Therapeutic tyrosine kinase inhibitors for multiple sclerosis

Abstract

The present application relates to the field of therapeutic tyrosine kinase inhibitors, in particular Bruton's tyrosine kinase ("BTK") inhibitors, for use in the treatment of subjects suffering from recurrent multiple sclerosis.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority to U.S. Provisional Application No. 63 / 415,027, filed on October 11, 2022, and U.S. Provisional Application No. 63 / 433,873, filed on December 20, 2022, which are hereby incorporated by reference in their entireties for any purpose. Technical Field

[0002] The present application relates to the field of therapeutic tyrosine kinase inhibitors, in particular Bruton tyrosine kinase ("BTK") inhibitors, for the treatment of relapsing forms of multiple sclerosis (RMS). Background Art

[0003] Multiple sclerosis (MS) is a neurological disease that affects more than 1 million people worldwide. It is the most common cause of neurological disability in young and middle-aged adults and has significant physical, psychological, social and economic impacts on subjects and their families. MS involves an immune-mediated process in which an abnormal response of the body's immune system targets the central nervous system (CNS). During the course of the disease, sclerosis, i.e., lesions or scars, occur in the myelin sheaths of nerve cells, thereby interfering with the transmission of electrical signals. Sclerosis accumulates over time and causes the debilitating symptoms experienced by MS patients. MS patients typically experience one of four clinical courses, each of which may be mild, moderate or severe: clinically isolated syndrome, relapsing-remitting syndrome, secondary progressive syndrome and primary progressive syndrome. Approximately 85% of MS patients suffer from a relapsing-remitting form of the disease, in which they experience well-defined relapses (also known as flare-ups or acute exacerbations), which are episodes of acute worsening of neurological function, followed by a period of partial or complete recovery (remission) without disease progression. Within the scope of this application, "relapsing multiple sclerosis," "relapsing MS," or "RMS" may include clinically isolated syndrome ("CIS"), relapsing-remitting multiple sclerosis ("RRMS"), and relapsing secondary progressive multiple sclerosis ("R-SPMS"). See, e.g., Lublin et al., Defining the clinical course of multiple sclerosis; 2013 revised edition, Neurology 2014; 83:278-286.

[0004] Immunomodulatory drugs have become the mainstay of MS treatment. The results of the latest clinical studies have confirmed the efficacy of agents targeting B lymphocytes, especially B cell depletion agents such as ocrelizumab (anti-CD20) (Hauser et al., N Engl J Med. 2017; 376 (3): 221-34). Targeting B cells represents a departure from the popular framework based on animal models, which proves the therapeutic benefits from regulating T cell activity and the position of B cells as the center of current MS drug development (Lehmann-Horn K et al., Int J Mol Sci. 2017; 18 (10): 2048). The importance of immune cells residing in the CNS is also well known and needs to be considered in the pathogenesis of MS (Hemmer B et al., Nat Clin Pract Neurol. 2006; 2 (4): 201-11).

[0005] Despite these recent advances, there remains a significant unmet need for therapies targeting neuroinflammation in the CNS with the goal of halting the long-term disability and neurodegenerative processes in people with relapsing forms of MS (RMS) and progressive forms of the disease (primary progressive MS ("PPMS") and non-relapsing secondary progressive MS ("NR-SPMS")) (Stys PK et al., Nat Rev Neurosci. 2012; 13(7):507-14). Even recent highly effective disease-modifying therapies primarily act on peripheral adaptive immunity and have only a modest or temporary ability to halt neuroinflammatory and neurodegenerative processes and prevent disease progression, as recently demonstrated in studies of progressive forms of MS (Montalban X et al., N Engl J Med. 2017; 376(3):209-20; Kappos L et al., Lancet 2018; 391(10127):1263-73).

[0006] In addition to existing strategies to modulate cellular components of adaptive immunity, increasing evidence indicates that innate immunity mediated by the myeloid cell lineage (bone marrow-derived monocytes / macrophages and CNS-resident microglia) is responsible for many of the neurodegenerative aspects of MS that persist despite the effectiveness of approved disease-modifying therapies in preventing acute relapses (Hemmer B et al., Lancet Neurol. 2015; 14(4):406-19; Rahmanzadeh R et al., Rev Neurosci. 2018 Jun 8). Immune modulation targeting innate immunity has the potential to limit "smoldering neuroinflammation" and other manifestations of disease progression that are not addressed by currently approved therapies.

