PPARalpha / gamma agonists for treatment of liver failure

Abstract

The present invention relates to compounds for the treatment of hepatic failure.

Description

[0001] The present invention belongs to the field of medicine and relates to compounds for treating liver failure. Background Art

[0002] Liver failure is a severe inability of the liver to perform its normal functions. Manifestations of liver failure herein include acute liver failure (ALF), decompensated cirrhosis, acute decompensation of cirrhosis (AD), and acute-on-chronic liver failure (ACLF).

[0003] Acute liver failure (ALF)

[0004] The term "ALF" describes a condition characterized by an acute loss of liver function in the absence of pre-existing chronic liver disease. Acute liver failure is also known as fulminant liver failure. ALF is also referred to as fulminant liver failure, acute liver necrosis, fulminant liver necrosis, and fulminant hepatitis. ALF is a rare and severe consequence of sudden hepatocyte injury and can evolve into a lethal outcome within days or weeks. Multiple injuries to hepatocytes result in a consistent pattern: a rapid increase in transaminases, altered mental status, and coagulation disorders. The absence of pre-existing liver disease distinguishes ALF from liver failure due to end-stage chronic liver disease (decompensated cirrhosis, acute decompensation, and acute-on-chronic liver failure). In ALF, substances that cause hepatocyte injury induce direct toxic necrosis, or apoptosis and immune injury, which is a slower process. The time from symptom onset to the onset of hepatic encephalopathy distinguishes different forms of acute liver failure: direct and very rapid injury (within hours), called hyperacute liver failure; and slower immune-based injury (days to weeks), considered acute or subacute. The term "hepatic encephalopathy" or HE as used herein refers to confusion, altered level of consciousness, and coma that occur due to liver failure. In the late stage, it is called hepatic coma or liver coma. In developed countries, the five most common causes of ALF are acetaminophen (paracetamol) toxicity, ischemia, drug-induced liver injury, hepatitis B, and autoimmunity, which account for nearly 80% of cases. Hepatitis A, hepatitis B, and hepatitis E are the main causes of ALF in developing countries. The remaining causes of ALF account for less than 15% of the total and include heat stroke, pregnancy-related injuries (e.g., acute fatty liver of pregnancy and HELLP [hemolysis, elevated liver enzymes, and low platelets] syndrome), Budd-Chiari syndrome, non-hepatic virus infections such as herpes simplex, and diffuse infiltrative malignancies. Without treatment, the prognosis is poor, so it is crucial to promptly identify and manage patients with acute liver failure. Whenever possible, patients with acute liver failure should be managed in the intensive care unit of a liver transplant center.

[0005] Decompensated cirrhosis and acute decompensation (AD)

[0006] The term "cirrhosis" as used herein refers to a condition characterized by the replacement of liver tissue by fibrosis and regenerative nodules, which results in the loss of liver function until decompensation. Ascites (fluid retention in the abdominal cavity) is the most common complication associated with decompensated cirrhosis. It is associated with poor quality of life, increased risk of infection, and poor long-term outcomes. Other potentially life-threatening complications are hepatic encephalopathy and bleeding from esophageal varices. Decompensated cirrhosis has many possible clinical manifestations. These signs and symptoms can be a direct result of hepatocellular failure or a secondary result of the resulting portal hypertension. The effects of portal hypertension include splenomegaly, gastroesophageal varices, and portal collateral circulation, which is the result of the formation of venous collateral veins between the portal venous system and the periumbilical veins due to portal hypertension.

[0007] Cirrhosis is divided into two clinical categories: compensated cirrhosis and decompensated cirrhosis.

[0008] The term "compensated cirrhosis" as used herein refers to a liver that is severely scarred but can still perform many important body functions. Patients with compensated cirrhosis have few or no symptoms and can survive without serious clinical complications. Patients in the early stages of compensated cirrhosis are characterized by low levels of portal hypertension and the absence of esophageal varices. Patients in the late stages of compensated cirrhosis are characterized by higher levels of portal hypertension and the presence of esophageal varices, but no ascites and no bleeding.

[0009] The term "decompensated cirrhosis" as used herein refers to a liver that is extensively scarred and does not function properly. Patients with decompensated cirrhosis experience a variety of symptoms such as fatigue, loss of appetite, jaundice, weight loss, ascites and / or edema, hepatic encephalopathy and / or bleeding. Patients in the early stages of decompensated cirrhosis are characterized by the presence of ascites in patients who have never bled, with or without esophageal varices. Patients in the late stages of decompensated cirrhosis are characterized by more severe ascites, which occurs alone or in combination with bleeding, bacterial infection, and / or hepatic encephalopathy. Complications associated with decompensated cirrhosis can occur, such as ascites, edema, bleeding problems, loss of bone mass and bone density, hepatomegaly, irregular menstruation in women and gynecomastia in men, impaired mental status, pruritus, renal failure, and muscle atrophy.

[0010] The term "acute decompensation" refers to the sudden deterioration of liver function in patients with advanced chronic liver disease, compensated cirrhosis, or stable decompensated cirrhosis, which requires immediate hospitalization. At the time of admission, patients with AD have multiple symptoms, including severe ascites, hepatic encephalopathy, variceal bleeding, with or without sepsis and / or impaired renal function and / or coagulopathy and / or impaired cardiovascular function and / or impaired respiratory function. AD is a life-threatening condition with a total mortality rate of 11% at 28 days.

[0011] Acute-on-chronic liver failure (ACLF)

[0012] ACLF is the most severe liver condition observed in patients with known chronic liver disease with acute decompensation of liver function.

[0013] ACLF is a sudden and life-threatening deterioration of the clinical condition of patients with advanced cirrhosis or cirrhosis due to chronic liver disease. Three main features characterize this syndrome: it usually occurs in the context of intense systemic inflammation, often in close temporal relationship with a pro-inflammatory triggering event (e.g., infection or alcoholic hepatitis), and is associated with single-organ or multi-organ failure affecting the minimal function of vital organs (liver, kidney, brain, coagulation, and / or cardiovascular function and / or respiratory system). For sepsis, organ failure is identified by using the modified sequential organ failure assessment score (SOFA score) or the EASL-CLIF Consortium Organ Failure Score system, which takes into account the function of the liver, kidney, and brain, as well as coagulation, circulation, and respiration, thus allowing stratification of patients into subgroups with different death risks. Several classifications have been proposed to grade ACLF (APASL, EASL / CLIF, NASCELD). Using EASL / CLIF, patients are stratified into four prognostic grades (no acute-on-chronic liver failure and acute-on-chronic liver failure grades 1, 2, and 3) according to the number of organ failures at the time of diagnosis. The susceptibility to ACLF is related to the severity of the underlying chronic liver disease (i.e., fibrosis progression to cirrhosis). Regardless of the underlying chronic liver disease (cholestatic liver disease, metabolic liver disease, chronic viral hepatitis, and non-alcoholic steatohepatitis (NASH), alcoholic hepatitis), compensated cirrhosis and stable decompensated cirrhosis are the main conditions associated with the development of ACLF. In Western countries, alcoholic cirrhosis accounts for 50 - 70% of all underlying liver diseases in ACLF, while cirrhosis related to viral hepatitis accounts for approximately 10 - 30% of all cases.

