Medicine for improving infertility or pregnancy state

Abstract

Provided is a drug for restoring a normal immune state by suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy. A drug for suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restoring a normal immune state, the drug comprising, as an active ingredient, a compound selected from the group consisting of (i) a compound represented by formula (I) (in the formula, R1 represents a hydrogen atom or a hydrogen atom); ) or a pharmaceutically acceptable salt thereof; (ii) cyclosporins; and (iii) a compound selected from the group consisting of natamycin or a derivative thereof. # imgabs0 #

Description

[0001] This application is a divisional application of the application with the application date of September 27, 2019, application number 2019800838946, and title "Drug for improving infertility or pregnancy status". Technical Field

[0002] The present invention relates to a drug for improving infertility or pregnancy status affected by immune interaction between the mother and the fetus, and the drug contains specific immunosuppressive components. In particular, in representative examples of such drugs, there can be mentioned: drugs for suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restoring a normal immune state. Background Art

[0003] It is estimated that there are approximately 190 million infertile people worldwide, including those with repeated implantation failure (RIF) and recurrent pregnancy loss (RPL), accounting for 8% - 12% of fertile couples (Reference 1).

[0004] There are many causes of infertility, which can be roughly classified into problems of fertilized eggs, fetuses, the mother, and problems related to the interaction between the mother and the fetus, etc.

[0005] Problems with fertilized eggs, fetuses, or the mother can be treated by existing treatment methods, and 80% - 90% of patients can give birth successfully. However, the remaining 10% - 20% of infertile patients, including those caused by abnormalities related to the interaction between the mother and the fetus, that is, immunity between the mother and the fetus, are difficult to be treated by existing treatment methods (Reference 2).

[0006] One of the reasons for this difficulty can be considered that the development of new treatments for these abnormalities related to the immunity between the mother and the fetus has been delayed.

[0007] Some immunosuppressants or immunomodulators have been listed as candidates, and the treatment method has been studied for this problem, but at present, there are hardly any suitable and effective treatment methods for clinical use (Reference 3).

[0008] Good immune interaction between the mother and the fetus mainly suppresses rejection immunity against the fetus and induces immune tolerance. The development of immunology in the fields of organ transplantation (References 4 - 12) and cancer (References 13 - 18) is rapid, and there are many common immune mechanisms between them and pregnancy ( Figure 1a ).

[0009] Both innate immunity, which rapidly eliminates foreign substances that have invaded the body, and acquired immunity, which induces an attack against foreign antigens or the acquisition of immune tolerance based on information recognized by dendritic cells (DCs), are fundamental immunological mechanisms, but they have different characteristics in organ transplantation, cancer, or pregnancy.

[0010] The main immunological mechanisms during transplantation include: the rejection of T cells induced by direct recognition of the peptide / allogeneic HLA (Alo-HLA) complex expressed on the surface of donor dendritic cells and indirect recognition of the Alo-peptide / autologous HLA complex expressed on the surface of recipient dendritic cells through the T cell antigen receptor (References 4-7).

[0011] A strong graft reaction is considered to be mainly caused by the direct recognition of T cells, which is accompanied by chronic rejection caused by anti-Alo-HLA specific antibodies produced by B cells. Recipient B cells recognize and bind to the peptide / allogeneic HLA (Alo-HLA) complex expressed on the surface of donor dendritic cells, and differentiate into plasma cells through the indirect recognition of the Alo-HLA-derived peptide / autologous HLA class II complex on the surface of this B cell by Th2 cells (Reference 8).

[0012] Two avoidance mechanisms have been elucidated in cancer immunity. First, immunosuppressive cytokines (TGF-β) produced by cancer cells with genetic abnormalities induce bone marrow-derived suppressor cells and regulatory T cells (Tregs) (References 15-16).

[0013] Second, IFN-γ produced by cytotoxic T lymphocytes (CTLs) induces the expression of programmed death ligand (PD-L1) on the surface of cancer cells and tumor-infiltrating macrophages. The PD-1 receptor binds to PD-L1 and can inhibit CTLs (References 15, 17, 18).

[0014] The expression of HLA-G on the surface of villous trophoblast cells is the first stage in successful pregnancy and is the key to achieving avoidance of innate immunity and induction of immune tolerance (References 19-26). However, immune imbalance at the maternal-fetal interface and the breach of the placental barrier may induce existing immune responses in the same way as the response to other foreign substances, resulting in harmful effects on placental construction, fetal growth, or causing maternal complications. The recognition of fetal antigens through the placenta or fetal antigens in the placenta induces the production of specific antibodies against intracellular target proteins in fetal cells in the mother.

[0015] The immune response during pregnancy is similar to the immune response seen in transplantation. However, the difference is that, since it is speculated that there are not enough DCs in the fetus in the early stages of pregnancy, the direct recognition of peptide / Alo-HLA complexes during pregnancy may also be very weak. Furthermore, the antigenicity of the presented antigen is weak due to the fact that the fetus has half of the allogeneic antigens. The process of antibody production is the same as in transplantation.

[0016] Therefore, innate immunity is an important immune response during pregnancy, and subsequent DC-induced T cell activation may be weaker than in transplantation. The production of specific antibodies against fetal antigens is considered in rhesus D (Rh-D) incompatible pregnancy and fetal hemochromatosis. However, other fetal antigens, including peptides derived from Alo-HLA, may also act as targets, and it is predicted that Th2 activation in patients with pregnancy experience and a high Th2 cell ratio is involved in infertility.

[0017] In order to acquire the fetus and successfully continue the pregnancy, some responses need to be made to the maternal immune system, including accepting the fertilized egg while preparing the implantation environment, suppressing the attack on the fertilized egg and the fetus, and immune tolerance ( Figure 1b )(References 19 - 43).

[0018] Dysfunction of these mechanisms leads to uncontrolled immune responses against the fetus, causing infertility. In addition, such infertility may occur not only in women without pregnancy experience and women who have changed partners, but also after miscarriage or childbirth.

[0019] It is generally believed that the maternal tolerance to the same antigen increases after successful pregnancy and childbirth. However, even implantation disorders, miscarriages, and childbirth increase the opportunity for the mother to recognize fetal antigens. As a result, the possibility of rejection increases. These phenomena may enhance the sensitivity to fetal antigens and promote rejection. It may not be possible to enable these patients to successfully become pregnant using existing treatment methods.

[0020] Although the detailed immune mechanisms that play a role in normal pregnancy have not been fully elucidated, including mothers who have experienced the last pregnancy with the same partner, opportunities to induce immune tolerance can be induced before or after implantation. In each pregnancy, it is necessary to suppress the rejection caused by the mother's innate immunity.

[0021] Fetal-derived extravillous trophoblasts do not express the histocompatibility antigens HLA-A, -B, or -D (References 44), so it is not a target for CTLs, but can be a target for natural killer (NK) cells. However, trophoblasts express HLA-C, E, and G, rather than the above HLA types (References 19, 20, 45 - 49).

[0022] Fetal maternal HLA-C mismatch is associated with maternal T cell activation, but under several conditions including semen priming, the presence of adequate progesterone, and HLA-G, the immune response can be switched to immune tolerance (References 26, 45 - 48)( Figure 2a ). This reaction promotes the differentiation of DC from immature DC (imDC) to tolerogenic DC (tDC), followed by the induction of immune tolerance through the designated regulatory T cells (References 50 - 53). Similar observations have also been made for minor histocompatibility antigens such as HMHAI, KIAA0020, BCL2A1, and male antigen (H - Y), which are expressed on extravillous trophoblast cells (References 54 - 57).

[0023] HLA - E inhibits the activity of NK cells in the decidua (Reference 49), and the expression of HLA - G on the surface of extravillous trophoblast cells induces avoidance of NK attack and inhibits macrophage activation (References 21 - 24). Suppressed NK / NKT cells down - regulate the production of perforin, granzyme, or granulysin and type 1 cytokines. The production of type 1 cytokines by macrophages is also inhibited, contributing to the reduction of NK / NKT cell activity( Figure 2b ).

[0024] The main mechanism of immune rejection in patients with RIF or RPL is Th1 - type immunity (References 58 - 64), which is repeated but different from Th1, Th2, Th17, Treg, NK / NKT, and DC in peripheral blood (Reference 63). Despite the immune changes occurring in utero as described above, the immune problems in RIF patients are usually caused by the predominance of Th1 - type immunity, with the activity of Th1 - type immunity continuously increasing since before pregnancy. On the other hand, in RPL patients, there are various factors that activate the immune rejection of the fetus.

[0025] The immune response starts after implantation, and at the maternal - fetal interface during pregnancy, fetal antigens can be recognized through the following three pathways:

[0026] - Extravillous trophoblast after implantation,

[0027] - Syncytiotrophoblast in the placenta, and

[0028] - Circulation of maternal fetal cells or antigens after placental completion.

[0029] The hypothesis of different immune changes between RIF and RPL is supported by the subsets of NK cells in the uterus of infertile patients. It has been reported that in RIF patients, CD56 bright / NKp44+ cells increase, CD56 dimOn the other hand, the number of / NKp46+ cells decreases, while CD56 dim / NKp46+ cells increase in patients with RPL (References 37, 65 - 70)( Figure 3a ).

[0030] Different NK cells attack target cells through different mechanisms. CD56 bright / NKp44+ and CD56 dim / NKp46+ cells, together with granzyme B, induce apoptosis of target cells through granulysin and perforin respectively (References 71, 72). Long-term stimulation is required to induce granulysin production by CD56 brim / NKp44+ cells, but does not induce perforin production accompanied by granzyme B in CD56 dim / NKp46+ cells. Therefore, long-term exposure to Th1-type immunity leads to activation of CD56 bright / NKp44+ in the uterus of patients with RIF (References 71, 72).

[0031] Based on these insights, it is relatively easy to determine diagnostic parameters and select RIF patients suitable for immunosuppressive therapy. However, in patients with RPL, there are many opportunities for maternal recognition of fetal antigens through different pathways and at different times during pregnancy, so the selection of suitable patients is more complex.

[0032] The implantation of the fertilized egg, the infiltration of the decidua in the uterus into the chorion, and the transfer of antigens from the fetus to the maternal blood circulation increase over time after placental construction and accelerate after the second trimester of pregnancy. Two peaks of immune response theoretically occur at the maternal-fetal interface, but the timing and intensity of these immune responses against the fetus vary. To ensure fetal safety, it is important to suppress allogeneic immune attack in the early stage of pregnancy and achieve complete immune tolerance of the fetus. Figure 3b Some patterns of maternal immune response in the uterus are shown.

[0033] On the other hand, according to the types and modes of action of helper T cells, acquired immunity is further divided into "cellular immunity" and "humoral immunity". As diseases or symptoms related to the immune system of the mother and fetus, for example, for "cellular immunity", infertility caused by implantation disorders, infertility caused by placental construction disorders, pregnancy-induced hypertension, etc. can be listed. On the other hand, for humoral immunity related to the mother and fetus, blood group incompatible pregnancy or fetal hemochromatosis can be listed.

[0034] Regarding the relationship between immunity and pregnancy, for example, in Patent Document 1, a therapeutic agent containing a specific immunosuppressive agent as an active ingredient is described as a therapeutic agent for infertility caused by "cellular immunity".

[0035] Although the placenta is constructed in such a way as to avoid the mixing of maternal and fetal blood, a small amount of fetal antigens, including blood cells, enter the maternal circulation through the placenta (fetal-maternal transfusion, FMT). FMT most commonly occurs during childbirth, but in most cases it has no clear clinical significance (References 1a - 3a), and it can also occur during any pregnancy, including pregnancies that result in induced or spontaneous abortion.

[0036] When antigens and foreign antigens are recognized as being beyond the maternal immune tolerance capacity, antibodies against fetal antigens are produced in the mother. The pathogenic antibodies generated migrate to the circulatory system through the placenta, like other IgG antibodies, and attack target fetal cells or antigens.