[0007] The Bruton's tyrosine kinase (BTK) pathway is crucial for signaling in B lymphocytes and myeloid cells, including CNS microglia. Each of these cell types is implicated in the pathophysiology of multiple sclerosis (MS). In addition, because BTK signaling is crucial for the maturation of B cells into antibody-secreting plasma cells, BTK inhibition can modulate both cellular and humoral immunity. Therefore, inhibitors of BTK signaling represent a dual mechanism targeting both aspects of the immune system.

[0008] Therefore, compounds that inhibit BTK that can both suppress antigen-induced B cell activation leading to neuroinflammation and modulate maladaptive microglia in the brain and spinal cord associated with neuroinflammation may be used to treat RMS with superior benefit compared to currently available therapies.

[0009] After stopping some MS disease-modifying treatments, rebound disease activity, characterized by recurrence of neurological symptoms and brain lesions, has been reported. For example, the drainage of autoreactive lymphocytes from lymph nodes after treatment is a proposed mechanism for rebound disease activity with sphingosine-1-phosphate (S1P) receptor modulators. (Barry B et al., Neurol Ther 2019; 8(2): 241-50; González-Suarez I et al., Brain Behav 2017; 7: e00671). Therefore, new treatments that do not cause rebound disease activity in patients with RMS after discontinuation of treatment are needed.

[0010] Drug-induced liver injury has been identified in the ongoing phase 3 trial of tolebrutinib. The reported events occurred between months 2 and 3 after initiating tolebrutinib, and the elevations in liver enzymes appeared reversible after tolebrutinib discontinuation. Therefore, there is a need to mitigate the risk of liver injury and provide safe treatments for patients with RMS. Summary of the Invention

[0011] Accordingly, the following embodiments are provided. In some embodiments, a method of reducing the incidence of multiple sclerosis (MS) relapses in a subject with relapsing multiple sclerosis (RMS) in need thereof is provided, the method comprising the steps of: a) administering to a subject in need thereof a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one for at least 12 weeks; and b) ceasing administration of the BTK inhibitor, wherein the incidence of MS relapses in the subject after ceasing administration of the BTK inhibitor is equal to or less than the incidence of MS relapses in the subject during the 1 year prior to administration of the BTK inhibitor.

[0012] In some embodiments, the subject remains relapse-free for at least 4 weeks after discontinuation of administration of the BTK inhibitor.

[0013] In some embodiments, the subject remains relapse-free for at least 6 weeks after discontinuation of administration of the BTK inhibitor.

[0014] In some embodiments, the subject remains relapse-free for at least 21 weeks after discontinuation of administration of the BTK inhibitor.

[0015] In some embodiments, there is provided a method of reducing the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to the subject in need thereof for at least 12 weeks; and b) ceasing administration of the BTK inhibitor, wherein the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject after ceasing administration of the BTK inhibitor is equal to or less than the baseline of new gadolinium (Gd)-enhancing T1 hyperintense lesions or new or enlarging T2 hyperintense lesions measured in the subject during the 4 weeks prior to administration of the BTK inhibitor.

[0016] In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 2.

[0017] In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject is equal to or less than 1 up to 21 weeks after cessation of administration of said BTK inhibitor.

[0018] In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 4 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 1.

[0019] In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject is equal to or less than 3 up to 21 weeks after discontinuation of administration of the BTK inhibitor.

[0020] In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject is equal to or less than 1 up to 6 weeks after cessation of administration of the BTK inhibitor.

[0021] In some embodiments, there is provided a method of reducing the total number of gadolinium (Gd)-enhancing T1 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to the subject in need thereof for at least 12 weeks; and b) ceasing administration of the BTK inhibitor, wherein the total number of gadolinium (Gd)-enhancing T1 hyperintense lesions measured in the subject after ceasing administration of the BTK inhibitor is equal to or less than the baseline number of gadolinium (Gd)-enhancing T1 hyperintense lesions measured in the subject before administration of the BTK inhibitor.