[0014] The severity of the underlying disease can be assessed by the Model for End-Stage Liver Disease (MELD) score.

[0015] ACLF requires an inciting event that occurs in the setting of cirrhosis and / or chronic liver disease and rapidly progresses to multi-organ failure with high mortality. The inciting event can be hepatitis B reactivation or superimposed viral hepatitis, alcohol, drugs, ischemia, surgery, sepsis, or idiopathic. However, approximately 40% of ACLF patients do not have an inciting event.

[0016] At the onset of liver failure, translocation of bacterial products (with or without translocation of live bacteria from the intestinal lumen) plays a key role in the development of multi-organ dysfunction and failure via a strong systemic inflammatory response syndrome.

[0017] The host response determines the severity of the injury. Inflammation and neutrophil dysfunction have important roles in the pathogenesis of ACLF, and a prominent pro-inflammatory cytokine profile causes the transition from stable decompensated cirrhosis to AD and ultimately ACLF. In these patients, the inflammatory response may lead to immune dysregulation, which may predispose to infection, and the infection in turn further exacerbates the pro-inflammatory response, leading to a vicious cycle. Cytokines are thought to play important roles in ACLF. Serum levels of several cytokines have been described as elevated in patients with ACLF, including tumor necrosis factor (TNF)-α, sTNF-αR1, sTNF-αR2, interleukin (IL)-2, IL-2R, IL-4, IL-6, IL-8, IL-10, and interferon-α.

[0018] Hyperbilirubinemia is almost invariably present, and jaundice is considered an essential criterion for AD and ACLF. Different authors have used different cut-off levels of jaundice, with serum bilirubin ranging from 6 - 20 mg / dL. In addition to jaundice, another hallmark of liver dysfunction is coagulopathy. Coagulation tests are usually abnormal in cirrhotic patients due to impaired synthesis and increased consumption of clotting factors. The ongoing liver injury is ultimately an inexorable downward spiral and death.

[0019] The most common organ to fail in addition to the liver is the kidney. Renal failure can be classified into four types: hepatorenal syndrome, parenchymal disease, hypovolemia-induced renal failure, and drug-induced renal failure. Bacterial infection (such as spontaneous bacterial peritonitis) is the most common inciting factor for renal failure in cirrhosis, followed by hypovolemia (secondary to gastrointestinal bleeding, over-diuretic therapy).

[0020] HE is one of the common manifestations of AD and ACLF. HE can be an inciting factor or a consequence of AD and ACLF. Ammonia is central to the pathogenesis of HE. In fact, multiple studies have emphasized the key role of hyperammonemia in the development of HE in patients with cirrhosis and other liver diseases. Due to liver failure, large amounts of serum ammonia escape hepatic metabolism and can reach the brain, and such high ammonia concentrations in the brain are closely associated with a high incidence of cerebral edema and herniation.

[0021] In addition, brain swelling is an important feature of both AD and ACLF, similar to the situation in ALF.

[0022] One of the hallmarks of AD and ACLF is cardiovascular failure similar to that in patients with ALF. This cardiovascular abnormality is associated with an increased risk of death, particularly in those patients who develop renal dysfunction.

[0023] Respiratory complications in AD and ACLF can be classified into acute respiratory failure (e.g., pneumonia) and those due to cirrhosis (e.g., portopulmonary hypertension and hepatopulmonary syndrome). Patients with cirrhosis have an increased risk of pneumonia.

[0024] Patients with AD and ACLF have a statistically higher mortality than patients without ACLF at the same MELD score. Regardless of the precipitating event, the final common pathway leading to acute liver function deterioration and multiple organ failure seems to be the overactivation of systemic inflammation, followed by a period of immune system paralysis. The initial cytokine storm leads to profound alterations in the macro- and microcirculation and disruption of normal organ function, resulting in multiple organ failure.

[0025] Early intervention to reduce or correct the injury is crucial. For patients with more than 3 organ failures, the management of ACLF is currently based on supportive treatment of organ failure, mainly in the intensive care setting. However, the proportion of cases with previous episodes of acute decompensation (development of ascites, encephalopathy, gastrointestinal bleeding, bacterial infection) is very frequent in patients with ACLF. In fact, the occurrence of liver failure in patients with cirrhosis represents a decisive time point in medical management because this condition is often associated with rapidly progressive multiple organ dysfunction. The lack of liver detoxification, metabolic, and regulatory functions, as well as the altered immune response, lead to life-threatening complications such as renal failure, increased susceptibility to infection, hepatic coma, and systemic hemodynamic dysfunction. In addition, only 20% of patients with advanced cirrhosis can be treated with liver transplantation.

[0026] There is a need for adequate treatment of liver failure, particularly AD, ACLF, ALF, and decompensated cirrhosis. SUMMARY OF THE INVENTION

[0027] The present invention relates to a PPARα / γ agonist selected from aleglitazar, moglitazar, or tesaglitazar, a pharmaceutically acceptable salt thereof, or a combination thereof, for use in a method of treating liver failure in a subject in need thereof.

[0028] The present invention also provides the use of a PPARα / γ agonist in the preparation of a medicament for a method of treating liver failure, wherein the PPARα / γ agonist is selected from aleglitazar, moglitazar or tesaglitazar, a pharmaceutically acceptable salt thereof or a combination thereof.

[0029] The present invention further provides a method for treating liver failure, the method comprising administering to a subject in need a pharmaceutically effective amount of a PPARα / γ agonist, wherein the PPARα / γ agonist is selected from aleglitazar, moglitazar or tesaglitazar, a pharmaceutically acceptable salt thereof or a combination thereof.

[0030] In one specific embodiment, the compound is aleglitazar or a pharmaceutically acceptable salt thereof.

[0031] In another specific embodiment, the compound is moglitazar or a pharmaceutically acceptable salt thereof.

[0032] In another specific embodiment, the compound is tesaglitazar or a pharmaceutically acceptable salt thereof.

[0033] In one specific embodiment, the PPARα / γ agonist of the present invention is used for treating liver failure selected from acute decompensation (AD), acute-on-chronic liver failure (ACLF), acute liver failure (ALF) and decompensated cirrhosis.

[0034] In one specific embodiment, the PPARα / γ agonist of the present invention is used for treating AD.

[0035] In another specific embodiment, the PPARα / γ agonist of the present invention is used for treating decompensated cirrhosis.

[0036] More specifically, the PPARα / γ agonist of the present invention is used for treating ACLF.

[0037] In another embodiment, the PPARα / γ agonist of the present invention is administered to a subject suffering from AD, decompensated cirrhosis with or without ACLF or at risk of AD and ACLF.

[0038] In another embodiment, the PPARα / γ agonist of the present invention is administered to a subject suffering from decompensated cirrhosis or at risk of decompensated cirrhosis or acute decompensation.

[0039] In one specific embodiment, the PPARα / γ agonist of the present invention is used for preventing decompensated cirrhosis.

[0040] In yet another embodiment, the PPARα / γ agonist of the present invention is used in a method for reversing decompensated cirrhosis into compensated cirrhosis.