[0037] After the construction of the placenta is completed, the amount of antigen transferred from the fetus to the mother increases as the pregnancy progresses. Therefore, the production of pathogenic antibodies by the mother against the fetus also increases, and a deterioration in the fetal condition is observed in proportion to the production of pathogenic antibodies, especially accelerating after the second trimester.

[0038] Blood group incompatibility

[0039] For example, a pregnancy in which the mother is Rho(D) negative and the fetus is Rho(D) positive is considered a blood group incompatible pregnancy. After the placenta is constructed, although in trace amounts, fetal antigens containing blood cell components are transferred from the fetus to the mother through the placenta. At this time, for antigens that exceed the maternal immune tolerance capacity or are not tolerated among the transferred fetal antigens, the mother produces antibodies, which, like other antibodies, are transferred to the fetus through the placenta and target and attack fetal cells. In blood group incompatible pregnancies, anti-D antibodies produced by the mother are transferred to the fetus through the placenta, destroying red blood cells in the fetal blood, causing fetal anemia, and subsequently severe fetal hydrops and intrauterine fetal death (Reference 4a). This condition is not clearly manifested in the first pregnancy and becomes severe in the second and subsequent pregnancies as the chance of sensitization increases. In addition, after the placenta is constructed, the amount of transferred antigen gradually increases as the pregnancy progresses, so the condition develops with the number of gestational weeks. Especially in the second trimester and later when the transfer amount increases, most cases deteriorate rapidly. The currently known treatments are as follows: Plasma exchange is performed to remove the anti-D antibodies produced by the mother, and fetal blood transfusion is performed on the fetus that has already developed anemia to facilitate childbirth in a low-risk state. Or, to prevent sensitization to the D antigen, women with Rh-incompatible pregnancies must be treated with Rh immunoglobulin (Ig) during pregnancy, and if the patient has not been sensitized, treatment should be carried out after childbirth or termination of pregnancy. This is not only the case for RhD, but for other blood groups as well, blood group incompatible pregnancies may occur due to incompatibility between the mother and the fetus.

[0040] For a mother with anti-D antibodies, in order to measure the blood flow velocity of the middle cerebral artery (MCA) of the fetus, which is a predictive index of the antibody titer in the mother's blood and fetal anemia during pregnancy, management based on Doppler ultrasound detection is required (Reference 5a).

[0041] On the other hand, fetal hemochromatosis is a disease that causes severe liver failure during the fetal and neonatal periods. Alloimmune fetal liver injury is speculated to be the cause of this disease. The pathogenic antigen has not been identified yet, but it will develop during pregnancy when the protein (enzyme, etc.) related to fetal iron metabolism in the fetus is different from that in the mother.

[0042] After pregnancy, after the placenta is constructed, fetal proteins related to fetal iron metabolism are transferred to the mother through the placenta. Due to the mother's immune response to the transferred fetal protein antigen, pathogenic antibodies are produced in the mother's body. The basic symptom is that the pathogenic antibodies produced in the mother's body are transferred to the fetus through the placenta, and fetal iron metabolism disorder occurs because the pathogenic antibodies attack fetal proteins related to iron metabolism in the fetus.

[0043] The recurrence rate of fetal hemochromatosis in fetuses from the same mother is 90%. For treatment, since around 1990, a combination therapy of medical treatment using iron chelators and antioxidants and liver transplantation has been carried out, but the survival ratio of infants is at most about 50%. In 2009, a treatment method based on exchange transfusion and high-dose gamma globulin therapy for newborn fetuses was reported as a new treatment method, and the survival ratio of infants improved to 75%.

[0044] The current treatment method is as follows: a method of preventing the onset of fetal hemochromatosis by administering high-dose gamma globulin therapy to the mother during pregnancy. However, due to the need for a large amount of gamma globulin, further treatment methods are required.

[0045] Pregnancy-induced hypertension

[0046] The situation where hypertension occurs during pregnancy is called pregnancy-induced hypertension (HDP). Hypertension observed before pregnancy or hypertension observed at 20 weeks of pregnancy is called chronic hypertension with pregnancy (CH). The situation where hypertension occurs only after 20 weeks of pregnancy is classified as gestational hypertension (GH). The situation where hypertension and proteinuria are observed is classified as preeclampsia (PE). Since 2018, even if proteinuria is not observed, if there is liver dysfunction, kidney dysfunction, neuropathy, coagulation disorder, or poor fetal development, it is classified as preeclampsia. When pregnancy-induced hypertension becomes severe, related diseases such as HELLP syndrome, eclampsia, and central neuropathy sometimes occur.

[0047] HELLP syndrome

[0048] HELLP syndrome is a condition that represents a series of symptoms (hemolysis: H, liver dysfunction: EL, thrombocytopenia: LP) that endanger the lives of the mother and fetus during pregnancy or childbirth, and is a disease related to pregnancy-induced hypertension. When HELLP syndrome is observed, it is necessary to urgently end the ongoing pregnancy by rapid delivery or cesarean section.

[0049] Eclampsia

[0050] Eclampsia is a condition in which peripartum patients have abnormal hypertension and experience convulsions or loss of consciousness and impaired vision. It can also occur before childbirth, during childbirth, or in the puerperium. Eclampsia is a circulatory disorder and dysfunction of the brain tissue related to hypertension, and it is also a disease related to pregnancy-induced hypertension.

[0051] In pregnancy-induced hypertension and its related diseases (such as HELLP syndrome, eclampsia, etc.), sometimes very dangerous states occur for both the mother and fetus, such as fetal growth disorders, placental abruption, fetal dysfunction, and fetal death. Therefore, preventing the onset or delaying the onset of pregnancy-induced hypertension and its related diseases (eclampsia, HELLP syndrome, etc.) during pregnancy has become an extremely important issue.

[0052] Although the causes of HELLP syndrome and eclampsia are not yet clear, they are known to be related to pregnancy-induced hypertension (References 1b, 2b). If hypertension, renal insufficiency, increasing age, and obesity, which are the inducing factors of the fundamental problems of the mother, are removed from the categories of pregnancy-induced hypertension, the remaining category is the construction disorder of the placenta, which can be considered to be caused by abnormal maternal-fetal immunity (References 3b - 10b). It is considered that abnormal maternal-fetal immunity is attributed to the inhibition of attacks formed by cellular immunity and T cell-mediated humoral immunity, and insufficient immune tolerance to fetal antigens (Reference 11b).

[0053] Prior art documents

[0054] Patent documents

[0055] Patent Document 1: International Publication No. WO2016 / 068208 Summary of the invention

[0056] Problems to be solved by the invention

[0057] An object of the present invention is to provide a drug containing specific immunosuppressive components for improving infertility or pregnancy status affected by the immune interaction between the mother and fetus, and in particular, to provide a drug for suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restoring a normal immune state.

[0058] Meanwhile, the object of the present invention is to treat or improve blood group incompatible pregnancy or fetal hemochromatosis by restoring a normal immune state.

[0059] Furthermore, the object of the present invention is to prevent or delay the onset of pregnancy-induced hypertension syndrome and / or its related diseases by suppressing the activation of maternal rejection immunity against the fetus and promoting tolerance to the fetus.

[0060] Means for solving the problems

[0061] That is, in order to solve the above problems, the present invention includes the following embodiments.

[0062] (Embodiment 1)

[0063] A drug for suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restoring a normal immune state, wherein the drug contains, as an active ingredient, a compound selected from the group consisting of:

[0064] (i) a compound represented by formula (I) or a pharmaceutically acceptable salt thereof;

[0065] [Chemical formula 1]

[0066]

[0067] (ii) cyclosporins; and

[0068] (iii) rapamycin or its derivatives;

[0069] (In formula (I), R 1 and R 2 , R 3 and R 4 , R 5 and R 6 adjacent to each other are independent of each other,

[0070] (a) represents two adjacent hydrogen atoms, or R 2 may be an alkyl group, or

[0071] (b) another bond may be formed between each of the bonded carbon atoms;

[0072] R 7 is a hydrogen atom, a hydroxyl group, a protected hydroxyl group, or together with R 1 represents an oxo group;

[0073] R 8 and R 9 independently represent a hydrogen atom, a hydroxyl group;

[0074] R 10represents a hydrogen atom, an alkyl group, an alkyl group substituted with one or more hydroxyl groups, an alkenyl group, an alkenyl group substituted with one or more hydroxyl groups, or an alkyl group substituted with an oxo group;

[0075] X represents an oxo group, (a hydrogen atom, a hydroxyl group), (a hydrogen atom, a hydrogen atom), or a group represented by the formula -CH 2 O-;

[0076] Y represents an oxo group, (a hydrogen atom, a hydroxyl group), (a hydrogen atom, a hydrogen atom), or a group represented by the formula N-NR 11 R 12 or N-OR 13 ;

[0077] R 11 and R 12 independently represent a hydrogen atom, an alkyl group, an aryl group, or a tosyl group;

[0078] R 13 、R 14 、R 15 、R 16 、R 17 、R 18 、R 19 、R 22 and R 23 independently represent a hydrogen atom or an alkyl group;

[0079] R 24 represents a ring that can contain one or more heteroatoms that can be optionally substituted as desired;

[0080] n represents 1 or 2;

[0081] In addition to the above meanings, furthermore, Y, R 10 and R 23 can also form, together with the carbon atom to which they are bonded, a saturated or unsaturated 5- or 6-membered heterocyclic group containing one or more heteroatoms selected from a nitrogen atom, a sulfur atom, and an oxygen atom, and the heterocyclic group can be substituted with one or more groups selected from an alkyl group, a hydroxyl group, an alkoxy group, a benzyl group, a group represented by the formula -CH 2 Se(C 6 H 5 ).

[0082] (Embodiment 2)

[0083] A drug for enhancing the action of steroid hormones by activating and nuclear translocation of steroid hormone receptors, wherein a compound selected from the group consisting of the following components is used as an active ingredient:

[0084] (i) A compound represented by the formula (I) or a pharmaceutically acceptable salt thereof;

[0085] (ii) Cyclosporins; and

[0086] (iii) Rapamycin or its derivatives.

[0087] Here, steroid hormones include glucocorticoids, mineralocorticoids, estrogens, progesterone, androgens, etc. It is also possible to provide a drug which, before implantation during pregnancy, mainly promotes the differentiation of the endometrium through progesterone and immunosuppression in the uterus, making the uterine environment for receiving the fertilized egg or fetus favorable.

[0088] (Embodiment 3)

[0089] A drug for inhibiting the activity of natural killer / natural killer T cells or macrophages, which are representative of innate immunity that may be activated by fertilized egg or fetal components in the uterus, wherein the compound selected as the active ingredient is from the group consisting of:

[0090] (i) The compound represented by formula (I) or a pharmaceutically acceptable salt thereof;

[0091] (ii) Cyclosporins; and

[0092] (iii) Rapamycin or its derivatives.

[0093] (Embodiment 4)

[0094] A drug for inhibiting the activity of antigen-presenting cells (dendritic cells, macrophages, etc.), cytotoxic T cells, or T cells that produce intercellular mediators, which may directly or indirectly attack the fertilized egg or fetus by acquired immunity in the uterus and present antigens of fertilized egg or fetal components, wherein the compound selected as the active ingredient is from the group consisting of:

[0095] (i) The compound represented by formula (I) or a pharmaceutically acceptable salt thereof;

[0096] (ii) Cyclosporins; and

[0097] (iii) Rapamycin or its derivatives.

[0098] (Embodiment 5)

[0099] A drug for inducing antigen-presenting cells required for immune tolerance of the fertilized egg or fetus, or for inducing the differentiation of undifferentiated dendritic cells into tolerogenic dendritic cells, wherein the compound selected as the active ingredient is from the group consisting of:

[0100] (i) The compound represented by formula (I) or a pharmaceutically acceptable salt thereof;

[0101] (ii) Cyclosporins; and

[0102] (iii) Rapamycin or its derivatives.