[0022] In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject is equal to or less than 4 up to 21 weeks after cessation of administration of the BTK inhibitor.

[0023] In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject is equal to or less than 2 up to 21 weeks after cessation of administration of the BTK inhibitor.

[0024] In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject from baseline is equal to or less than 1 up to 4 weeks after discontinuation of administration of the BTK inhibitor.

[0025] In some embodiments, the dosage of the BTK inhibitor is 60 mg once daily.

[0026] In some embodiments, the lesion is measured by MRI.

[0027] In some embodiments, the BTK inhibitor is administered to the subject for at least 16 weeks.

[0028] In some embodiments, the BTK inhibitor is administered to the subject for at least 24 weeks.

[0029] In some embodiments, the BTK inhibitor is administered to the subject for at least 48 weeks.

[0030] In some embodiments, the BTK inhibitor is administered to the subject for at least 72 weeks.

[0031] In some embodiments, the BTK inhibitor is administered to the subject for at least 96 weeks.

[0032] In some embodiments, there is provided a method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof, the method comprising determining whether the patient has elevated transferrin levels or elevated ferritin levels, and when the patient is found not to have elevated transferrin levels or elevated ferritin levels, administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

[0033] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof is provided, the method comprising determining the patient's iron status (iron panel), and when the patient is found to have appropriate iron status, administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

[0034] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the patient does not have elevated transferrin levels or elevated ferritin levels.

[0035] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: (a) performing an iron status test in the blood or serum of a patient; (b) detecting a level of the iron status test within a normal range; and (c) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the iron status test detects any one or more of an iron level, a ferritin level, a transferrin saturation level, and a total iron binding capacity (TIBC) level in the patient's blood or serum, and wherein a normal range for the iron status test includes one or more of: (i) an iron level of 60 to 170 μg / dL, (ii) a ferritin level of 500 μg / L or less, (iii) a transferrin saturation level of 50% or less in male patients or a transferrin saturation level of 40% or less in female patients, and (iv) a TIBC of 240 to 450 μg / dL.

[0036] In some embodiments, a method for treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of: (a) detecting a transferrin saturation level within a normal range in the patient's blood or serum; and (b) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the transferrin saturation level within a normal range in the blood or serum of a male patient is ≤50% transferrin saturation, and the transferrin saturation level within a normal range in the blood or serum of a female patient is ≤40% transferrin saturation.

[0037] In some embodiments, a method for treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of: (a) detecting a ferritin level in the blood or serum of a patient that is within a normal range; and (b) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the ferritin level in the blood or serum of the patient that is within a normal range is ≤500 μg / L. In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of: (a) performing a liver function test in a patient; (b) detecting adequate liver function in the patient; and (c) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the liver function test measures one or more of the following levels in the patient's blood: aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, alkaline phosphatase, total and direct bilirubin, and total protein, and wherein a patient with adequate liver function has one or more of the following: ALT ≤ 1.5 x upper limit of normal (ULN), AST level ≤ 1.5 x ULN, alkaline phosphatase ≤ 2 x ULN (unless caused by a non-liver related disorder or explained by a stable chronic liver disorder), and total bilirubin ≤ 1.5 x ULN (unless due to Gilbert's syndrome or non-liver-related disorder).

[0038] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: (a) administering a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound) to a patient in need thereof; (b) measuring alanine aminotransferase (ALT) levels in said patient; (c) detecting an ALT level >8x upper limit of normal (ULN); (d) ceasing administration of said compound to said patient; and optionally (e) monitoring ALT levels in said patient; and (f) resuming administration of said therapeutically effective amount of said compound to said patient when it is determined that said patient's ALT level is <1.5x ULN.

[0039] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: (a) administering a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound) to a patient in need thereof; (b) measuring alanine aminotransferase (ALT) levels in said patient; (c) detecting an ALT level >5x upper limit of normal (ULN) during a period of at least two weeks; (d) ceasing administration of said compound to said patient; and optionally (e) monitoring ALT levels in said patient; and (f) resuming administration of a therapeutically effective amount of said compound to said patient when it is determined that said patient's ALT level is <1.5x ULN.