[0041] According to another embodiment, the PPARα / γ agonist of the present invention is used in a method for preventing hepatic decompensation in a subject suffering from ACLF.

[0042] In another embodiment, the PPARα / γ agonist of the present invention is used for treating ALF.

[0043] In another embodiment, the PPARα / γ agonist of the present invention is used for preventing renal failure or preventing hepatic encephalopathy.

[0044] According to a specific embodiment, the PPARα / γ agonist of the present invention is administered to a subject suffering from ACLF without renal failure, or a subject suffering from ACLF with non-renal organ failure and renal dysfunction.

[0045] According to another embodiment, the PPARα / γ agonist of the present invention is used for treating sepsis-related ACLF.

[0046] In a specific embodiment, the present invention further relates to a method for treating liver failure selected from acute decompensation (AD), acute-on-chronic liver failure (ACLF), acute liver failure (ALF), and decompensated cirrhosis AD, the method comprising administering to a subject in need a pharmaceutically effective amount of the PPARα / γ agonist of the present invention.

[0047] In another specific embodiment, the present invention further relates to a method for preventing decompensated cirrhosis, the method comprising administering to a subject in need a pharmaceutically effective amount of the PPARα / γ agonist of the present invention.

[0048] In another specific embodiment, the present invention further relates to a method for reversing decompensated cirrhosis into compensated cirrhosis, the method comprising administering to a subject in need a pharmaceutically effective amount of the PPARα / γ agonist of the present invention.

[0049] In another specific embodiment, the present invention further relates to a method for preventing hepatic decompensation in a subject suffering from ACLF, the method comprising administering to the subject a pharmaceutically effective amount of the PPARα / γ agonist of the present invention.

[0050] In another specific embodiment, the present invention further relates to a method for preventing renal failure or preventing hepatic encephalopathy, the method comprising administering to a subject in need a pharmaceutically effective amount of the PPARα / γ agonist of the present invention.

[0051] In another specific embodiment, the present invention further relates to a method for treating ACLF associated with sepsis, the method comprising administering to a subject in need a pharmaceutically effective amount of the PPARα / γ agonist of the present invention.

[0052] In one specific embodiment, the present invention further relates to the use of the PPARα / γ agonist of the present invention in the preparation of a medicament for a method of treating liver failure selected from acute decompensation (AD), acute-on-chronic liver failure (ACLF), acute liver failure (ALF), and decompensated cirrhosis AD.

[0053] In another specific embodiment, the present invention further relates to the use of the PPARα / γ agonist of the present invention in the preparation of a medicament for a method of preventing decompensated cirrhosis.

[0054] In another specific embodiment, the present invention further relates to the use of the PPARα / γ agonist of the present invention in the preparation of a medicament for a method of reversing decompensated cirrhosis into compensated cirrhosis.

[0055] In another specific embodiment, the present invention further relates to the use of the PPARα / γ agonist of the present invention in the preparation of a medicament for a method of preventing liver decompensation in a subject with ACLF.

[0056] In another specific embodiment, the present invention further relates to the use of the PPARα / γ agonist of the present invention in the preparation of a medicament for a method of preventing renal failure or preventing hepatic encephalopathy.

[0057] In another specific embodiment, the present invention further relates to the use of the PPARα / γ agonist of the present invention in the preparation of a medicament for a method of treating ACLF associated with sepsis. BRIEF DESCRIPTION OF THE DRAWINGS

[0058] Figure 1: Effects of Cpd.1 (teglicol) on liver injury and systemic inflammation in an acute liver failure model. Mice were treated daily with 1 mg / kg Cpd.1 or vehicle (Veh.) for 3 days and then injected with LPS / GalN. Blood samples were collected 6 hours after injection of LPS / GalN for measurement of serum liver markers and cytokine levels.

[0059] Figure 1A Shows the effect of Cpd.1 on ASAT after injection of GalN / LPS.

[0060] Figure 1B Shows the effect of Cpd.1 on ALAT after injection of GalN / LPS.

[0061] Figure 1CShow the effect of Cpd.1 on total bilirubin after injection of GalN / LPS.

[0062] Figure 1D Show the effect of Cpd.1 on total bile acid after injection of GalN / LPS.

[0063] Figure 1E Show the effect of Cpd.1 on circulating IL6 after injection of GalN / LPS.

[0064] Data are mean values.

[0065] #, ##, indicate p < 0.05, p < 0.01, p < 0.001, compared with vehicle (Veh.), and two-tailed Mann-Whitney test was used to evaluate statistical significance.

[0066] Figure 2: Effects of Cpd.1 (teglicolozole), Cpd.2 (moglicolozole), and Cpd.3 (aloglicolozole) on LPS activation of THP1 macrophages. After differentiation into macrophages, THP1 cells were treated with the indicated compounds for 24 h and then stimulated with LPS. Cell supernatants were collected 6 h after LPS to measure MCP1 secretion. The % inhibition of MCP1 secretion was calculated relative to the mean LPS-vehicle (Veh.) condition.

[0067] Figure 2A Show the effect of Cpd.1 on MCP1 secretion in THP1 differentiated macrophages.

[0068] Figure 2B Show the effect of Cpd.2 on MCP1 secretion in THP1 differentiated macrophages.

[0069] Figure 2C Show the effect of Cpd.3 on MCP1 secretion in THP1 differentiated macrophages.

[0070] Data are mean values.

[0071] #, ##, indicate p < 0.05, p < 0.01, p < 0.001, using two-tailed Mann-Whitney test, compared with untreated condition

[0072] $, $$$ indicate p < 0.05, p < 0.001, using non-parametric Kruskal-Wallis test to evaluate statistical significance of compound treatment relative to LPS alone. Detailed implementation

[0073] The present invention relates to PPARα / γ agonists in methods for treating liver failure, said PPARα / γ agonists being selected from aleglitazar, moglitazar or tesaglitazar, pharmaceutically acceptable salts thereof or combinations thereof.

[0074] Definitions

[0075] In the context of the present invention, the following terms have the following meanings.

[0076] Tesaglitazar (Cpd.1) (also known as AZ 242) is (S)-2-ethoxy-3-(4-(4-((methylsulfonyl)oxy)phenethoxy)phenyl)propanoic acid and corresponds to the compound of formula I (CAS number 251565-85-2):

[0077] (I).