[0103] (Embodiment 6)

[0104] A drug for inhibiting the humoral immune response against fetal components including human leukocyte antigen (HLA), that is, inhibiting the production of fetal-specific antibodies, wherein the compound selected from the group consisting of the following components is used as the active ingredient:

[0105] (i) The compound shown in formula (I) or its pharmaceutically acceptable salt;

[0106] (ii) Cyclosporines; and

[0107] (iii) Rapamycin or its derivatives. It should be noted that the conditions caused by the production of fetal-specific antibodies include infertility, rejection of fertilized eggs and fetuses in infertility, blood group incompatible pregnancy, neonatal hemochromatosis, etc.

[0108] (Embodiment 7)

[0109] A drug for inhibiting the production of pathogenic antibodies in the mother's body that cause problems in continued pregnancy, wherein the compound selected from the group consisting of the following components is used as the active ingredient:

[0110] (i) The compound shown in formula (I) or its pharmaceutically acceptable salt;

[0111] (ii) Cyclosporines; and

[0112] (iii) Rapamycin or its derivatives. Here, the pathogenic antibodies include autoantibodies represented by antiphospholipid antibody syndrome, etc.

[0113] (Embodiment 8)

[0114] A drug for inhibiting the activation of the mother's rejection immunity against the fetus and / or promoting the tolerance to the fetus, wherein the compound selected from the group consisting of the following components is used as the active ingredient:

[0115] (i) The compound shown in formula (I) or its pharmaceutically acceptable salt;

[0116] (ii) Cyclosporines; and

[0117] (iii) Rapamycin or its derivatives.

[0118] (Embodiment 9)

[0119] A drug for preventing or delaying the occurrence of pregnancy-induced hypertension syndrome and / or diseases associated with pregnancy-induced hypertension syndrome, wherein a compound selected from the group consisting of the following components is used as an active ingredient:

[0120] (i) A compound represented by formula (I) or a pharmaceutically acceptable salt thereof;

[0121] (ii) Cyclosporins; and

[0122] (iii) Rapamycin or a derivative thereof.

[0123] (Embodiment 10)

[0124] The drug according to Embodiment 9, wherein the disease associated with pregnancy-induced hypertension syndrome is HELLP syndrome.

[0125] (Embodiment 11)

[0126] The drug according to Embodiment 9, wherein the disease associated with pregnancy-induced hypertension syndrome is eclampsia.

[0127] (Embodiment 12)

[0128] The drug according to any one of Embodiments 1 to 11, wherein the active ingredient is a compound of formula (I) or a pharmaceutically acceptable salt thereof, and the compound of formula (I) is tacrolimus or a pharmaceutically acceptable salt thereof.

[0129] Furthermore, the present invention also includes the following embodiments.

[0130] (Embodiment 13)

[0131] A drug for suppressing over-activated immunity before pregnancy or reactive immunity after pregnancy, wherein a compound selected from the group consisting of the following components is used as an active ingredient:

[0132] (i) A compound represented by formula (I) or a pharmaceutically acceptable salt thereof;

[0133] (ii) Cyclosporins; and

[0134] (iii) Rapamycin or a derivative thereof.

[0135] (Embodiment 14)

[0136] The drug according to Embodiment 13, which comprises administering tacrolimus or a pharmaceutically acceptable salt thereof to a patient.

[0137] In addition, the compounds of the present invention can be used as drugs for suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restoring normal immune status. Therefore, the use of the compounds of the present invention can provide the following treatments. Similarly, the compounds of the present invention can be used as drugs for the following treatments.

[0138] (Embodiment 15)

[0139] Treatment of a humoral immunity-related disease in the relationship between mother and fetus or a drug for treatment.

[0140] (Embodiment 16)

[0141] The treatment or drug for treatment according to Embodiment 15, wherein the humoral immunity-related disease in the relationship between mother and fetus is incompatible blood type pregnancy.

[0142] (Embodiment 17)

[0143] The treatment or drug for treatment according to Embodiment 15, wherein the humoral immunity-related disease in the relationship between mother and fetus is fetal hemochromatosis.

[0144] (Embodiment 18)

[0145] The treatment or drug for treatment according to Embodiment 15, which is applicable to the second and subsequent pregnancies.

[0146] (Embodiment 19)

[0147] The treatment or drug for treatment according to Embodiment 15, wherein administration starts from the early stage of pregnancy.

[0148] (Embodiment 20)

[0149] The treatment or drug for treatment according to Embodiment 15, wherein administration starts from the early stage of pregnancy at a dosage of 1 to 10 mg / day.

[0150] (Embodiment 21)

[0151] The treatment or drug for treatment according to Embodiment 15, wherein administration starts from the early stage of pregnancy at a dosage of 3 to 6 mg / day.

[0152] (Embodiment 22)

[0153] The treatment or drug for treatment according to Embodiment 15, wherein for a patient who may have incompatible blood type pregnancy, the compound of formula (I) is administered at a dosage of 1 to 10 mg / day starting from the early stage of pregnancy.

[0154] Furthermore, considering the mechanism of action of the compounds of the present invention, the compounds of the present invention can be drugs for the following methods.

[0155] (Embodiment 23)

[0156] Suppress humoral immunity involving the action on B cells by a high Th2 cell ratio and its activity.

[0157] Effects of the Invention

[0158] According to the present invention, over-activated immunity before pregnancy or over-reactive immunity after pregnancy is suppressed, and a normal immune state is restored. As a result, blood group incompatible pregnancy or fetal hemochromatosis can be treated or improved.

[0159] In addition, according to the present invention, activation of the rejection immunity of the mother against the fetus is suppressed and tolerance to the fetus is promoted. As a result, the onset of pregnancy-induced hypertension syndrome and / or its related diseases can be prevented or delayed. BRIEF DESCRIPTION OF THE DRAWINGS

[0160] Figure 1a It is a diagram showing that maternal immunity has a large number of common immune mechanisms with organ transplantation and cancer.

[0161] Figure 1b It is a diagram showing that recognition of implantation, suppression of fetal attack, and fetal immune tolerance are important for successful pregnancy, and any dysfunction of these may lead to infertility.

[0162] Figure 2a It is a diagram showing the association between fetal-maternal HLA-C mismatch and maternal T cell activation. The immune response can be converted into the direction of immune tolerance under various conditions.

[0163] Figure 2b It is a diagram showing that extravillous trophoblast (EVT) does not express HLA-A, -B, -D, and thus may become a target of NK cells (CD16+ / CD56 dim ), rather than a target of cytotoxic T cells. EVT expresses HLA-C, E, and G. HLA-C expression is related to immune tolerance, HLA-E inhibits NK cell activity, HLA-G plays a role in avoiding NK cell attack, and inhibits the production of type I cytokines by macrophages (see Figure 3b ). ILT represents Ig-like transcript, KIR represents killer cell Ig-like receptor, and HLA represents human leukocyte antigen. HLA-A, B, and C belong to MHC class Ia, HLA-E, F, and G belong to MHC class Ib, and HLA-DR, DQ, and DP belong to MHC class II.

[0164] Figure 3a This is a graph showing that both recurrent implantation failure (RIF) and recurrent miscarriage (RPL) are associated with dominant Th1 immunity. Systemic persistent Th1 dominant immunity sometimes reflects the state of the uterus before implantation in RIF patients, but after implantation in RPL patients, the state of the uterus sometimes cannot accurately reflect the state of the whole body. This theory can be inferred from the NK cell subsets in the uterus.

[0165] Figure 3b This is a presumptive diagram of some of the changing patterns of Th1 immunity. The timing of activation is: just after pregnancy before implantation when the mother first recognizes the fetus, and in the second trimester when fetal antigens enter the maternal circulation through the placenta.

[0166] Figure 4 It is a diagram showing the intracellular mechanism of action of tacrolimus. Tacrolimus recognizes and binds to specific receptors, acting on some cells and molecular pathways. Activated FKBP inhibits the NFAT pathway by inhibiting calcineurin activity, and binds to the steroid hormone chaperone complex, thereby inducing the release of hormone receptors and nuclear transfer from the complex. GR represents glucocorticoid receptor, NFAT represents nuclear factor of activated T cells, and ER represents microsomal.

[0167] Figure 5a This is a diagram that suggests that tacrolimus can be used to treat infertility. Activation of progesterone receptors can induce maturation of the endometrium during implantation. The main effect of tacrolimus is direct inhibition of activated NK / NKT cells and activated Th1 cells. Inducing imDC to mature into tDC can affect immune tolerance to the fetus.

[0168] Figure 5b : is a graph showing the immunological control by tacrolimus for the treatment of infertility. Unlike the use of tacrolimus in organ transplantation or collagen disease, tacrolimus is used to restore the increased immune level to normal level in infertility. Therefore, the dosage of tacrolimus used for the treatment of infertility can be low compared to the dosage used for the treatment of other diseases.

[0169] Figure 6 The upper part is a graph showing the patient's Th1, Th2 and their ratio. Initially, a high Th1 / Th2 ratio means infertility due to abnormalities in the immune system. The lower part is a graph showing the titer of anti-D antibodies in pregnant women during pregnancy. It can be seen that the increase in antibody titer is slow due to the administration of tacrolimus from the early pregnancy, but the dosage is increased (5 mg / day) at the 28th week of pregnancy, which begins to rise rapidly, and the titer of D antibody is stable and does not rise further.

[0170] Figure 7It is a graph showing the weight of a fetus in gestational weeks and the blood flow velocity in the middle cerebral artery. Even after 28 weeks when it is necessary to increase the dosage of tacrolimus (5 mg / day) from the early stage of pregnancy, the weight increases smoothly, and the blood flow velocity as a measure of fetal anemia corresponds to the number of weeks.

[0171] Figure 8 It is a graph showing the changes during pregnancy in the proportions of Th1 and Th2 cells and NK cell activity in CD4-positive cells. The proportions of Th1 and Th2 cells in CD4-positive cells continuously decrease, while the NK cell activity decreases in the second trimester of pregnancy and then significantly increases in the test at 32 weeks of pregnancy. Detailed Description of the Invention

[0172] The present invention will be described in detail below.

[0173] That is, the present invention provides a drug for suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restoring a normal immune state, wherein the drug contains, as an active ingredient, a compound selected from the group consisting of:

[0174] (i) a compound represented by formula (I) or a pharmaceutically acceptable salt thereof;

[0175] [Chemical formula 2]

[0176]

[0177] (ii) cyclosporines; and

[0178] (iii) rapamycin or a derivative thereof;

[0179] (In formula (I), R 1 and R 2 , R 3 and R 4 , R 5 and R 6 adjacent to each other are independent of each other,

[0180] (a) represents two adjacent hydrogen atoms, or R 2 can be an alkyl group, or

[0181] (b) another bond can be formed between each of the bonded carbon atoms (i.e., a double bond is formed);

[0182] R 7 is a hydrogen atom, a hydroxyl group, a protected hydroxyl group, or together with R 1 represents an oxo group;

[0183] R 8 and R 9 independently represent a hydrogen atom, a hydroxyl group;

[0184] R 10 represents a hydrogen atom, an alkyl group, an alkyl group substituted with one or more hydroxyl groups, an alkenyl group, an alkenyl group substituted with one or more hydroxyl groups, or an alkyl group substituted with an oxo group;

[0185] X represents an oxo group, (a hydrogen atom, a hydroxyl group), (a hydrogen atom, a hydrogen atom), or a group represented by the formula -CH 2 O-;

[0186] Y represents an oxo group, (a hydrogen atom, a hydroxyl group), (a hydrogen atom, a hydrogen atom), or a group of the formula N-NR 11 R 12 or N-OR 13 ;

[0187] R 11 and R 12 independently represent a hydrogen atom, an alkyl group, an aryl group, or a tosyl group;

[0188] R 13 、R 14 、R 15 、R 16 、R 17 、R 18 、R 19 、R 22 and R 23 independently represent a hydrogen atom or an alkyl group;

[0189] R 24 represents a ring that can contain one or more heteroatoms that can be optionally substituted;

[0190] n represents 1 or 2;

[0191] In addition to the above meanings, further, Y, R 10 and R 23 can also form, together with the carbon atom to which they are bonded, a saturated or unsaturated 5- or 6-membered ring heterocyclic group containing one or more heteroatoms selected from a nitrogen atom, a sulfur atom, and an oxygen atom, and the heterocyclic group can be substituted with one or more groups selected from an alkyl group, a hydroxyl group, an alkoxy group, a benzyl group, a group represented by the formula -CH 2 Se(C 6 H 5 )) and an alkyl group substituted with one or more hydroxyl groups).