[0040] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: (a) administering a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound) to a patient in need thereof; (b) measuring an alanine aminotransferase (ALT) level in said patient; (c) detecting an ALT level >3x upper limit of normal (ULN); (d) measuring one or more of total bilirubin and international normalized ratio (INR) in said patient; (e) detecting one or more of total bilirubin >2xULN and INR >1.5; (f) ceasing administration of said compound to said patient; and optionally (g) monitoring ALT levels in said patient; and (h) resuming administration of said therapeutically effective amount of said compound to said patient when it is determined that said patient's ALT level is <1.5x ULN.

[0041] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: (a) administering a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound) to a patient in need thereof; (b) measuring the alanine aminotransferase (ALT) level in said patient; (c) detecting an ALT level >3x upper limit of normal (ULN); (d) discontinuing administration of said compound to said patient if said patient experiences one or more of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, and eosinophilia >5%; and optionally (e) monitoring the ALT level in said patient; and (f) resuming administration of said therapeutically effective amount of said compound to said patient when it is determined that said patient's ALT level is <1.5x ULN.

[0042] In some embodiments, the ALT level in step (b) is determined at least monthly.

[0043] In some embodiments, the ALT level in step (d) is monitored at least once a week.

[0044] In some embodiments, the ALT level in step (d) is monitored once every 2 to 3 days.

[0045] In some embodiments, there is provided a method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof, comprising administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the patient is not currently receiving strong and moderate inducers of cytochrome P450 3A (CYP3A) or strong inhibitors of the CYP2C8 liver enzyme.

[0046] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof is provided, the method comprising the steps of: (a) advising the patient to limit alcohol consumption during treatment; and (b) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the patient is female and is advised to limit alcohol consumption to 14 grams / day or less, or the patient is male and is advised to limit alcohol consumption to 28 grams / day or less.

[0047] In another embodiment, the dose of the BTK inhibitor is from about 5 mg to about 60 mg. In another embodiment, the dose is 5 mg. In another embodiment, the dose is 15 mg. In another embodiment, the dose is 30 mg. In another embodiment, the dose is 60 mg. In another embodiment, the BTK inhibitor compound is administered as a monotherapy. In some embodiments, RMS is selected from clinically isolated syndrome (CIS), relapsing-remitting multiple sclerosis (RRMS), and relapsing secondary progressive multiple sclerosis (R-SPMS). In another embodiment, the subject is human.

[0048] In some embodiments, the dose is once daily. In some embodiments, the dose is administered once daily with food. In some embodiments, the 15 mg dose is administered once daily with food. In some embodiments, the 30 mg dose is administered once daily with food. In some embodiments, the 60 mg dose is administered once daily with food. BRIEF DESCRIPTION OF THE DRAWINGS

[0049] Figure 1 An exemplary overall design of treatment is shown. LTS = Long Term Safety Study; R - Randomization; S = Screening; W = Week.

[0050] Figure 2A The number of new Gd-enhancing T1-hyperintense lesions after a 4-week placebo run-in (cohort 2) and after 12 weeks of BTK inhibitor treatment during a 4-week placebo run-out period (cohort 1) are shown. Data are mean ± SE. Gd: gadolinium; SE: standard error; W: week.

[0051] Figure 2B The number of new / enlarging T2 lesions after a 4-week placebo run-in (cohort 2) and the number of new / enlarging T2 lesions after 12 weeks of BTK inhibitor treatment during a 4-week placebo run-in period (cohort 1) are shown. Data are mean ± SE. Gd: gadolinium; SE: standard error; W: week.

[0052] Figure 3 Shown are B cell counts in Cohort 1 after the first BTK inhibitor dose and placebo exhaustion.

[0053] Figure 4 The number of new Gd-enhancing T1-hyperintense lesions after 12 weeks of BTK inhibitor treatment until the start of the long-term safety study is shown. Data are means (standard error). DBP = double-blind period; W = week.

[0054] Figure 5 The numbers of new / enlarging T2 lesions after 12 weeks of BTK inhibitor treatment until the start of the long-term safety study are shown. Data are means (standard error). DBP = double-blind period; W = week.