[0078] Moglitazar (Cpd.2) (previously known as BMS 298585) is N-[(4-methoxyphenoxy)carbonyl]-N-[[4-[2-(5-methyl-2-phenyl-4- azolyl)ethoxy]phenyl]methyl]glycine, also known as 2-[(4-methoxyphenoxy)carbonyl-[[4-[2-(5-methyl-2-phenyl-1,3- azol-4-yl)ethoxy]phenyl]methyl]amino]acetic acid and corresponds to the compound of formula II (CAS number 331741-94-7):

[0079] (II)

[0080] Aleglitazar (Cpd.3) (previously known as Ro-0728804, R-1439) is (2S)-2-methoxy-3-{4-[2-(5-methyl-2-phenyl-1,3- azol-4-yl)ethoxy]-1-benzothiophen-7-yl}propanoic acid and corresponds to the compound of formula III (CAS number 475479-34-6):

[0081] (III)

[0082] The term "pharmaceutically acceptable salts" includes inorganic as well as organic acid salts. Representative examples of suitable inorganic acids include hydrochloric acid, hydrobromic acid, hydroiodic acid, phosphoric acid, etc. Representative examples of suitable organic acids include formic acid, acetic acid, trichloroacetic acid, trifluoroacetic acid, propionic acid, benzoic acid, cinnamic acid, citric acid, fumaric acid, maleic acid, methanesulfonic acid, etc. Other examples of pharmaceutically acceptable inorganic or organic acid addition salts include those listed in J. Pharm. Sci. 1977, 66, 2 and in the Handbook of Pharmaceutical Salts: Properties, Selection, and Use, edited by P. Heinrich Stahl and Camille G. Wermuth 2002. "Pharmaceutically acceptable salts" also includes inorganic and organic base salts. Representative examples of suitable inorganic bases include sodium or potassium salts, alkaline earth metal salts (such as calcium or magnesium salts) or ammonium salts. Representative examples of suitable salts formed with organic bases include, for example, salts formed with methylamine, dimethylamine, trimethylamine, piperidine, morpholine or tris(2-hydroxyethyl)amine.

[0083] As used herein, the term "treatment" refers to any action aimed at improving the health status of a patient, such as the treatment, prevention, and delay of a disease. In certain embodiments, such term refers to improving or eradicating a disease or its related symptoms. In other embodiments, the term refers to minimizing the spread or worsening of a disease, which is caused by administering one or more therapeutic agents to a subject suffering from such disease.

[0084] As used herein, the terms "subject", "individual" or "patient" are interchangeable and refer to an animal, preferably a mammal, even more preferably a human, including adults, children, neonates, and humans in the prenatal stage. However, the term "subject" can also refer to non-human animals, especially mammals, such as dogs, cats, horses, cows, pigs, sheep, and non-human primates, etc.

[0085] The expression "at least substituted with" means that the group is substituted with one or several groups from the list.

[0086] In the context of the present invention, the term "about" applied to a numerical value means that value + / - 10%. For the sake of clarity, this means that "about 100" refers to values included in the range of 90 - 110. In addition, in the context of the present invention, the term "about X" (where X is a numerical value) also specifically discloses the value of X, but also discloses the lower and higher values of the range so defined, more specifically discloses the value of X.

[0087] Compounds for use in the present invention

[0088] The present invention provides a PPARα / γ agonist for use in a method of treating liver failure, said PPARα / γ agonist being selected from aleglitazar, moglitazar or tesaglitazar, a pharmaceutically acceptable salt thereof or a combination thereof.

[0089] In one specific embodiment, the PPARα / γ agonist is selected from aleglitazar, moglitazar, tesaglitazar or a combination thereof. In one specific embodiment, the PPARα / γ agonist is selected from aleglitazar, moglitazar or tesaglitazar. In another specific embodiment, the PPARα / γ agonist is tesaglitazar.

[0090] In one specific embodiment, the compounds used according to the present invention are selected from:

[0091] Cpd.1: Tesaglitazar;

[0092] Cpd.2: Moglitazar; and

[0093] Cpd.3: Aleglitazar;

[0094] In a more specific embodiment, the compound used according to the present invention is Cpd.3: Tesaglitazar or a pharmaceutically acceptable salt thereof.

[0095] The compounds used according to the present invention may be in the form of a pharmaceutically acceptable salt, in particular an acid or base salt compatible with pharmaceutical use. The salts of the compounds used according to the present invention include pharmaceutically acceptable acid addition salts, pharmaceutically acceptable base addition salts, pharmaceutically acceptable metal salts, ammonium salts and alkylated ammonium salts. These salts may be obtained during the final purification step of the compound or by incorporating the salt into a previously purified agonist.

[0096] Liver failure

[0097] In one specific embodiment, the subject is a patient suffering from liver failure selected from AD, ACLF, ALF and cirrhosis (such as compensated or decompensated cirrhosis). In one specific embodiment, the subject is a patient suffering from liver failure selected from ACLF, ALF and decompensated cirrhosis.

[0098] Alternatively, the subject in need of treatment is a subject at risk of liver failure selected from AD, ACLF, ALF and cirrhosis. In one specific embodiment, the subject is at risk of liver failure selected from AD, ACLF, ALF and decompensated cirrhosis. In particular, the subject may be a patient at risk of AD, ACLF or decompensated cirrhosis due to chronic liver disease.

[0099] In a specific embodiment, the subject has ALF. In another embodiment, the subject has ALF caused by drug-induced liver injury, acetaminophen toxicity, ischemia, hepatitis A, hepatitis B or hepatitis E, autoimmunity, heat stroke, pregnancy-related injury (e.g., acute fatty liver of pregnancy and HELLP [hemolysis, elevated liver enzymes, and low platelets] syndrome), Budd-Chiari syndrome, non-hepatotropic virus infection such as herpes simplex, and diffuse infiltrative malignancy. In yet another embodiment, the subject has ALF caused by drug-induced liver injury, acetaminophen toxicity, ischemia, hepatitis A, hepatitis B or hepatitis E, autoimmunity. In yet another embodiment, the subject has ALF caused by acetaminophen toxicity.

[0100] In another specific embodiment, the subject is at risk of ALF. In another embodiment, the subject is at risk of ALF caused by drug-induced liver injury, acetaminophen toxicity, ischemia, hepatitis A, hepatitis B or hepatitis E, autoimmunity, heat stroke, pregnancy-related injury (e.g., acute fatty liver of pregnancy and HELLP [hemolysis, elevated liver enzymes, and low platelets] syndrome), Budd-Chiari syndrome, non-hepatotropic virus infection such as herpes simplex, and diffuse infiltrative malignancy. In yet another embodiment, the subject is at risk of ALF caused by drug-induced liver injury, acetaminophen toxicity, ischemia, hepatitis A, hepatitis B or hepatitis E, autoimmunity. In yet another embodiment, the subject is at risk of ALF caused by acetaminophen toxicity.

[0101] In a specific embodiment, the subject has compensated or decompensated cirrhosis, particularly decompensated cirrhosis. In a specific embodiment, the subject has alcoholic cirrhosis, such as alcoholic compensated cirrhosis or alcoholic decompensated cirrhosis, more particularly alcoholic decompensated cirrhosis. In another specific embodiment, the subject has compensated or decompensated cirrhosis secondary to non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject has decompensated cirrhosis secondary to non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject has compensated or decompensated cirrhosis secondary to non-alcoholic steatohepatitis (NASH). In another specific embodiment, the subject has decompensated cirrhosis secondary to non-alcoholic steatohepatitis (NASH).

[0102] In a specific embodiment, the subject is at risk of compensated or decompensated cirrhosis, particularly decompensated cirrhosis. In a specific embodiment, the subject is at risk of alcoholic cirrhosis, such as alcoholic compensated cirrhosis or alcoholic decompensated cirrhosis, more specifically alcoholic decompensated cirrhosis. In another specific embodiment, the subject is at risk of compensated or decompensated cirrhosis secondary to non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject is at risk of decompensated cirrhosis secondary to non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject is at risk of compensated or decompensated cirrhosis secondary to non-alcoholic steatohepatitis (NASH). In another specific embodiment, the subject is at risk of decompensated cirrhosis secondary to non-alcoholic steatohepatitis (NASH).