[0192] In the compound of formula (I), R 24Represents a ring capable of containing one or more heteroatoms that can be substituted as desired, specifically a 5- to 7-membered carbocyclic ring or a 5- or 6-membered heterocyclic group. As the 5- or 6-membered heterocyclic group, for example, it is a saturated or unsaturated 5- or 6-membered ring heterocyclic group containing one or more heteroatoms selected from a nitrogen atom, a sulfur atom, and an oxygen atom. As a preferred R 24 , there can be enumerated a ring (C 5 -C 7 ) alkyl that can have suitable substituents. For example, the following groups can be exemplified.

[0193] (a) 3,4-dioxo-cyclohexyl;

[0194] (b) 3-R 20 -4-R 21 -cyclohexyl.

[0195] Here, R 20 represents a hydroxyl group, an alkoxy group, an oxo group, or OCH 2 OCH 2 CH 2 OCH 3 , and R 21 represents a hydroxyl group, -OCN, an alkoxy group, a heteroaryloxy group that can have suitable substituents, -OCH 2 OCH 2 CH 2 OCH 3 , a protected hydroxyl group, chlorine, bromine, iodine, aminooxaloyloxy, azide, or p-trimethoxysulfonylcarbonyloxy, or R 25 R 26 CHCOO- (wherein, R 25 represents a hydroxyl group or a protected amino group that can be protected as desired, and R 26 represents a hydrogen atom or a methyl group), or an oxygen atom (i.e., -O-) where R 20 and R 21 together form an epoxy ring; or

[0196] (c) cyclopentyl, and the cyclopentyl can be substituted by methoxymethyl, a hydroxylmethyl group that can be protected as desired, acyloxymethyl (wherein the acyl moiety is a dimethylamino group that can be quaternized as desired or a carboxyl group that can be esterified), one or more protected amino groups and / or hydroxyl groups, or aminooxaloyloxymethyl. A preferred example is 2-formyl-cyclopentyl.

[0197] Each definition, its specific examples, and its preferred embodiments used in this specification will be described in detail below.

[0198] "Lower", unless otherwise specified, means a group having 1 to 6 carbon atoms.

[0199] Preferred examples of the alkyl moiety of "alkyl" and "alkyloxy" include: straight-chain or branched-chain aliphatic hydrocarbon residues, such as: methyl, ethyl, propyl, isopropyl, butyl, isobutyl, pentyl, neopentyl, hexyl and other lower alkyl groups having 1 to 6 carbon atoms.

[0200] Preferred examples of "alkenyl" include: straight-chain or branched-chain aliphatic hydrocarbon residues having 1 double bond, such as: vinyl, propenyl (allyl, etc.), butenyl, methallyl, pentenyl, hexenyl and other lower alkenyl groups.

[0201] Preferred examples of "aryl" include: phenyl, tolyl, xylyl, cumenyl, naphthyl, anthryl, etc.

[0202] Preferred protecting groups for "protected hydroxyl" and "protected amino" include, for example: 1-(lower alkylthio)(lower)alkyl such as methylthiomethyl, ethylthiomethyl, propylthiomethyl, isopropylthiomethyl, butylthiomethyl, isobutylthiomethyl, hexylthiomethyl and other lower alkylthiomethyl; as a further preferred group, C 1 ~C 4 alkylthiomethyl; as the most preferred group, methylthiomethyl; trisubstituted silyls such as tris(lower)alkylsilyls such as trimethylsilyl, triethylsilyl, tributylsilyl, tert-butyl-dimethylsilyl, tris(tert-butyl)silyl, and lower alkyl-diarylsilyls such as methyl-diphenylsilyl, ethyl-diphenylsilyl, propyl-diphenylsilyl, tert-butyl-diphenylsilyl, etc., as a further preferred group, tris(C 1 ~C 4 )alkylsilyl and C 1 ~C 4 alkyldiphenylsilyl; as the most preferred group, tert-butyl-dimethylsilyl and tert-butyl-diphenylsilyl; acyl groups such as aliphatic acyl groups derived from carboxylic acids, sulfonic acids and carbamic acids, aliphatic acyl groups substituted by aromatic acyl groups and aromatic groups; etc.

[0203] As the aliphatic acyl group, for example, there may be mentioned: formyl, acetyl, propionyl, butyryl, isobutyryl, valeryl, isovaleryl, pivaloyl, hexanoyl, carboxyacetyl, carboxypropionyl, carboxybutyryl, carboxyhexanoyl and other lower alkanoyl groups which may have one or more suitable substituents such as carboxyl groups; for example, cyclopropyloxyacetyl, cyclobutyloxypropionyl, cycloheptyloxybutyryl, menthyloxyacetyl, menthyloxypropionyl, menthyloxybutyryl, menthyloxyvaleryl, menthyloxyhexanoyl and other cyclo(lower)alkoxy(lower)alkanoyl groups which may have one or more suitable substituents such as lower alkyl groups; camphorsulfonyl; for example, carboxymethylcarbamoyl, carboxyethylcarbamoyl, carboxypropylcarbamoyl, carboxybutylcarbamoyl, carboxypentylcarbamoyl, carboxyhexylcarbamoyl and other carboxy(lower)alkylcarbamoyl groups, or for example, trimethylsilylmethoxycarbonylethylcarbamoyl, trimethylsilylethoxycarbonylpropylcarbamoyl, triethylsilylethoxycarbonylpropylcarbamoyl, tert-butyldimethylsilylethoxycarbonylpropylcarbamoyl, trimethylsilylpropoxycarbonylbutylcarbamoyl and other tri(lower)alkylsilyl(lower)alkoxycarbonyl(lower)alkylcarbamoyl groups and other lower alkylcarbamoyl groups which may have one or more suitable substituents such as carboxyl groups or protected carboxyl groups.

[0204] As the aromatic acyl group, for example, there may be mentioned: benzoyl, methylbenzoyl, toluoyl, naphthoyl, nitrobenzoyl, dinitrobenzoyl, nitronaphthoyl and other aryl acyl groups which may have one or more suitable substituents such as nitro groups; for example, benzenesulfonyl, toluenesulfonyl, dimethylaminesulfonyl, naphthalenesulfonyl, fluorobenzenesulfonyl, chlorobenzenesulfonyl, bromobenzenesulfonyl, iodobenzenesulfonyl and other arylsulfonyl groups which may have one or more suitable substituents such as halogen groups.

[0205] As the aliphatic acyl group substituted by an aromatic group, for example, there may be mentioned: phenylacetyl, phenylpropionyl, phenylbutyryl, 2-trifluoromethyl-2-methoxy-2-phenylacetyl, 2-ethyl-2-trifluoromethyl-2-phenylacetyl, 2-trifluoromethyl-2-propoxy-2-phenylacetyl and other aryl(lower)alkanoyl groups which may have one or more suitable substituents such as lower alkoxy groups or trihalo(lower)alkyl groups.

[0206] Among the above acyl groups, as the more preferred acyl groups, there may be mentioned: C 1 ~C 4 alkanoyl groups which may have a carboxyl group, and cyclo(C 1 ~C 4 )alkoxy(C 5 ~C 6 ) having two (C1 ~C 4 )alkanoyl, camphorsulfonyl, carboxy (C 1 ~C 4 )alkylcarbamoyl, tris(C 1 ~C 4 )alkylsilyl (C 1 ~C 4 )alkoxycarbonyl (C 1 ~C 4 )alkylcarbamoyl, benzoyl which may have one or two nitro groups, benzenesulfonyl having a halogen, having C 1 ~C 4 alkoxytrihalo (C 1 ~C 4 )alkylphenyl (C 1 ~C 4 )alkanoyl, among these, as the most preferred groups, examples include: acetyl, carboxypropionyl, menthyloxyacetyl, camphorsulfonyl, benzoyl, nitrobenzoyl, dinitrobenzoyl, iodobenzenesulfonyl, and 2-trifluoromethyl-2-methoxy-2-phenylacetyl.

[0207] As the "5- to 7-membered carbocyclic ring", examples include 5- to 7-membered cycloalkyl or cycloalkenyl, for example, cyclopentyl, cyclohexyl, cycloheptyl, cyclopentenyl, cyclohexenyl, or cycloheptenyl can be cited.

[0208] As preferred examples of the "heterocyclic group containing one or more heteroatoms selected from a nitrogen atom, a sulfur atom, and an oxygen atom in a saturated or unsaturated 5- or 6-membered ring", examples include: pyrrolyl, tetrahydrofuranyl, and the like.

[0209] The part of the "heteroaryl which may have suitable substituents" in the "heteroaryloxy which may have suitable substituents" can include: as the group R 1 illustrated in the compound shown by the formula in EP-A-532,088, for example, preferably 1-hydroxyethylindol-5-yl. The disclosure thereof is incorporated herein by reference as part of the description.

[0210] Active ingredient

[0211] In the present invention, as the active ingredient, (i) the compound represented by formula (I) or a pharmaceutically acceptable salt thereof, (ii) cyclosporins, or (iii) rapamycin or a derivative thereof can be used. It should be noted that, as the active ingredient, two or more of (i) the compound represented by formula (I), (ii) cyclosporins, or (iii) rapamycin or a derivative thereof can also be used in combination. The respective active ingredients are described below.

[0212] (i) The compound represented by formula (I)

[0213] The compounds represented by formula (I) or pharmaceutically acceptable salts thereof that can be used in the present invention are as described above. Specifically, for example, they are described in EP-A-184162, EP-A-323042, EP-A-423714, EP-A-427680, EP-A-465426, EP-A-480623, EP-A-532088, EP-A-532089, EP-A-569337, EP-A-626385, WO89 / 05303, WO93 / 05058, WO96 / 31514, WO91 / 13889, WO91 / 19495, WO93 / 5059, etc.

[0214] In particular, the compounds known as FR900506 (= FK506, tacrolimus), FR900520 (ascomycin), FR900523, and FR900525 are substances produced by the genus Streptomyces, such as Streptomyces tsukubaensis No. 9993 (Depository: 1-3, Higashi 1-chome, Tsukuba-shi, Ibaraki-ken, Japan, Institute of Biotechnology, National Institute of Advanced Industrial Science and Technology, Ministry of Economy, Trade and Industry (formerly: Institute of Microbial Technology, Ministry of International Trade and Industry), Date of deposit: October 5, 1984, Deposit number: Microbial Research Institute Deposit No. 927) or Streptomyces hygroscopicus subsp. yakushimaensis No. 7238 (Depository: 1-3, Higashi 1-chome, Tsukuba-shi, Ibaraki-ken, Japan, Institute of Biotechnology, National Institute of Advanced Industrial Science and Technology, Ministry of Economy, Trade and Industry, Date of deposit: January 12, 1985, Deposit number: Microbial Research Institute Deposit No. 928) (EP-A-0184162). In particular, FK506 (generic name: tacrolimus) represented by the following structural formula is a representative compound.

[0215] [Chemical formula 3]

[0216]

[0217] Chemical name: 17-Allyl-1,14-dihydroxy-12-[2-(4-hydroxy-3-methoxycyclohexyl)-1-methylethenyl]-23,25-dimethoxy-13,19,21,27-tetramethyl-11,28-dioxa-4-azatricyclo[22.3.1.04,9]octacos-18-ene-2,3,10,16-tetraone.