[0055] Figure 6 Shown are changes in T2 lesion volume over 12 weeks of BTK inhibitor treatment until the start of the long-term safety study. Data are mean (standard error). DBP = double-blind period; W = week. DETAILED DESCRIPTION

[0056] Reference will now be made in detail to certain embodiments, examples of which are illustrated in the accompanying drawings. Although this application provides illustrative embodiments, it should be understood that they are not intended to limit the invention to those embodiments. On the contrary, the present invention is intended to cover all alternatives, modifications, and equivalents that may be included within the disclosure defined by the appended claims.

[0057] The section headings used in this application are only for organizational purposes and should not be interpreted as limiting the desired subject matter in any way. In the event that any document incorporated by reference conflicts with any term defined in this specification, this specification shall prevail. Although the teachings of the present invention have been described in conjunction with each embodiment, it is not intended that the teachings of the present invention be limited to these embodiments. On the contrary, as will be appreciated by those skilled in the art, the teachings of the present invention encompass various alternatives, modifications, and equivalents. I. Definition

[0058] Unless otherwise stated, the following terms used in the specification and claims are defined for the purposes of this application and have the following meanings:

[0059] As used herein, "BTK inhibitor," "BTK inhibitor compound," "tobrutinib," and "compound" refer to (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one having the following structure: It is also known as 4-amino-3-(4-phenoxyphenyl)-1-[(3R)-1-(prop-2-enoyl)piperidin-3-yl]-1,3-dihydro-2H-imidazo[4,5-c]pyridin-2-one and has the following structure: and / or pharmaceutically acceptable salts thereof.

[0060] "Pharmaceutically acceptable carrier" or "pharmaceutically acceptable excipient" means a carrier or excipient that can be used to prepare a pharmaceutical composition that is generally safe, non-toxic, and neither biologically nor otherwise undesirable, and includes carriers or excipients that are acceptable for veterinary as well as human pharmaceutical use. "Pharmaceutically acceptable carrier / excipient" as used in the specification and claims includes both one and more than one such excipient.

[0061] “Treating” or “treatment” of a disease includes: (1) preventing a disease, e.g., preventing the development of clinical symptoms of a disease in a mammal that may have been exposed to or is susceptible to the disease but has not yet experienced or displayed symptoms of the disease; (2) inhibiting the disease, such as preventing or reducing the development of the disease or its clinical symptoms; or (3) Alleviate the disease, such as causing regression of the disease or its clinical symptoms.

[0062] "Optional" or "optionally" means that the subsequently described event or circumstance can but need not occur, and that the description includes instances where the event or circumstance occurs and instances where it does not.

[0063] A "therapeutically effective amount" means an amount of a BTK inhibitor compound that, when administered to a mammal for treating a disease, is sufficient to effect such treatment for the disease. The "therapeutically effective amount" will vary depending on the compound, the disease and its severity, and the age, weight, etc., of the mammal to be treated.

[0064] "Ceasing" or "cessation" when used with respect to the administration of an active pharmaceutical ingredient (API) means temporarily or permanently removing the API from the subject.

[0065] Before the present teachings are described in detail, it is to be understood that this application is not limited to specific compositions or method steps, as these may vary.

[0066] It should be noted that, as used in this specification and the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "a conjugate" includes a plurality of conjugates, and reference to "a cell" includes a plurality of cells, etc.

[0067] Numerical ranges include the numbers that define the range. Measured values and measurable values should be understood as approximate, taking into account significant figures and measurement-related errors. In addition, the use of "comprise, comprises, comprising," "contain, contains, containing," "include, includes, and including" is not intended to be limiting. It should be understood that the foregoing summary of the invention and detailed description are merely exemplary and explanatory and are not intended to limit the teachings of the present invention.

[0068] Unless otherwise specified in the above description, embodiments described in this specification as “comprising” various components are also considered to be “consisting of the described components” or “consisting essentially of the described components”; embodiments described in this specification as “consisting of various components” are also considered to be “comprising the described components” or “consisting essentially of the described components”; embodiments described in this specification as “consisting essentially of various components” are also considered to be “consisting of the described components” or “comprising the described components” (this interchangeability does not apply to the use of these terms in the claims).

