

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