[0103] In another specific embodiment, the subject has compensated or decompensated cirrhosis and is at risk of AD and ACLF. In another embodiment, the subject has decompensated cirrhosis and is at risk of AD and ACLF.

[0104] In another specific embodiment, the subject has ACLF or is at risk of ACLF.

[0105] As described above, ACLF is a multi-organ syndrome that typically occurs in subjects with cirrhosis, particularly in subjects with decompensated cirrhosis, with at least one organ failure and high short-term mortality. ACLF can occur in patients with chronic liver disease in response to an overexerted precipitating factor.

[0106] In a specific embodiment, the subject has chronic liver disease with cirrhosis and is at risk of developing ACLF.

[0107] The term "chronic liver disease" is used herein to refer to liver diseases associated with chronic liver injury, regardless of the underlying cause. Chronic liver disease can be caused by, for example, alcohol abuse (alcoholic hepatitis), viral infection processes (such as viral hepatitis A, B, C, E), autoimmune processes (autoimmune hepatitis), non-alcoholic steatohepatitis (NASH), cancer, or chronic exposure to mechanical or chemical liver injury. Chemical liver injury can be caused by a variety of substances, such as toxins, alcohol, carbon tetrachloride, trichloroethylene, iron, or drugs.

[0108] In a specific embodiment, the subject has chronic liver disease with cirrhosis. In a specific embodiment, the subject has cirrhosis secondary to:

[0109] - Alcohol abuse,

[0110] - Viral hepatitis (such as viral hepatitis caused by infection with hepatitis A, B, C, D, E or G virus),

[0111] - Use of drugs,

[0112] - Metabolic diseases,

[0113] - Biliary tract diseases,

[0114] - Primary biliary cholangitis,

[0115] - Primary sclerosing cholangitis, or

[0116] - NASH.

[0117] The present invention is particularly suitable for preventing recurrence of AD and ACLF or managing AD and ACLF.

[0118] In one specific embodiment, subjects with decompensated cirrhosis, AD or ACLF showed high MELD scores. The term "MELD score" or "Model for End-Stage Liver Disease" as used herein refers to a scoring system for assessing the severity of liver dysfunction. MELD uses the values of serum bilirubin, serum creatinine and international normalized ratio (INR) of the patient to predict survival. It is calculated according to the following formula:

[0119] MELD = 3.78 [Ln serum bilirubin (mg / dL)] + 11.2 [Ln INR] + 9.57 [Ln serum creatinine (mg / dL)] + 6.43, where Ln refers to the Napierian logarithm.

[0120] Bilirubin is the yellow breakdown product of normal heme catabolism. Bilirubin is excreted in bile and urine. Most bilirubin (70 - 90%) is derived from hemoglobin degradation and, to a lesser extent, from other hemoproteins. In serum, bilirubin is typically measured in two forms: direct bilirubin and total bilirubin. Direct bilirubin is related to conjugated bilirubin and includes both conjugated bilirubin and bilirubin covalently bound to albumin. Indirect bilirubin is related to unconjugated bilirubin. Serum bilirubin levels can be measured by any suitable method known in the art. Illustrative non - limiting examples of methods for determining serum bilirubin include methods using diazo reagents, methods using DPD, methods using bilirubin oxidase, or direct spectrophotometric determination of bilirubin. Briefly, the method for determining bilirubin levels in serum using a diazo reagent is based on the formation of azobilirubin, which can act as an indicator by adding a mixture of p - aminobenzoic acid and sodium nitrite. The method for determining serum bilirubin based on the use of DPD is based on the fact that bilirubin reacts with 2,5 - dichlorobenzene diazonium salt (DPD) in 0.1 mol / HCl to form azobilirubin with a maximum absorbance at 540 - 560 nm. The staining intensity is proportional to the concentration of bilirubin. Unconjugated bilirubin that reacts in the presence of a detergent (e.g., Triton TX - 100) is measured as total bilirubin, while only conjugated bilirubin reacts in the absence of a detergent. The method for determining the serum level of bilirubin using bilirubin oxidase is based on the reaction catalyzed by bilirubin oxidase, which oxidizes bilirubin to biliverdin with a maximum absorbance at 405 - 460 nm. The concentration of bilirubin is proportional to the measured absorbance. The concentration of total bilirubin is determined by adding sodium dodecyl sulfate (SDS) or sodium cholate, which causes the separation and precipitation reaction of unconjugated bilirubin from albumin. Serum bilirubin levels can also be determined by direct spectrophotometry at 454 nm and 540 nm. Measurements at these two wavelengths are used to reduce hemoglobin interference.

[0121] The term "international normalized ratio" or "INR" as used herein refers to a parameter used to determine the tendency of blood coagulation. The INR is the ratio of the patient's prothrombin time to that of a normal (control) sample, raised to the power of the ISI value of the analytical system used. The prothrombin time (PT) measures factors I (fibrinogen), II (prothrombin), V, VII, and X, and it is used in conjunction with the activated partial thromboplastin time. The prothrombin time is the time required for plasma to coagulate after adding tissue factor. This measures the extrinsic pathway of coagulation. The INR normalizes the results of the prothrombin time and is calculated by the formula: INR=(PT 测试 / PT 正常 ) <isi>。

[0122] The ISI value of this formula is the international sensitivity index of any tissue factor, and it represents how a particular batch of tissue factor compares to the international reference tissue factor. The ISI generally ranges between 1.0 and 2.0.

[0123] The value of the MELD score is strongly correlated with short-term mortality. The lower the value of the MELD score, the lower the mortality, and the higher the value of the MELD score, the higher the mortality. Thus, the 3-month mortality of patients with a low MELD score (e.g., MELD below 9) is approximately 1.9%, while the 3-month mortality of patients with a high MELD score (e.g., MELD score of 40 or higher) is approximately 71.3%.

[0124] The term "high MELD score" as used herein refers to a patient having a MELD score higher than 9, such as at least 10, at least 15, at least 19, at least 20, at least 25, at least 29, at least 30, at least 35, at least 39, at least 40, at least 45 or higher. In one specific embodiment, the present invention is applied to subjects with a MELD score higher than 20.

[0125] In another specific embodiment, the patient to be treated shows impaired renal function. The term "impaired renal function" as used herein, also known as "renal function impairment", "kidney impairment (condition)", "renal insufficiency", "kidney injury", and "renal failure", refers to a medical condition in which the kidneys cannot adequately filter waste products from the blood. Renal failure is mainly determined by a decrease in the glomerular filtration rate, which is the rate at which blood is filtered in the glomeruli of the kidneys. In renal failure, there may be problems such as an increase in body fluids (leading to swelling), an increase in acid levels, an elevated potassium level, a decreased calcium level, an increased phosphate level, and anemia in the later stages.

[0126] The PPARα / γ agonist used according to the present invention as selected above can be used in any stage of ACLF. In one specific embodiment, the subject has ACLF grade 2 or 3.