[0069] As used herein, the terms "or a combination thereof" and "or combinations thereof" refer to any and all permutations and combinations of the terms listed preceding the term. For example, "A, B, C, or a combination thereof" is intended to include at least one of: A, B, C, AB, AC, BC, or ABC, and if order is important in the particular context, also BA, CA, CB, ACB, CBA, BCA, BAC, or CAB. Continuing with this example, specifically included are combinations containing repetitions of one item or term or multiple items or terms, such as BB, AAA, AAB, BBC, AAABCCCC, CBBAAA, CABABB, etc. Those skilled in the art will understand that, unless otherwise apparent from the context, there is typically no limit on the number of items or terms in any combination.

[0070] Unless the context requires otherwise, "or" is used in an inclusive sense, that is, equivalent to "and / or". II. BTK Inhibitor Compounds Administered

[0071] In some embodiments, the BTK inhibitor compound (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is administered for treating relapsing forms of multiple sclerosis (RMS) in a subject in need thereof. In some embodiments, the BTK inhibitor compound is a pharmaceutically acceptable salt of (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, a therapeutically effective amount of the BTK inhibitor compound is administered. In some embodiments, a dose of 5 to 60 mg of the BTK inhibitor compound is administered.

[0072] The BTK inhibitor compounds can be prepared according to the methods and protocols described in, for example, U.S. Pat. No. 9,688,676 B2 (particularly at columns 62, line 8 to 65, line 32, and 67, lines 28 to 69, which are incorporated herein by reference).

[0073] The following preparation of (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one compounds is provided to enable those skilled in the art to prepare BTK inhibitor compounds. The synthetic routes should not be considered as limiting the scope of this application, but are merely illustrative and representative examples thereof.

[0074] Exemplary Synthesis of (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one: Into a 100 mL round-bottom flask was placed (R)-4-amino-3-(4-phenoxyphenyl)-1-(piperidin-3-yl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (150 mg, 0.37 mmol, 1.00 equiv), DCM-CH3OH (6 mL), TEA (113 mg, 1.12 mmol, 3.00 equiv). Propyl-2-enoyl chloride (40.1 mg, 0.44 mmol, 1.20 equiv) was subsequently added dropwise and stirred at 0°C for 5 min. The resulting solution was stirred at 0°C for 2 h. The resulting mixture was concentrated in vacuo. The residue was applied to a silica gel column containing dichloromethane / methanol (30:1). The crude product (100 mg) was purified by preparative HPLC using the following conditions (column, XBridgePrep C 18Purification was performed using an OBD column, 5 μm, 19 x 150 mm; the mobile phase consisted of water (containing 0.05% TFA) and ACN (25.0% ACN increasing to 45.0% ACN over 8 minutes). 54.5 mg of (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one was obtained as a white solid. LC-MS m / z: 465.2 (M+1). III. Treatment Methods

[0075] The present application provides a method for reducing the incidence of multiple sclerosis (MS) relapses in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof for at least 12 weeks; and b) ceasing administration of the BTK inhibitor, wherein the incidence of MS relapses in the subject after ceasing administration of the BTK inhibitor is equal to or less than the incidence of MS relapses in the subject during the year prior to administration of the BTK inhibitor. The present application also provides a method of reducing the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to the subject in need thereof for at least 12 weeks; and b) ceasing administration of the BTK inhibitor, wherein the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject after ceasing administration of the BTK inhibitor is equal to or less than the baseline of new gadolinium (Gd)-enhancing T1 hyperintense lesions or new or enlarging T2 hyperintense lesions measured in the subject during the 4 weeks prior to administration of the BTK inhibitor. The present application also provides a method for reducing the total number of gadolinium (Gd) enhanced T1 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the following steps: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof for at least 12 weeks; and b) ceasing administration of the BTK inhibitor, wherein the total number of gadolinium (Gd) enhanced T1 hyperintense lesions measured in the subject after ceasing administration of the BTK inhibitor is equal to or less than the baseline number of gadolinium (Gd) enhanced T1 hyperintense lesions measured in the subject before administration of the BTK inhibitor. In some embodiments, the dose of the BTK inhibitor is from about 5 to about 60 mg. In some embodiments, the subject is a mammal. In some embodiments, the mammal is a human. In some embodiments, the subject has one or more symptoms of RMS prior to treatment, and the treatment reduces or eliminates the one or more symptoms. In some embodiments, the subject has neuropathic pain, musculoskeletal pain, or spasticity caused by RMS.