[0218] As a particularly preferred embodiment, in the compound represented by formula (I), R 3 and R 4 , R 5 and R 6 Each adjacent pair forms another bond formed between each of these bonded carbon atoms (thus, between R 3 and R 4 , R 5 and R 6 a double bond is formed in the moiety),

[0219] R 1, R 2 , R 8 and R 23 are independently hydrogen atoms,

[0220] R 9 is a hydroxyl group, R 10 is methyl, ethyl, propyl or allyl,

[0221] R 7 is a hydroxyl group,

[0222] X is (a hydrogen atom, a hydrogen atom) or an oxo group,

[0223] Y is an oxo group,

[0224] R 14 , R 15 , R 16 , R 17 , R 18 , R 19 and R 22 are each methyl,

[0225] R 24 is 3-R 20 -4-R 21 -cyclohexyl,

[0226] Here, R 20 is a hydroxyl group, an alkoxy group, an oxo group, or -OCH 2 OCH 2 CH 2 OCH 3 ,

[0227] R 21 is a hydroxyl group, -OCN, an alkoxy group, a heteroaryloxy group which may have suitable substituents, a 1-tetrazolyl group or a 2-tetrazolyl group, -OCH 2 OCH 2 CH 2 OCH 3 , a protected hydroxyl group, chlorine, bromine, iodine, an aminocarbonyloxy group, an azide group or a p-trimethoxysulfonylcarbonyloxy group; or is R 25R 26 CHCOO- (wherein R 25 is a hydroxyl group or a protected amino group that can be protected as desired, and R 26 is a hydrogen atom or a methyl group); or R 20 and R 21 together form an oxygen atom of an epoxy ring (i.e., -O-), in addition, n is 1 or 2.

[0228] As another preferred embodiment, as the compound represented by formula (I), examples include: tacrolimus, ascomycin or its derivatives.

[0229] Furthermore, as preferred examples of the compound represented by formula (I) of the present invention, examples also include: compounds described in EP0184162, EP323042, EP424714, EP427680, EP465426, EP474126, EP480623, EP484936, EP532088, EP532089, EP569337, EP626385, WO89 / 05303, WO93 / 05058, WO96 / 31514, WO91 / 13889, WO91 / 19495, WO93 / 5059, WO96 / 31514, etc., and the disclosures thereof are incorporated herein by reference as part of the description.

[0230] Pharmaceutically acceptable salts of the compound represented by formula (I)

[0231] The term "pharmaceutically acceptable salt" in the compound represented by formula (I) of the present invention refers to a salt prepared from a pharmaceutically acceptable non-toxic base or acid. When the compound of formula (I) of the present invention is acidic, its corresponding salt can be suitably prepared from a pharmaceutically acceptable non-toxic base including inorganic bases and organic bases. Salts from such inorganic bases include: salts of aluminum, ammonium, calcium, copper (divalent and monovalent), ferric, ferrous, lithium, magnesium, manganese (trivalent and divalent), potassium, sodium, zinc, etc. Preferred are salts of ammonium, calcium, magnesium, potassium and sodium. Salts prepared from pharmaceutically acceptable non-toxic organic bases include salts of primary, secondary and tertiary amines from both natural and synthetic sources. Pharmaceutically acceptable non-toxic organic bases include: for example, arginine, betaine, caffeine, choline, N,N'-dibenzylethylenediamine, diethylamine, 2-diethylaminoethanol, 2-dimethylaminoethanol, ethanolamine, ethylenediamine, N-ethylmorpholine, N-ethylpiperidine, glucamine, glucosamine, histidine, hydrabamine, isopropylamine, dicyclohexylamine, lysine, methylglucamine, morpholine, piperazine, piperidine, polyamine resin, procaine, purine, theobromine, triethylamine, trimethylamine, tripropylamine, tromethamine, etc.

[0232] When the compound represented by formula (I) of the present invention is basic, its corresponding salt can be suitably prepared from pharmaceutically acceptable non-toxic inorganic acids and organic acids. Such acids include, for example, acetic acid, benzenesulfonic acid, benzoic acid, camphorsulfonic acid, citric acid, ethanesulfonic acid, fumaric acid, gluconic acid, glutamic acid, hydrobromic acid, hydrochloric acid, hydroxyethanesulfonic acid, lactic acid, maleic acid, malic acid, mandelic acid, methanesulfonic acid, mucic acid, nitric acid, pamoic acid, pantothenic acid, phosphoric acid, succinic acid, sulfuric acid, tartaric acid, p-toluenesulfonic acid, etc. Citric acid, hydrobromic acid, hydrochloric acid, maleic acid, phosphoric acid, sulfuric acid and tartaric acid are preferred.

[0233] Solvates or hydrates of the compound represented by formula (I)

[0234] The compound represented by formula (I) of the present invention can also form solvates, and this situation is also included within the scope of protection of the present invention. As preferred solvates, hydrates and ethanolates can be cited.

[0235] Crystal forms of the compound represented by formula (I)

[0236] The compound represented by formula (I) of the present invention can exist in an amorphous form and / or one or more crystalline forms, and all such amorphous forms and crystalline forms of the compound represented by formula (I) and their mixtures are intended to be included within the scope of the present invention. Further, for the crystal forms of the compound represented by formula (I), solvates with water (i.e., hydrates) or solvates with common organic solvents can also be formed. Solvates and hydrates of the crystal forms of the compound represented by formula (I), especially pharmaceutically acceptable solvates and hydrates, are likewise included within the scope of the compounds defined by formula (I) and their pharmaceutically acceptable salts.

[0237] Isomers of the compound represented by formula (I)

[0238] In the compound represented by formula (I) of the present invention, there may sometimes be one or more pairs of stereoisomers such as optical isomers and geometric isomers resulting from conformational isomers or asymmetric carbon atoms and double bonds, and such conformational isomers or isomers are also included within the scope of the compounds of the present invention.

[0239] Preparation method of the compound of formula (I)

[0240] The compounds of formula (I) of the present invention are substances known from the literature, and their preparation methods are disclosed in, for example, EP-A-184162, EP-A-323042, EP-A-423714, EP-A-427680, EP-A-465426, EP-A-480623, EP-A-532088, EP-A-532089, EP-A-569337, EP-A-626385, WO89 / 05303, WO93 / 05058, WO96 / 31514, WO91 / 13889, WO91 / 19495, WO93 / 5059, etc. Alternatively, tacrolimus is commercially available under the trade name Prograf (registered trademark) from Astellas Pharma Inc.

[0241] (ii) Cyclosporins

[0242] Examples of cyclosporins include, for example, cyclosporin A, B, D, etc., which are described in the Merck Index (12th edition) No. 2821. It should be noted that cyclosporin is commercially available, for example, under the trade name Sandimmune from Novartis Pharma K.K.

[0243] (iii) Rapamycin or its derivatives

[0244] Rapamycin (also known as sirolimus) is described in the Merck Index (12th edition) No. 8288, and its derivatives can also be used. Preferred examples of rapamycin derivatives include: the O-substituted derivatives of formula (A) on page 1 of WO95 / 16691 in which the 40-position hydroxyl group is replaced by -OR 1 (where R 1 is hydroxyalkyl, hydroxyalkoxyalkyl, acylaminoalkyl, and aminoalkyl), such as 40-O-(2-hydroxy)ethyl-rapamycin, 40-O-(3-hydroxy)propyl-rapamycin, 40-O-[2-(2-hydroxy)ethoxy]ethyl-rapamycin, and 40-O-(2-acetamidoethyl)-rapamycin. It should be noted that rapamycin (sirolimus) is commercially available under the trade name Rapalimus from Nobelpharma Co., Ltd.

[0245] [Chemical formula 4]

[0246]

[0247] The compounds of formula (I) shown in the present invention, cyclosporins, rapamycin and its derivatives have a similar basic skeleton, namely a tricyclic macrolide skeleton, and have at least one similar biological property (for example, immunosuppressive effect).

[0248] Any other optional ingredients

[0249] In addition to the above-mentioned active ingredients, the drug of the present invention may contain one or more therapeutically active substances having a therapeutic effect on other diseases, illnesses, and symptoms, as long as there is no possibility of inhibiting the activity of the active ingredients and it is harmless to the administration subject (hereinafter also referred to as the patient).

[0250] Examples of such therapeutically active substances include estrogens such as estrone, estradiol, and estriol, progesterone, prednisone, and the like.

[0251] The drug of the present invention

[0252] The drug of the present invention contains, as an active ingredient, a compound selected from the group consisting of (i) a compound of formula (I) or a pharmaceutically acceptable salt thereof, (ii) cyclosporins, and (iii) rapamycin or a derivative thereof. Furthermore, it may also contain a pharmaceutically acceptable carrier that is harmless to the administration subject. The carrier that can be used can be any one of solid, semi-solid, or liquid types. Examples include, but are not limited to, any one selected from water, electrolyte solutions, and sugar solutions. Furthermore, the drug of the present invention may also contain adjuvants. Examples of adjuvants include lubricants, stabilizers, preservatives, emulsifiers, thickeners (viscosity increasing agents), colorants, fragrances (odorants), excipients, preservatives, buffers, flavoring agents, suspending agents, emulsifiers, solubilizing agents, and the like.

[0253] Dosage form

[0254] The drug containing the active ingredient of the present invention can be provided in various dosage forms. Examples of dosage forms include tablets, capsules, pills, granules, powders, syrups, suppositories, lozenges, pellets, emulsions, suspensions, and other known forms. Among these, for example, as an oral administration preparation, any one of tablets, capsules, pills, granules, powders, liquids, syrups, and gels is preferred, any one of tablets, capsules, and granules is more preferred, and tablets are further preferred. It should be noted that, as described later, for example, parenteral administration preparations such as injections, suppositories, and transdermal absorption preparations can also be prepared.

[0255] Method for manufacturing the drug

[0256] The drug of the present invention can be manufactured using known manufacturing methods. As an example, it can be manufactured by separately manufacturing the active ingredient and any other optional ingredients each time by component, and then mixing the respective components in such a way as to achieve the desired content.

[0257] Administration subject of the drug

[0258] As the subject to which the drug of the present invention is administered, mammals can be cited. As mammals, humans, domestic animals such as cows, horses, pigs, and sheep as animals other than humans, monkeys, chimpanzees, and pet animals such as dogs, cats, rats, and rabbits can be cited, and humans are preferably cited.

[0259] Route of administration

[0260] The method of administering the drug of the present invention (route of administration) can be appropriately determined according to the age, condition, treatment period, etc. of the subject to which the drug is administered. Specifically, it can be either oral administration or parenteral administration, but oral administration is preferred (the example in the examples is oral administration). As parenteral administration, methods such as injection administration, administration as a suppository, and administration as a transdermal absorption type preparation can be cited. As the types of injection administration, for example, intramuscular, intraperitoneal, subcutaneous, intravenous, and local injections can be cited. In addition, the drug of the present invention can be administered through various routes such as transdermal, nasal, vaginal, and rectal routes.

[0261] Dosage

[0262] The dosage of the drug varies depending on the disease, illness, or type of symptom of the patient receiving the drug administration, the severity, various test results, and the type of active ingredient of the drug. Furthermore, the dosage of the drug also varies depending on the age of the patient to be treated, the number of times of treatment based on the treatment method of the present invention, and various test results, etc. As an example, from the viewpoint of the content of the active ingredient contained in the drug, the drug of the present invention is administered at a low dosage that is lower than the dosage used as an immunosuppressant in the treatment of biological transplantation and immune system diseases, etc. For example, when the subject of drug administration is a human, there is no particular limitation, but depending on the symptoms of the patient, as the amount of the active ingredient per day, it is preferably administered in the range of 0.5 to 10 mg or 1 to 10 mg, and more preferably in the range of 0.5 to 6 mg or 3 to 6 mg. It should be noted that unless otherwise stated below, the description of the dosage of the drug applies to the case where the subject is a human, and the dosage is expressed as the amount of the active ingredient.

[0263] In addition, in the case of oral administration, the number of times of administration per day is preferably 1 to 4 times, more preferably 1 to 3 times, and further preferably 1 to 2 times, and there is no particular limitation.