[0127] In another embodiment, the subject has ACLF without renal failure. In one specific embodiment, the subject has ACLF with renal failure. In another specific embodiment, the subject has AD or ACLF with non-renal organ failure and renal dysfunction.

[0128] In another embodiment, the subject is at risk of ACLF. In yet another embodiment, the subject has at least one ACLF-inducing event. In another embodiment, the inducing event is selected from alcoholic hepatitis; bacterial, fungal or viral infection; sepsis, poisoning; visceral hemorrhage and drug-induced liver insufficiency. In another embodiment, the inducing event is a bacterial infection. In a further specific embodiment, the PPARα / γ agonist of the present invention is used in a method for treating sepsis-related AD or ACLF.

[0129] In another embodiment, the PPARα / γ agonist of the present invention is used in a method for treating or preventing hepatic encephalopathy. In a specific embodiment, the PPARα / γ agonist of the present invention is used in a method for treating or preventing hepatic encephalopathy in a subject with compensated or decompensated cirrhosis, particularly decompensated cirrhosis. In another embodiment, the PPARα / γ agonist of the present invention is used in a method for treating hepatic encephalopathy in a subject with AD or ACLF.

[0130] In the context of the present invention, the PPARα / γ agonist of the present invention is administered to a subject in a therapeutically effective amount. A "therapeutically effective amount" means an amount of a drug that effectively achieves the desired therapeutic result. The therapeutically effective amount of a drug can vary depending on factors such as the individual's disease state, age, sex and weight, as well as the ability of the drug to elicit the desired response in the individual. A therapeutically effective amount is also an amount where the therapeutic beneficial effects exceed any toxic or harmful effects of the agent. The effective dose and dosage regimen of a drug depend on the disease or disorder to be treated and can be determined by those skilled in the art. A physician of ordinary skill in the art can readily determine and prescribe the effective amount of the desired pharmaceutical composition. For example, a physician can start with a drug dose in the pharmaceutical composition at a level lower than that required to achieve the desired therapeutic effect and gradually increase the dose until the desired effect is achieved. Generally, a suitable dose of the composition of the present invention is an amount of the compound that is the lowest effective dose that produces a therapeutic effect according to a specific dosage regimen. Such an effective dose generally depends on the above factors.

[0131] The PPARα / γ agonists of the present invention can be formulated in pharmaceutical compositions which further comprise one or several pharmaceutically acceptable excipients or vehicles (such as saline solution, physiological solution, isotonic solution, etc.), which are compatible with the pharmaceutical use and are well-known to those of ordinary skill in the art. These compositions can further comprise one or several reagents or vehicles selected from dispersants, solubilizers, stabilizers, preservatives, etc. The reagents or vehicles which can be used for these preparations (liquid and / or injectable and / or solid) are specifically methylcellulose, hydroxymethylcellulose, carboxymethylcellulose, polysorbate 80, mannitol, gelatin, lactose, vegetable oil, gum arabic, liposomes, etc. These compositions can be formulated in the form of injectable suspensions, syrups, gels, oils, ointments, pills, tablets, suppositories, powders, gel caps, capsules, aerosols, etc., and finally formulated using Galenic forms or devices ensuring extended and / or slow release. For such preparations, reagents such as cellulose, carbonates or starches can be advantageously used.

[0132] The PPARα / γ agonists of the present invention can be administered by different routes and in different forms. For example, it can be administered systemically, orally, parenterally, by inhalation, by nasal spray, by nasal drip or by injection such as intravenously, by intramuscular route, by subcutaneous route, by transdermal route, by topical route, by intra-arterial route, etc. Of course, according to the methods well-known to those of ordinary skill in the art, the administration route will be adapted to the form of the drug.

[0133] In a specific embodiment, the compound is formulated as a tablet. In another specific embodiment, the compound is administered orally.

[0134] The frequency and / or dose of administration can be adjusted by those of ordinary skill in the art according to the patient, the pathology, the form of administration, etc. Generally, the PPARα / γ agonists of the present invention can be administered at a dose of 0.01 mg / day to 4000 mg / day, such as 50 mg / day to 2000 mg / day, such as 100 mg / day to 2000 mg / day; especially 100 mg / day to 1000 mg / day. If necessary, it can be administered once a day or even several times a day. In one embodiment, the compound is administered at least once a day, such as once a day, twice a day or three times a day. In a specific embodiment, the PPARα / γ agonist is administered once or twice a day. In particular, oral administration can be carried out during a meal, such as during breakfast, lunch or dinner, once a day by taking a tablet containing the PPARα / γ agonist.

[0135] In suitable cases, the course of treatment with the PPARα / γ agonist of the present invention is at least 1 week, particularly at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20 or 24 weeks or longer. In a specific embodiment, the course of treatment lasts at least 1 month, at least 2 months or at least 3 months. In a specific embodiment, the course of treatment lasts at least 1 year or longer, depending on the condition of the subject being treated.

[0136] In a specific embodiment, the PPARα / γ agonist of the present invention ("the drug") is used as the sole active ingredient for the treatment disclosed herein.

[0137] In yet another embodiment, the drug is used in combination therapy.

[0138] In a specific embodiment, the drug is used in combination with a therapy for an inciting event.

[0139] In a specific embodiment, the inciting event is a bacterial, fungal or viral infection. Accordingly, the drug can be combined with an antimicrobial or antiviral agent. The most suitable agent will be selected according to the organism or virus causing the infection, as is well known in the art. In a specific embodiment, the inciting event is hepatitis B virus reactivation. In such a case, the drug can be combined with a nucleoside or nucleoside analogue. Illustrative antiviral drugs include but are not limited to tenofovir, tenofovir alafenamide and entecavir. In another specific embodiment, the inciting event is a bacterial infection and the drug can be combined with an antibiotic. Antibiotics for treating bacterial infections are well known in the art. Illustrative families of antibiotics include but are not limited to β-lactam antibiotics (such as penicillin), tetracyclines, cephalosporins, quinolones, lincosamides, macrolides, sulfonamides, glycopeptides, aminoglycosides and carbapenems. In a specific embodiment, the drug can be combined with an antibiotic of the carbapenem family such as ertapenem.

[0140] In another specific embodiment, the inciting event is acute variceal bleeding. Accordingly, the drug can be combined with a vasoconstrictor such as terlipressin, somatostatin or an analogue such as octreotide or vapreotide, particularly octreotide. Such treatment can be accompanied by endoscopic therapy (preferably endoscopic variceal ligation, performed under diagnostic endoscopy within less than 12 hours after admission). Short-term antibiotic prophylaxis can also be implemented, such as using ceftriaxone.

[0141] In another specific embodiment, the inciting event is alcoholic hepatitis. Accordingly, the drug can be combined with prednisolone, suitable for patients with severe alcoholic hepatitis.