[0076] In some embodiments, the subject with RMS has at least one documented relapse within the past year, and / or greater than two documented relapses within the past two years, and / or has more than one active Gd-enhancing brain lesion on MRI scans in the past six months and prior to screening.

[0077] In some embodiments, the subject remains relapse-free for at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 8 weeks, at least 9 weeks, at least 10 weeks, at least 11 weeks, at least 12 weeks, at least 13 weeks, at least 14 weeks, at least 15 weeks, at least 16 weeks, at least 17 weeks, at least 18 weeks, at least 19 weeks, at least 20 weeks, or at least 21 weeks after stopping administration of the BTK inhibitor.

[0078] In some embodiments, a dose of about 5-10 mg, 10-15 mg, 15-20 mg, 20-25 mg, 25-30 mg, 30-35 mg, 35-40 mg, 40-45 mg, 45-50 mg, 50-55 mg, or 55-60 mg is administered. In some embodiments, the dose is 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 45 mg, 50 mg, 55 mg, or 60 mg. In some embodiments, the dose is 5 mg. In some embodiments, the dose is 15 mg. In some embodiments, the dose is 30 mg. In some embodiments, the dose is 60 mg.

[0079] In some embodiments, the dosage is administered once a day. The daily dosage can be delivered as a single dose or divided into multiple portions. For example, in some embodiments, the dosage is administered once a day (e.g., approximately every 24 hours). In some embodiments, the dosage is administered twice a day. In some embodiments, the dosage is subdivided into two parts and administered twice a day (e.g., approximately once every 12 hours). In some embodiments, the dosage is subdivided into three parts and administered three times a day (e.g., approximately once every 8 hours). In some embodiments, the dosage is subdivided into four parts and administered four times a day (e.g., approximately once every 6 hours).

[0080] In some embodiments, the dose is administered orally. In some embodiments, the dose is administered in tablet form. In some embodiments, the dose is administered in the form of a pill, capsule, semisolid, powder, sustained-release formulation, solution, suspension, elixir, aerosol, or any other suitable composition.

[0081] In some embodiments, the BTK inhibitor compound is administered to the subject for a period of at least about 12 weeks, 16 weeks, 24 weeks, 48 weeks, 72 weeks, or 96 weeks. In some embodiments, the BTK inhibitor compound is administered to the subject for a period of at least about 12 weeks. In some embodiments, the dosage is once daily.

[0082] In some embodiments, the dose is administered with food. In some embodiments, the dose is administered once daily with food. In some embodiments, a dose of 5 mg, 15 mg, 30 mg, or 60 mg is administered with food. In some embodiments, a dose of 5 mg, 15 mg, 30 mg, or 60 mg is administered once daily with food. In some embodiments, a dose of 60 mg is administered once daily with food. In some embodiments, the dose is administered as an oral solution or tablet. In some embodiments, the dose is administered as an oral solution or tablet with food. In some embodiments, the dose is administered once daily as an oral solution or tablet. In some embodiments, the dose is administered once daily as an oral solution or tablet with food. In some embodiments, a dose of 60 mg is administered as an oral solution or tablet. In some embodiments, a dose of 60 mg is administered as an oral solution or tablet with food. In some embodiments, a dose of 60 mg is administered once daily as an oral solution or tablet. In some embodiments, a dose of 60 mg is administered once daily as an oral solution or tablet with food.

[0083] In some embodiments, administration of the BTK inhibitor reduces new active brain lesions. In some embodiments, administration of the BTK inhibitor reduces new active gadolinium (Gd) enhancing T1 hyperintense lesions. In some embodiments, administration of the BTK inhibitor reduces new or enlarging T2 lesions.