[0264] The drug containing the active ingredient of the present invention can be administered stepwise or in combination with other therapeutic drugs. In the case of administering in combination with other therapeutic drugs, the drug of the present invention and other therapeutic drugs can be formulated into preparations and administered simultaneously or at different dosing intervals.

[0265] When the drug containing the active ingredient of the present invention is administered stepwise or in combination with other therapeutic drugs, the same dosage form can generally be used. When these drugs are physically combined for administration, the dosage form and administration route should be selected according to the suitability of the combined drugs. Therefore, the term simultaneous administration can be understood to include the simultaneous or sequential administration of two drugs, or the administration as a fixed-dose combination of two active ingredients.

[0266] As the aforementioned other therapeutic drugs, for example, the following can be cited: estrogens including estrone, estradiol, estriol, progesterone, prednisone, etc. Further, for example, the following can be cited: immunoglobulins such as anti-D immunoglobulin.

[0267] Furthermore, the drug of the present invention can also be combined with physical therapies such as plasmapheresis and fetal blood transfusion.

[0268] A drug for suppressing excessive activation of the immune system before pregnancy or excessive reactive immunity after pregnancy and restoring a normal immune state

[0269] Tacrolimus is one of the related substances (tacrolimus, rapamycin, ascomycin, myriamycin) isolated from soil actinomycetes in Japan. It is a macrolide derivative antibiotic having a 23-membered ring macrolide structure (Reference 73). Tacrolimus is a calcium / calmodulin-dependent phosphatase that binds to the FK506-binding protein (FKBP) receptor and inhibits the activity of calcineurin (References 74-78). This calcineurin inhibitor (CNI) inhibits the calcium-dependent signal that plays a role in moving the nuclear factor of activated T cells (NFAT) into the nucleus in cells stimulated through the T cell receptor ( Figure 4 ) (References 79-83). Based on the successful use of tacrolimus in the fields of transplantation and autoimmune diseases, the detailed mechanism of signal transduction in cells has been elucidated (References 84, 85).

[0270] It has been reported that tacrolimus acts not only on the CN-NFAT pathway of T cells but also on other cell types including natural killer (NK) / natural killer T (NKT) cells, macrophages, B cells, and dendritic cells (DC cells) (References 86-92). Direct inhibition occurs in T cells, NK / NKT cells, and macrophages. In some studies, it has been reported that tacrolimus has a negative impact on the maturation of tDCs (References 88, 89), but on the other hand, the positive effect of tacrolimus in inducing the maturation of immature DC cells (imDCs) into tolerogenic DC cells (tDC cells) has also been shown (References 26, 90, 91).

[0271] B cells (activation, antibody production, and class switching) are inhibited by T follicular helper cells 88 (Reference 87). These insights suggest that tacrolimus inhibits rejection by suppressing activated NK / NKT cells and macrophages, can induce tolerance to the fetus, and can also induce the differentiation of imDCs into tDCs.

[0272] Figure 5a Shows the mechanism of suppressing activated natural killer / natural killer T cells or macrophages by tacrolimus, and the mechanism of inducing the differentiation of immature dendritic cells into tolerogenic dendritic cells.

[0273] Thus, it is possible to inhibit pre-pregnancy over-activated immunity or post-pregnancy hyper-reactive immunity, restore the normal immune state, and treat or improve blood group incompatible pregnancy or fetal hemochromatosis.

[0274] Specifically, tacrolimus is activated by binding to FKBP52 in the progesterone receptor chaperone complex and then being released from the complex (References 33, 112, 113).

[0275] Subsequently, the activated progesterone receptor induces the maturation of endometrial epithelial cells in the presence of progesterone. Galectin-1 is produced by these cells, inducing Th1 apoptosis, tDCs, and uterine NK cells in mature endometrial epithelial cells (References 30, 31, 34, 35).

[0276] Second, tacrolimus directly inhibits the activity of type 1 cells, NK / NKT cells, and macrophages through the CN-NFAT pathway (References 86, 87).

[0277] Third, the differentiation of imDCs into tDCs is induced through the CN-NFAT pathway, resulting in the induction of Treg cells (References 26, 51, 90, 91).

[0278] The induction of tDCs also occurs through other pharmacological mediators such as immunosuppressive drugs (cyclosporine, rapamycin, deoxyspergualin, mycophenolate mofetil, Sanglifehrin A), anti-inflammatory drugs (corticosteroids, aspirin), 1α,25-dihydroxyvitamin D3, N-acetyl-L-cysteine, cyclic AMP-inducing substances (PGE2, histamine, β2-agonists, neuropeptides), glucosamine, and cobalt protoporphyrin (Reference 26).

[0279] It should be noted that the level of immunosuppression with tacrolimus for infertility is different from its use in transplantation. The latter uses tacrolimus to suppress persistent immunity at a level lower than normal immunity, while the former needs to suppress pre-pregnancy over-activated immunity or post-pregnancy hyper-reactive immunity and restore the normal immune state (Figure 5b )。

[0280] Pregnancy with blood group incompatibility

[0281] Pregnancy with blood group incompatibility is a disorder that occurs under the following conditions.

[0282] (i) An antigen that is not present on the red blood cell membrane of the mother is present on the red blood cell membrane of the fetus.

[0283] (ii) After fetal blood flows into the mother through the placenta, pathogenic antibodies against the antigen on the fetal red blood cell membrane are produced in the mother's body (the titer of pathogenic antibodies, such as anti-D antibody titer, anti-red blood cell antibody, etc. increases).

[0284] (iii) The pathogenic antibodies are transferred to the fetus through the placenta and attack the fetal red blood cells.

[0285] (iv) Hemolysis of the fetal red blood cells occurs, leading to fetal anemia.

[0286] Therefore, by administering the drug of the present invention (such as tacrolimus) to the pregnant woman from before the increase in the titer of pathogenic antibodies in (ii), for example, from just after pregnancy, the increase in the titer of pathogenic agents (inhibition of antibody production) can be inhibited, and the symptoms caused by pregnancy with blood group incompatibility can be inhibited, so that pregnancy with blood group incompatibility can be treated or improved.

[0287] For the dosage, 1 mg / day to 10 mg / day can be exemplified as the active ingredient. The dosage is preferably 3 to 6 mg / day.

[0288] In addition, the attack of pathogenic antibodies passing through the placenta on fetal red blood cells in women, once the antigen in the form of fetal red blood cell membrane is recognized (due to previous pregnancy or miscarriage, etc.), retains the memory for producing pathogenic antibodies, so pregnancy with blood group incompatibility becomes more likely to occur during the second and subsequent pregnancies starting from the first pregnancy.

[0289] It should be noted that in the case where a woman has infertility and becomes pregnant using, for example, the drug of the present invention (1 to 4 mg / day as the active ingredient), continuous administration is carried out, and when an increase in the titer of pathogens, for example, is confirmed, the drug of the present invention (such as 5 to 10 mg / day as the active ingredient) can be further administered.

[0290] Furthermore, even in the case where a woman has infertility and becomes pregnant using a method other than the drug of the present invention, for example, the drug of the present invention can be used for the treatment of pregnancy with blood group incompatibility. For example, the drug of the present invention (such as 1 to 10 mg / day as the active ingredient) can be administered from the early stage of pregnancy.

[0291] Fetal hemochromatosis

[0292] Fetal hemochromatosis is a symptom that occurs under the following conditions.

[0293] (i) The enzyme related to iron metabolism in the fetus is different from that in the mother.

[0294] (ii) After fetal blood flows into the mother through the placenta, pathogenic antibodies against this enzyme are produced in the mother's body.

[0295] (iii) The pathogenic antibodies are transferred to the fetus through the placenta and attack the iron metabolism enzyme of the fetus.

[0296] (iv) The iron metabolism of the fetus stops, and iron deposits in the liver, leading to liver cirrhosis.

[0297] Therefore, by administering the drug of the present invention (such as tacrolimus) to a pregnant woman from before the increase in the titer of the pathogenic antibody in (ii), for example, from just after pregnancy, the increase in the titer of the pathogenic antibody (inhibition of antibody production) can be inhibited, and the symptoms caused by the pathogenic antibody can be inhibited. Thus, fetal hemochromatosis can be treated or improved.

[0298] Regarding the dosage of the compound as the active ingredient of the present invention at this time, it is preferably 1 to 10 mg / day, and more preferably 3 to 6 mg / day.

[0299] Pregnancy-induced hypertension and its related diseases (HELLP syndrome, eclampsia, etc.)

[0300] In pregnancy-induced hypertension and its related diseases (HELLP syndrome, eclampsia, etc.), sometimes very dangerous states occur simultaneously in the mother and the fetus, such as fetal growth retardation, placental abruption, fetal dysfunction, and fetal death. This state is caused by abnormal maternal-fetal immunity, and this abnormal maternal-fetal immunity is attributed to insufficient inhibition or promotion of immune tolerance of the attack on fetal components (antigens) including the placenta formed by cellular immunity and T cell-mediated humoral immunity.

[0301] Therefore, for example, by administering the drug of the present invention (such as tacrolimus) to a patient, the activation of the mother's rejection immunity against the fetus can be inhibited and the tolerance to the fetus can be promoted, better placental construction and its function can be achieved, and the onset of pregnancy-induced hypertension and its related diseases during pregnancy can be prevented and delayed.

[0302] In particular, in patients with a history of pregnancy-induced hypertension and its related diseases, usually the recognition of fetal antigens is enhanced after the first pregnancy. Therefore, in the second and subsequent pregnancies, it is preferable to administer the drug of the present invention (such as tacrolimus) to the patient earlier.

[0303] As an active ingredient, the dosage can be exemplified as 1 mg / day to 10 mg / day. For example, since the immunity of the mother against the fetus is strongly activated from the period when the fetal antigens flowing into the mother increase, it is preferable to appropriately increase the dosage in the later stage of pregnancy.

[0304] Examples

[0305] Specific embodiments are listed below to illustrate the present invention. However, the present invention is not limited to these embodiments, and it is understood that those skilled in the art can implement various changes and modifications among these without departing from the scope or gist of the present invention defined in the appended claims.

[0306] Measurement of anti-D antibody titer

[0307] It is carried out by the indirect Coombs test. The indirect Coombs test refers to a test for detecting whether the addition of anti-immunoglobulin antibody to a substance formed by mixing a patient's serum and a healthy person's blood causes red blood cell agglutination reaction (detecting irregular antibodies present in the serum) (for the Coombs test, refer to Japanese Journal of Obstetrics and Gynecology, Vol. 59, No. 10, N-617 to N-623).

[0308] Th1 / Th2 cell ratio

[0309] In recent years, the incidence of in vitro fertilization (IVF) and embryo transfer (ET) has been increasing worldwide. Along with this, the number of women who have experienced multiple IVF failures, including repeated implantation failure (RIF), has been increasing. When performing IVF / ET, the embryo is transferred into the uterine cavity during the period of 2 to 5 days after fertilization. It can be said that the semi-allograft embryo successfully implants on the decidua of the mother along with the establishment of maternal immune tolerance, thereby enabling the establishment of pregnancy (Reference 7a). The key to the establishment of a suitable immune response during implantation lies in successful implantation. Therefore, it is considered that immunological etiology plays an important role in RIF after IVF / ET.

[0310] T helper (Th) 1, Th2, Th17, and Treg cells play important roles in immune responses such as immune rejection and immune tolerance (Reference 8a). It is generally recognized that the immune state during pregnancy is associated with Th2 dominance, and Th1 immune response is associated with embryo rejection (References 6a, 9a). It is considered that the fundamental mechanism of embryo rejection is similar to the rejection reaction in allograft transplantation (Reference 10a). The embryo transplanted during IVF / ET may cause implantation failure due to the same immune response as the rejection reaction in allograft transplantation.