[0142] In another specific embodiment, the drug is used in combination with supportive therapy. In one specific embodiment, the supportive therapy is cardiovascular support. For example, the drug can be combined with therapies for acute kidney injury such as discontinuation of diuretics or volume expansion (using intravenous albumin). The drug can also be combined with vasoconstrictors such as terlipressin or norepinephrine, especially in cases where there is no response to volume expansion. In one specific embodiment, the supportive therapy is the treatment of encephalopathy. For example, the drug can be combined with lactulose. Optionally, lactulose therapy can be further completed by administering an enema to clear the bowel. In cases where the subject has lactulose-refractory severe hepatic encephalopathy, albumin dialysis can be used. In yet another specific embodiment, the drug can be combined with rifaximin. In another embodiment, the drug can be combined with lactitol. In one specific embodiment, the supportive therapy is extracorporeal liver support. For example, an extracorporeal liver assist device containing hepatocytes can be used. In another embodiment, in addition to administering the drugs provided herein, plasma exchange can also be performed. In yet another embodiment, the extracorporeal liver support is albumin exchange or endotoxin removal.

[0143] The following examples are used to illustrate the present invention and should not be considered as limiting the scope of the present invention.

[0144] Examples

[0145] Chemistry

[0146] Chemical names follow IUPAC nomenclature. Cpd.1 (teglicolozole), Cpd.2 (moglicolozole), and Cpd.3 (aglicolozole) are well-known and were synthesized according to methods known to those skilled in the art.

[0147] Teglicolozole (Cpd.1) was synthesized according to the method disclosed in WO9962872A1 and was also purchased from TOCRIS (Ref3965; batch 1A / 263468).

[0148] Moglicolozole (Cpd.2) was synthesized according to the method disclosed in WO2001021602.

[0149] Aglicolozole (Cpd.3) was synthesized according to the methods disclosed in WO2002092084A1 and A. Benardeau et al., Bioorg. Med. Chem. Lett., 2009, vol 19, p2468 - 2473.

[0150] Animal experiment

[0151] Animals were handled carefully to minimize stress. All experiments were conducted in accordance with the guidelines of the French Ministry of Agriculture regarding laboratory animal experiments (Law 87-848). This study was carried out in accordance with the animal health regulations (Council Directive No. 2010 / 63 / UE of 22 September 2010 and French Decree No. 2013-118 of 1 February 2013 on animal protection).

[0152] Example 1: Cpd.1 improves liver injury and function and reduces systemic inflammation in an acute liver failure model

[0153] A low dose of LPS in combination with the hepatotoxic agent D-galactosamine (GalN) promotes specific liver injury and induces the production of inflammatory cytokines in mice, thus reproducing the clinical manifestations of human acute liver injury (Pourcet et al., Gastroenterology, 2018, 154(5), p1449-1464.e20). Therefore, LPS / GalN-induced liver injury is a widely used mouse model for evaluating the effects of pharmacological reagents on acute liver failure.

[0154] Preclinical models of acute liver failure

[0155] To evaluate the efficacy of the compound on liver injury and function and the inflammatory response occurring during acute liver failure, male C57BL / 6J mice (8 weeks old, Janvier Labs) were given an intraperitoneal injection of 0.025 mg / kg LPS (Escherichia coli O111:B4, #L2630, Sigma-Aldrich), supplemented with 700 mg / kg D-galactosamine (GalN, G0500, Sigma-Aldrich).

[0156] Cpd.1 (1 mg / kg / day) or vehicle (1% carboxymethyl cellulose, 0.1% Tween 80) was administered by oral gavage during the three days prior to the injection of LPS / GalN (n = 10-12 per group). Mice were sacrificed 6 h after the injection of LPS / GalN. Just before sacrifice, blood samples were obtained by retro-orbital sinus puncture in animals lightly anesthetized with isoflurane (Isoflurin 1000 mg / g, GTIN 03760087152678, Axience). A group of mice (n = 4) received an intraperitoneal injection to serve as healthy controls.

[0157] Analysis in mouse serum

[0158] The Randox kit (AS 8306) using Daytona Plus automate was used to measure serum aspartate aminotransferase (ASAT) according to the manufacturer's recommendations. ASAT enzymatically converts α-ketoglutaric acid and L-aspartic acid into L-glutamic acid and oxaloacetic acid. In the presence of NADH, the generated oxaloacetic acid is converted by malate dehydrogenase to form L-malate and NAD+. The kinetics of the reaction were studied, and the concentration of ASAT could be calculated.

[0159] The Randox kit (AL 8304) using Daytona Plus automate was used to measure serum alanine aminotransferase (ALAT) according to the manufacturer's recommendations. ALAT enzymatically converts α-ketoglutaric acid and L-alanine into L-glutamic acid and pyruvic acid. In the presence of NADH, the generated pyruvic acid is converted by lactate dehydrogenase to form L-lactic acid and NAD+. The kinetics of the reaction were studied, and the concentration of ALAT could be calculated.

[0160] The Randox kit (BR 8377) using Daytona Plus automate was used to measure serum total bilirubin according to the manufacturer's recommendations. Bilirubin is oxidized by vanadate at approximately pH 2.9 to produce biliverdin. In the presence of detergent and vanadate, both conjugated and unconjugated bilirubin are oxidized. This oxidation reaction results in a decrease in the yellowish optical density, which is specific for bilirubin. The decrease in optical density at 450 / 546 nm is proportional to the concentration of total bilirubin in the sample.

[0161] The Randox kit (BI 3863) using Daytona Plus automate was used to measure serum total bile acids according to the manufacturer's recommendations. In the presence of Thio-NAD, the enzyme 3-α-hydroxysteroid dehydrogenase (3-α-HSD) converts bile acids into 3-ketosteroids and Thio-NADH. In the presence of excess NADH, enzyme cycling occurs effectively, and the rate of formation of Thio-NADH is determined by measuring the specific change in absorbance at 405 nm.

[0162] The concentration of serum interleukin-6 (IL6) was determined using a multiplex sandwich ELISA system (Mouse Magnetic Luminex #LSXAMSM-06, Biotechne) according to the manufacturer's instructions. Briefly, serum samples were added to magnetic particles pre-coated with cytokine-specific antibodies. After washing, IL6 was detected by adding biotinylated antibodies. Finally, streptavidin conjugated to phycoerythrin was added and analyzed using a Luminex 200 analyzer. The signal intensity of phycoerythrin is proportional to the concentration of the specific cytokine.

[0163] Results

[0164] As expected in this model, mice injected with LPS / GalN had severe liver injury, as evidenced by very high levels of ASAT (>2000 U / L) and ALAT (>3000 U / L). ( Figure 1A -B). Cpd.1 greatly alleviated liver injury by reducing ASAT and ALAT by 66% (p = 0.01) and 57% (p = 0.03), respectively. ( Figure 1A -B). In this model, the metabolism of liver function such as bilirubin and bile acids was also strongly altered, while Cpd.1 greatly improved these markers, as evidenced by a 73% reduction in total bilirubin (p = 0.003) and a 79% reduction in total bile acids (p = 0.004). ( Figure 1C -D). Interestingly, these hepatoprotective effects were associated with anti-inflammatory effects, as evidenced by a significant reduction in the pro-inflammatory cytokine IL6 (-78%, p = 0.01). ( Figure 1E ).

[0165] These results indicate that Cpd.1 exerted hepatoprotective and anti-inflammatory effects, thus alleviating liver injury and liver function alterations in acute liver failure.

[0166] Example 2: The compound of the present invention inhibits macrophage activation.

[0167] The human monocytic cell line THP-1 (Sigma) was used to test the efficacy of the compound in inhibiting immune cell activation. THP1 monocytes were cultured at 37 °C in a 5% CO2 incubator in RPMI 1640 medium (#10-040-CV, Corning) supplemented with 10% fetal bovine serum (FBS, #10270, Gibco), 1% penicillin / streptomycin (#15140, Gibco) and 25 mM Hepes (H0887, Sigma).

[0168] Cpd.1 was purchased from TOCRIS (Ref 3965; lot 1A / 263468).

[0169] To test the efficacy of the compound on macrophage activation, 2.5x10 4 THP-1 cells were cultured in 384-well plates and treated with 100 ng / mL PMA (#P8139, Sigma) for 24 h to induce differentiation into macrophages. Then, the medium was removed and replaced with medium without FBS containing the compound for 24 h. Finally, THP1 macrophages were stimulated with 100 ng / mL LPS (Klebsiella pneumoniae, #L4268, Sigma-Aldrich) for 6 h.

[0170] Monocyte chemoattractant protein 1 (MCP1) was measured in the cell supernatant by homogeneous time-resolved fluorescence (HTRF) (62 HMCP1PEG, Cisbio). Fluorescence was measured using an Infinite 500 (#30019337, Tecan) to determine the MCP1 concentration.

[0171] Results

[0172] Treatment of macrophages with LPS led to a 2-fold increase in MCP1 levels ( Figure 2A , B, and C). As Figure 2A shown, Cpd.1 decreased the level of LPS-induced MCP1 secretion in a dose-dependent manner, reaching 100% inhibition at 10 μM (p < 0.001). Treatment of THP1 macrophages with Cpd.2 and Cpd.3 also showed a dose-dependent decrease in MCP1 secretion, reaching 66% inhibition at 1 μM for Cpd.2 and 130% inhibition at 0.1 μM for Cpd.3 ( Figure 2B -C).

[0173] These results indicate that the compounds of the present invention have the potency to resist macrophage activation, thereby protecting against tissue damage induced by overactivation of the immune system.

[0174] Example 3: Compounds of the present invention protect hepatocytes from apoptosis

[0175] Hepatocyte death is a hallmark of liver failure, both in healthy patients and in patients with fibrotic livers due to underlying chronic liver diseases, and can be induced by various stressors (alcohol, drugs, cytokine storms, etc.).

[0176] To evaluate the effect of the compounds in protecting hepatocytes from cell death, apoptosis was induced by staurosporine in the human hepatoblastoma-derived HepG2 cell line (ECACC, #85011430, Sigma-Aldrich). HepG2 was cultured at 37 °C in a 5% CO 2 incubator in high-glucose DMEM medium (#41965, Gibco, France) supplemented with 10% fetal bovine serum (FBS, #10270, Gibco), 1% penicillin / streptomycin (#15140, Gibco), 1% sodium pyruvate (#11360, Gibco), and 1% MEM non-essential amino acids (#11140, Gibco).

[0177] To evaluate caspase 3 / 7 activity as an alternative marker of apoptosis, 1.5x10 4 cells were plated in 384-well plates (#781080, Greiner, France). After cell adhesion (8 h), the cells were serum-starved for 16 h in the presence of the compounds (dose range 0.3 to 10 μM) or vehicle. Then, the cells were treated with 10 μM staurosporine (#569397, Sigma-Aldrich, Germany) supplemented with the compounds for an additional 4 h, followed by cell lysis and caspase activity measurement.

[0178] Caspase 3 / 7 activity was measured using the Caspase-Glow TM 3 / 7 assay (#G8093, Promega, USA). Luminescence was measured using a Spark microplate reader (#30086376, Tecan, USA). The luminescence (RLU) is directly related to caspase 3 / 7 activity.

[0179] Results

[0180] Incubation of HepG2 cells with staurosporine induced apoptosis, as shown by a significant 5-fold increase in caspase 3 / 7 activity. Interestingly, three compounds of the present invention significantly inhibited caspase 3 / 7 activity in a dose-dependent manner: Cpd.1 achieved 12% inhibition at a dose of 10 μM (p < 0.001), Cpd.2 achieved 24% inhibition at a dose of 3 μM (p < 0.001), and Cpd.3 achieved 17% inhibition at a dose of 1 μM (p < 0.001).

[0181] These results indicate that the compounds of the present invention directly protect hepatocytes from cell death by inhibiting apoptosis.

[0182] In summary, these results indicate that treatment with the compounds of the present invention reduces the apparent activation of the immune system on the one hand through the direct anti-inflammatory effect on macrophages, while on the other hand they also directly reduce hepatocyte death. Thus, the compounds of the present invention show beneficial effects for the treatment of patients suffering from acute liver failure or acute-on-chronic liver failure.< / isi>

Claims

1. A PPARα / γ agonist in a method for treating liver failure in a subject in need thereof, wherein the PPARα / γ agonist is selected from aleglitazar, moglitazar, tesaglitazar, pharmaceutically acceptable salts thereof, or combinations thereof.

2. The PPARα / γ agonist for use according to claim 1, wherein the PPARα / γ agonist is aleglitazar or a pharmaceutically acceptable salt thereof, preferably aleglitazar.

3. The PPARα / γ agonist for use according to claim 1, wherein the PPARα / γ agonist is moglitazar or a pharmaceutically acceptable salt thereof, preferably moglitazar.

4. The PPARα / γ agonist for use according to claim 1, wherein the PPARα / γ agonist is tesaglitazar or a pharmaceutically acceptable salt thereof, preferably tesaglitazar.

5. The PPARα / γ agonist for use according to any one of claims 1-4, wherein the liver failure is selected from acute decompensation (AD), acute-on-chronic liver failure (ACLF), acute liver failure (ALF), and decompensated cirrhosis.

6. The PPARα / γ agonist for use according to any one of claims 1-4, wherein the subject has AD, decompensated cirrhosis with or without ACLF, or is at risk of AD and ACLF.

7. The PPARα / γ agonist for use according to any one of claims 1-4, wherein the subject has decompensated cirrhosis, or is at risk of decompensated cirrhosis or acute decompensation.

8. The PPARα / γ agonist for use according to any one of claims 1-4, which is used for preventing decompensated cirrhosis.

9. The PPARα / γ agonist for use according to any one of claims 1-4, which is used in a method for reversing decompensated cirrhosis into compensated cirrhosis.

10. The PPARα / γ agonist for use according to any one of claims 1-4, which is used in a method for preventing liver decompensation in a subject with ACLF.

11. The PPARα / γ agonist for use according to any one of claims 1-4, wherein the liver failure is ALF.

12. The PPARα / γ agonist for use according to any one of claims 1-4, which is used for preventing renal failure or preventing hepatic encephalopathy.

13. The PPARα / γ agonist for use according to any one of claims 1-4, wherein the subject has ACLF but without renal failure, or wherein the subject has ACLF and is accompanied by non-renal organ failure and renal dysfunction.

14. The PPARα / γ agonist for use according to any one of claims 1-4, which is used for treating sepsis-related ACLF.

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