[0311] Analysis of Th1 and Th2 cells

[0312] For the purpose of evaluating the baseline value of the Th1 / Th2 cell ratio, 10 ml of venous blood was collected in its entirety. Th1 cells and Th2 cells were determined by detecting the production of intracellular interferon (IFN)-γ and IL-4.

[0313] Specific staining of lymphocytes was performed by incubating whole blood with anti-CD4-PC5 or anti-CD8-PC5-conjugated monoclonal antibodies (mAbs) (Beckman Coulter, Fullerton, Ca, USA). Red blood cells (RBCs) were removed by hemolysis (using FACS Lysing solution; Becton Dickinson, BD Biosciences, Franklin Lake, NJ, USA), and lymphocytes were analyzed using a flow cytometer (FACSCalibur; Becton Dickinson). After surface staining of an activated whole blood sample with anti-CD4-PC5-conjugated mAbs, RBC hemolysis and specific intracellular staining with FastImmune (trademark) IFN-γ-FITC / IL-4-PE (Becton Dickinson) were performed in sequence according to the manufacturer's instructions. Th1 cells were designated as CD4 + lymphocytes accompanied by intracellular IFN-γ but not by intracellular IL-4. Th2 cells were detected as CD4 + lymphocytes accompanied by intracellular IL-4 but not by intracellular IFN-γ. The ratio of Th cells positive for intracellular IFN-γ to Th cells positive for intracellular IL-4 was expressed as the Th1 / Th2 cell ratio.

[0314] Example 1

[0315] Treatment of Rh-incompatible pregnancy based on tacrolimus by suppressing hyperactivated immunity before pregnancy or hyperreactive immunity after pregnancy and restoring a normal immune state

[0316] The patient was a 35-year-old woman with blood type A. The following treatment was performed on a patient with Rh-incompatible pregnancy where the mother was Rh(D) negative and the fetus was Rh(D) positive. That is, during the first pregnancy, anti-D immunoglobulin was not administered during the pregnancy, sensitization was established before delivery, and the anti-D antibody titer at delivery was 8-fold. At 39 weeks, delivery was performed by emergency cesarean section due to placental abruption. Five months after delivery, the antibody titer showed a maximum value of 64-fold.

[0317] She hoped to have a second child two years later, but suffered from infertility and underwent infertility treatment by in vitro fertilization. However, she failed in five embryo transfers, so she had a detailed examination of the immune system. At this time, it was confirmed that the ratio of Th1 / Th2 (Th1 32.4, Th2 1.3) was significantly increased (24.9). It was judged that the infertility was due to the abnormality of the immune system, and tacrolimus treatment was selected. Through the treatment with 4 mg / day of tacrolimus (oral administration: 2 mg in the morning and 2 mg in the evening), pregnancy was established with one embryo transfer.

[0318] The titer of anti-D antibody just after pregnancy was established was 4 times, but it reached 16 times at 24 weeks and 32 times at 26 weeks ( Figure 6 the upper part). After that, assuming that the fetal antigen transferred to the mother through the placenta further increased to prepare for the rapid increase in antibody titer, preparations for plasma exchange and fetal blood transfusion were started. In addition, considering that Th1 showed an upward trend again at 28 weeks, the dose of tacrolimus was increased to 5 mg / day (oral administration: 3 mg in the morning and 2 mg in the evening).

[0319] After that, there was no increase in the predicted anti-D antibody titer, and fetal anemia (increase in the blood flow velocity of the middle cerebral artery) was not observed. It remained at 32 times, and the growth of the fetus was also normal ( Figure 7 ), and a healthy baby boy weighing 2834 g was delivered on the second day of 37 weeks. It should be noted that the blood flow velocity of the middle cerebral artery and the estimated weight of the fetus were measured by fetal ultrasound examination.

[0320] Figure 7 It is a graph showing the change in the weight of the fetus during pregnancy. The weight increased over time, indicating that the fetus grew appropriately with the gestational age. At the same time, Figure 7 the blood flow velocity of the middle cerebral artery is also shown in, indicating that fetal anemia did not occur throughout the pregnancy.

[0321] By chemiluminescent immunoassay (ECLIA), the concentration of tacrolimus in cord blood was below the detection limit value, and the titer of anti-D antibody was 2 times. The fetal blood type was A Rho(D) positive, and the Hb (hemoglobin) value at birth was slightly low at 13.6. There were no external malformations, visceral malformations, and the physical functions were also normal.

[0322] Analysis

[0323] Fetal hemoglobin can be present in maternal blood from the early stage of pregnancy. Detection of HbF in maternal blood in the early stage of pregnancy usually shows that the HbF in fetal blood begins to transfer into maternal blood from around 9 weeks of pregnancy (References 4a, 11a, 12a). These findings suggest that the maternal immune response to fetal antigens may start at the early stage of pregnancy when fetal antigens begin to flow into the mother. On the other hand, anti-D antibody transfer to the fetus starts after the placenta is formed.

[0324] For this patient, since neutralizing anti-D immunoglobulin was not given to the mother during the first pregnancy, it is considered that the possibility of a large amount of fetal blood flowing into the mother during delivery due to placental abruption strongly established sensitization to fetal antigens. In addition, pregnancy was not established through normal infertility treatment, and the possibility of further exacerbating sensitization due to repeated failures was high. It is considered that due to these circumstances, the mother strongly recognizes fetal antigens including blood cell components, which not only represents the humoral immunity of anti-D antibody, but also the rejection caused by the cellular immune response to other fetal components due to a significant increase in the Th1 cell ratio may trigger infertility from the start of the second pregnancy.

[0325] Humoral immunity and cellular immunity respectively induce an increased anti-D antibody titer and an increased Th1 cell ratio. These are common immune responses to foreign antigens and fetal antigens.

[0326] In order to suppress over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restore a normal immune state, the inventors treated the patient with tacrolimus, which can inhibit cellular immunity in infertility. The detailed mechanism and results related to Th1 cells were previously described (References 13a - 15a). Based on these results, tacrolimus was administered from before pregnancy as infertility treatment, and since no tendency for a decrease in the Th1 cell ratio was observed after pregnancy was established, the drug was continued. At 28 weeks of pregnancy, since the Th1 cell ratio increased, the dose was increased to 5 mg / day. The maternal and fetal conditions had no complications and were stable, and the pregnancy progressed smoothly and the patient achieved a safe delivery.

[0327] At 24 weeks of pregnancy and later, the anti-D antibody titer may rise sharply due to the invasion of a large number of fetal red blood cells, but the result also inhibits the production of anti-D antibody, and no intensive care for the mother and fetus is required until delivery.

[0328] Although this effect was unexpected, the mechanism can be explained as follows. By suppressing the calcineurin / NFAT pathway, T cell function is downregulated, and subsequently, B cell activation and antibody production are inhibited, thereby suppressing antigen recognition and the production of anti-pathogen antibodies. It can also be considered that this is because continuous treatment with high-dose intravenous immunoglobulin with immunosuppressive effects was performed (References 16a to 19a).

[0329] As a conclusion, this treatment provides the following advantages, that is, without performing strong treatments such as plasma exchange therapy, high-dose gamma globulin therapy, and high-dose steroid therapy, the promotion of antibody production can be alleviated. The inventor believes that the treatment using tacrolimus is beneficial for allogeneic immune pregnancy.

[0330] Immunosuppression by administering tacrolimus can easily establish pregnancy. Furthermore, it can be considered that increasing tacrolimus during pregnancy for the hyperactivity of rejection immunity can sustain a stable pregnancy and inhibit the production of anti-D antibodies, and can avoid the onset of fetal anemia. It is speculated that this is the effect brought about by tacrolimus suppressing both cellular immunity and humoral immunity.

[0331] Example 2

[0332] For 42 patients who had 5 or more consecutive RIFs after in vitro fertilization / embryo transfer using morphologically and developmentally high-quality embryos and no abnormal observation results related to infertility were observed in serological tests, they were treated with or without tacrolimus from 2 days before embryo transfer until the pregnancy test day. The daily dosage of tacrolimus was determined based on the Th1 / Th2 cell ratio. Compared with 0% (0 / 17) in the untreated group, the clinical pregnancy rate of the treated patients was 64.0% (16 / 25) (Reference 114). Regarding the Th1 / Th2 cell ratio before embryo transfer, it was found that the results of assisted reproductive technology in tacrolimus-treated and untreated patients could be predicted, and the Th1 cell level was negatively correlated with the pregnancy outcome (n = 124) (Reference 115).

[0333] Regarding RPL, a patient with 11 consecutive miscarriages at 5 to 8 weeks of pregnancy was sequentially treated with low-dose aspirin, heparin, prednisone (5 mg / day), and high-dose gamma globulin therapy (1 g / kg every 3 days), but without success (Reference 116). However, by continuously treating with tacrolimus (2 mg / day) during pregnancy, a good pregnancy course was obtained without other treatments. In addition, regarding the immunosuppression of B cells using tacrolimus, no plasma exchange was used in RhD-incompatible pregnancy, and a good pregnancy course was achieved and successful delivery was obtained (data not shown). The mechanism of tacrolimus mainly depends on the suppression of cellular immunity, but also suppresses humoral immunity through T cells.

[0334] Tacrolimus can also affect other diseases caused by abnormalities in the immunity between the mother and fetus, as well as the construction and function of the placenta. In addition, it can prevent fetal growth retardation during pregnancy and pregnancy-induced hypertension in the mother.

[0335] From the perspective of suppressing humoral immunity, strong treatments such as plasma exchange therapy and high-dose gamma globulin therapy during pregnancy are not required. Tacrolimus can be a candidate drug for the treatment of neonatal hemochromatosis (which results from a humoral immune response against fetal antigens such as RhD-incompatible pregnancy) and antiphospholipid syndrome.

[0336] However, in the case of symptoms caused by existing antibodies after pregnancy, tacrolimus only inhibits the differentiation of B cells. Therefore, in order to rapidly inactivate the existing pathogenic antibodies, combination therapy with these stronger treatments is required.

[0337] Tacrolimus treatment is particularly beneficial in the initial stage of pregnancy, that is, starting from 5 to 6 weeks of pregnancy, for patients with a history of previous recurrent miscarriages or recurrent chemical abortions.

[0338] When performing strong treatments such as glucocorticoids at an immunosuppressive level and high-dose gamma globulin therapy, it is difficult to determine the optimal timing. Tacrolimus is also easily used in such cases.

[0339] Furthermore, in the explanation of Th1-dominant immunity, it is difficult to clarify the mechanism of rejection in infertile patients with a high Th2 cell ratio. However, if it is assumed that the rejection depends on antibodies against fetal HLA, tacrolimus is also effective in these cases.

[0340] Example 3

[0341] Treatment of neonatal hemochromatosis

[0342] The main purpose of this treatment method is to inhibit the recognition of fetal antigens in the mother's body and reduce the ability to produce pathogenic antibodies.

[0343] Although the diseases that occur in the fetus are different, similar to blood group incompatible pregnancy, after the placenta is constructed, fetal antigens flow from the fetus into the mother's body, are recognized in the mother, and pathogenic antibodies against the antigens are produced. Among them, IgG is transferred to the fetus through the placenta, resulting in diseases in the fetus. For this disease, in most cases, the pathogenic antibodies inhibit proteins related to fetal iron metabolism, iron deposits in the liver, leading to liver failure and resulting in intrauterine fetal death, postnatal death, or a serious condition that requires liver transplantation.

[0344] The mechanism of this treatment can be explained as follows: by inhibiting the calcineurin / NFAT pathway to inhibit T cell function and based on this, inhibiting B cell activation and antibody production, thereby inhibiting the recognition of fetal antigens and the production of anti-pathogen antibodies.

[0345] The fetal antigens of the pathogen that causes this disease have not been identified. Considering the situation where antigens caused by the fetus flow into the mother's body after the placenta is constructed, treatment is considered to start around 12 weeks of pregnancy. However, there are individual differences in placenta construction and the transfer period of fetal antigens is not clear. Therefore, for more effective treatment, it is preferably started from the early stage of pregnancy.

[0346] In the case of the only existing preventive method, the large-dose gamma globulin therapy administered to the mother, it is necessary to continuously administer the drug from 18 weeks until delivery, and the medical cost (600,000 yen / week) is very expensive. However, this treatment method can treat throughout pregnancy with a medical cost less than one-tenth of that, and it is also easy to appropriately change the dosage. Therefore, it is also possible to further save medical costs.

[0347] For the only existing preventive method, the large-dose gamma globulin therapy administered to the mother, since it is refined from a large amount of collected and pooled blood, there is a risk of exposure to infections that may be contained in the blood. In particular, the infection of parvovirus that causes fetal anemia becomes a problem. However, this treatment method has no risk of infection including other viruses at all.

[0348] In fetal hemochromatosis, there are more cases of any of miscarriage, premature birth, intrauterine growth retardation, oligohydramnios, fetal movement dysfunction, and placental edema during pregnancy. After birth, poor general condition (such as respiratory / circulatory dysfunction, etc.), fetal growth retardation, fetal hydrops, and signs of liver failure are confirmed. In the neonatal blood test results, coagulation disorders, cholestasis, abnormal transaminase values, etc. are seen. Disseminated intravascular coagulation syndrome not caused by sepsis, high ferritin, high alpha-fetoprotein, and high transferrin saturation rate are shown. In the image test results, low signals indicating iron deposition are observed in organs other than the liver in the MRI T2-weighted image. Through this treatment, the observation results of these fetuses during pregnancy and newborns after birth are improved, and thus it can be evaluated.

[0349] It is difficult to determine the immune status in the uterus based on information from the peripheral blood of the mother. In some studies, the correlation between the levels of NK cells in peripheral blood and decidua was evaluated, and there were also opposing opinions (References 117, 118). If the immune status of the uterus in RIF patients reflects the normal immune status of the whole body, then it may be simpler to determine the uterine immune status of RIF patients compared to RPL patients. In contrast, sometimes it takes time for the maternal peripheral blood in RPL patients to reflect the status of the uterus. In early RPL patients, the immune status of the maternal peripheral blood may not change or change very weakly. Depending on the situation, changes may sometimes be exhibited after miscarriage. The problem with tacrolimus treatment in these patients is that after tacrolimus treatment, the peripheral blood does not show changes in cell ratios, and the activity may be inhibited in the uterus.

[0350] Some immune parameters were evaluated in maternal blood. However, these parameters do not directly reflect the status of the fetus, but rather refer to the ability to analyze only the immune status of the mother and her reactivity to fetal antigens. Further research is needed to support the accurate and appropriate use of immunosuppressants and to provide more detailed information about the fetus.

[0351] The symptoms of infertility and sterility are different. It is speculated that for infertility, the normal maternal immune status is reflected in the uterus, but for sterility, the immune response in the uterus is not rapidly transmitted to the whole body, and most pregnancies will be interrupted before systemic changes occur. Therefore, new biomarkers are needed.

[0352] Example 4

[0353] Prevention or delay of the onset of pregnancy-induced hypertension syndrome and related diseases (HELLP syndrome and eclampsia)

[0354] The main purpose of this treatment method is to inhibit the activation of the mother's rejection immunity against the fetus and to promote tolerance to the fetus.

[0355] The patient was a 38-year-old woman with a history of preeclampsia and HELLP syndrome. At her first pregnancy at 32 years old, she complained of physical discomfort since the early stage of pregnancy. From the 15th week of pregnancy, a tendency of leg swelling, weight gain, and blood pressure increase was observed. From the 18th week of pregnancy, severe swelling increased, proteinuria and hypertension appeared, and she was diagnosed with preeclampsia (PE) in pregnancy-induced hypertension syndrome (HDP). At the 20th week of pregnancy, HELLP syndrome and eclampsia occurred, and an emergency cesarean section was performed, resulting in a stillbirth. After delivery, pulmonary edema, disseminated intravascular coagulation (DIC), and intra-abdominal hemorrhage, which were severe complications, were observed, and treatments such as mechanical ventilation management, albumin supplementation, and component transfusion were carried out.

[0356] This time, in the hematological test results before pregnancy, no abnormalities were found in liver function, kidney function, and coagulation function. No abnormal findings were also observed in the infertility-related test items such as antiphospholipid antibody syndrome (anti-CL-IgG antibody, anti-CL-IgM antibody, anti-PS / PT antibody, anti-CL-β2GP1 antibody, LAC, anti-PE-IgG antibody, anti-PE-IgM antibody), autoimmune diseases (anti-DNA antibody, antinuclear antibody), and coagulation function abnormalities.

[0357] Table 1 shows the conditions of the first pregnancy and this pregnancy.

[0358] (Table 1)

[0359]

[0360] AST: Aspartate aminotransferase

[0361] ALT: Alanine aminotransferase

[0362] LDH: Lactate dehydrogenase

[0363] Cr: Creatinine

[0364] WBC: White blood cell count

[0365] Hb: Hemoglobin

[0366] Plt: Platelet count

[0367] The ratio of Th1 (CD4g + IFN-g + ) / Th2 (CD4 + IL-4 + ) in CD4-positive cells was 15.2 / 2.1 (normal value: less than 10.3), and no obvious immune abnormalities were observed before pregnancy (Reference 12b). However, after fertilized egg implantation, maternal immune activation and immune abnormalities between the mother and fetus may inhibit placental construction and its function, presumably leading to fetal developmental disorders and pregnancy-induced hypertension. Considering this situation, in order to control the immune response between the mother and fetus after the patient confirmed pregnancy, tacrolimus was administered at a dose of 1 mg / day starting from 4 weeks of pregnancy.

[0368] The pregnancy progressed smoothly, and no proteinuria, edema, or hypertension was observed until 32 weeks of pregnancy. The fetus also grew well. However, in the following week, a tendency of proteinuria and blood pressure increase was observed, and it rapidly developed into HELLP syndrome about 3 days later. A 1490g male infant was delivered by cesarean section at 33 weeks and 3 days of pregnancy.

[0369] In the immunological observation results during pregnancy, the proportions of Th1 and Th2 cells in CD4-positive cells continuously decreased, while the NK cell activity (normal value: 18 - 40%) decreased in the second trimester and then increased significantly at 32 weeks of gestation ( Figure 8 ).

[0370] In this case, starting from the first trimester of pregnancy, treatment was carried out solely with tacrolimus at 1 mg / day, and combination treatment with low-dose aspirin (LDA) for the purpose of preventing HDP by improving blood flow was not performed (Reference 13b). Regarding the course of pregnancy, there were no problems at all during the second trimester of the previous pregnancy with HELLP syndrome, and the process was smooth until the late pregnancy. However, after 33 weeks of gestation, it rapidly became HELLP syndrome again as in the previous case.

[0371] In the immunological test observation results, the proportions of Th1 and Th2 cells in CD4-positive cells and the NK cell activity both decreased in the second trimester. Sufficient immunosuppression was observed with tacrolimus, but the NK cell activity increased at 32 weeks of gestation.

[0372] As a possibility, it is suggested that from the period when the influx of fetal antigens into the mother increases, the mother's immunity against the fetus is strongly activated, and in the late pregnancy, the immunosuppressive effect based on 1 mg / day of tacrolimus becomes insufficient. In addition, the possibility that T cells other than Tregs are simultaneously activated without a change in their cell proportions is also considered.

[0373] Although HELLP syndrome occurred twice in the same patient, its pathogenesis can be easily speculated to be the same. As severe complications of HDP, HELLP syndrome and eclampsia can be listed. In the previous pregnancy of this patient, both diseases occurred in the early pregnancy due to no treatment, resulting in a stillbirth. This time, it became HELLP syndrome, and early onset was avoided by administering tacrolimus alone. The onset was delayed by about 13 weeks compared with the previous time, and a baby was successfully obtained.

[0374] In patients with infertility related to immune abnormalities, the recognition of fetal antigens usually may be enhanced after the first pregnancy. Therefore, in the next pregnancy, it is speculated that HELLP syndrome and eclamptic seizures accompanied by the deterioration of pregnancy-induced hypertension will occur earlier. On the contrary, the onset time was successfully delayed compared with the previous time through tacrolimus treatment, and it was clarified that this effect was not due to the presence of combination drugs. It can be considered that by inhibiting the activation of the mother's rejection immunity against the fetus and promoting tolerance to the fetus, better placental construction and its function can be achieved, and hypertension during pregnancy and fetal growth disorders can be prevented. However, considering the situation where pregnancy could not be continued to full term and the growth of the fetus at birth was also relatively slow, it can be considered that a larger dosage needs to be given to this case.

[0375] In this case, we discussed the patient's condition through the ratio of Th1 and Th2 cells and NK cell activity in CD4-positive cells. The NK cell activity among them revealed abnormal immunity between the mother and the fetus. However, in order to evaluate preeclampsia, there are abnormalities in maternal immune tolerance to fetal antigens and enhanced rejection immunity, as well as many parameters such as Treg cells, Tfh cells, Th17 cells, cytokines, and chemokines that use inflammation as a biomarker (References 3b to 10b).

[0376] Evaluation based on more parameters is useful for understanding the detailed maternal status. It is expected to discover new parameters for evaluating the immune status between the mother and the fetus, and to increase the number of subjects for evaluating the treatment effects of preeclampsia syndrome and its related diseases.

[0377] Industrial Applicability

[0378] The changes in maternal immunity before and after pregnancy are hypothesized to be: (1) a state of being more activated than before pregnancy, (2) a state of being activated by first recognizing fetal antigens in the first trimester of pregnancy, and (3) a state of being activated by an increase in fetal antigens after the second trimester of pregnancy. According to the present invention, it is possible to suppress pre-pregnancy over-activated immunity or post-pregnancy over-reactive immunity and restore the normal immune state. As a result, not only can infertility related to cellular immunity (innate immunity, acquired immunity) in the relationship between the mother and the fetus be treated or improved, but also infertility related to humoral immunity, autoimmune diseases including antiphospholipid antibody syndrome, blood type-incompatible pregnancy, or fetal hemochromatosis can be treated or improved, and pregnancy can continue and a healthy baby can be delivered. Furthermore, by maintaining the immune state between the mother and the fetus well, the construction of the placenta can be achieved well, and maternal complications (preeclampsia, HELLP syndrome, eclampsia, etc. as related diseases) can also be avoided.

[0379] (List of References)

[0380] 1: Inhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. Hum Reprod Update. 2015;21:411-26.

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Claims

1. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for suppressing over-activated immunity before pregnancy or over-reactive immunity after pregnancy and restoring a normal immune state.

2. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for enhancing the action of steroid hormones by activation and nuclear translocation of steroid hormone receptors.

3. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for suppressing the activity of natural killer / natural killer T cells or macrophages, which represent innate immunity and may be activated by fertilized eggs or fetal components in the uterus.

4. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for suppressing the activity of antigen-presenting cells, cell-damaging T cells, or T cells that produce intercellular mediators, which may directly or indirectly attack fertilized eggs or fetuses through acquired immunity in the uterus and present antigens of fertilized egg or fetal components.

5. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for inducing antigen-presenting cells required for immune tolerance of fertilized eggs or fetuses, or for inducing the differentiation of undifferentiated dendritic cells into tolerogenic dendritic cells.

6. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for suppressing the humoral immune response against fetal components including human leukocyte antigen (HLA), i.e., suppressing the production of fetal-specific antibodies.

7. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for suppressing the production of pathogenic antibodies in the mother's body that cause problems in continuing pregnancy.

8. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for suppressing the activation of the mother's rejection immunity against the fetus and / or promoting tolerance to the fetus.

9. Use of tacrolimus or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for preventing or delaying the occurrence of preeclampsia and / or diseases associated with preeclampsia.

10. The use according to claim 9, wherein, the disease associated with preeclampsia is HELLP syndrome.

11. The use according to claim 9, wherein, the disease associated with preeclampsia is eclampsia.

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