[0084] In some embodiments, administration of the BTK inhibitor reduces the number of new gadolinium (Gd) enhancing T1 hyperintense lesions as measured by MRI. In some embodiments, the number of new Gd enhancing T1 hyperintense lesions is less than 1. In some embodiments, the number of new Gd enhancing T1 hyperintense lesions is equal to or less than 0.77, 0.7, 0.6, 0.5, 0.4, 0.3, 0.2, or 0.1. In some embodiments, after 12 weeks of BTK inhibitor treatment, no new Gd enhancing T1 hyperintense lesions form.

[0085] In some embodiments, administration of the BTK inhibitor reduces the number of new or enlarging T2 lesions as measured by MRI. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 2. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 1.9, equal to or less than 1.8, equal to or less than 1.7, equal to or less than 1.6, equal to or less than 1.5, equal to or less than 1.4, equal to or less than 1.3, equal to or less than 1.2, equal to or less than 1.1, equal to or less than 1.0, equal to or less than 0.9, equal to or less than 0.8, equal to or less than 0.7, equal to or less than 0.6, equal to or less than 0.5, equal to or less than 0.4, equal to or less than 0.3, equal to or less than 0.2, or equal to or less than 0.1. In some embodiments, after 12 weeks of BTK inhibitor treatment, no new or enlarging T2 lesions form.

[0086] In some embodiments, administration of the BTK inhibitor reduces the total number of Gd-enhancing T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

[0087] In some embodiments, the dose is 60 mg, and after 12 weeks of BTK inhibitor treatment, one or zero new Gd-enhancing T1 hyperintense lesions develop. In some embodiments, after 12 weeks of BTK inhibitor treatment, zero new Gd-enhancing T1 hyperintense lesions develop. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 2. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 2, equal to or less than 1.9, equal to or less than 1.8, equal to or less than 1.7, equal to or less than 1.6, equal to or less than 1.5, equal to or less than 1.4, equal to or less than 1.3, equal to or less than 1.2, equal to or less than 1.1, equal to or less than 1.0, equal to or less than 0.9, equal to or less than 0.8, equal to or less than 0.7, equal to or less than 0.6, equal to or less than 0.5, equal to or less than 0.4, equal to or less than 0.3, equal to or less than 0.2, or equal to or less than 0.1.

[0088] In some embodiments, administration of the BTK inhibitor reduces the total number of Gd-enhancing T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

[0089] In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 2 or equal to or less than 1. In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is zero. In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 4 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 1. In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 4 weeks after discontinuation of administration of the BTK inhibitor is zero.

[0090] In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of said BTK inhibitor is equal to or less than 2. In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of said BTK inhibitor is equal to or less than 1. In some embodiments, the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject is zero up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after stopping administration of the BTK inhibitor.

[0091] In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject is equal to or less than 3, equal to or less than 2, equal to or less than 1, or zero up to 21 weeks after discontinuation of administration of the BTK inhibitor. In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject is equal to or less than 3, equal to or less than 2, equal to or less than 1, or zero up to 6 weeks after discontinuation of administration of the BTK inhibitor.

[0092] In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 3. In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 2. In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after stopping administration of the BTK inhibitor is equal to or less than 1. In some embodiments, the total number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after stopping administration of the BTK inhibitor is zero. In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject up to 21 weeks after stopping administration of the BTK inhibitor is equal to or less than 4. In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject up to 21 weeks after discontinuation of administration of said BTK inhibitor is equal to or less than 2. In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject from baseline is equal to or less than 1 up to 4 weeks after discontinuation of administration of said BTK inhibitor.

[0093] In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject is equal to or less than 4 up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of said BTK inhibitor. In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject is equal to or less than 3 up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of said BTK inhibitor. In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject is equal to or less than 2 up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of said BTK inhibitor. In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in said subject is equal to or less than 1 up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after discontinuation of administration of said BTK inhibitor. In some embodiments, the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject is zero up to 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, or 4 weeks after cessation of administration of the BTK inhibitor.

[0094] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, for use in a method of reducing the incidence of multiple sclerosis (MS) relapses in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof for at least 12 weeks; and b) ceasing administration of the BTK inhibitor, wherein the incidence of MS relapses in the subject after ceasing administration of the BTK inhibitor is equal to or less than the incidence of MS relapses in the subject during the 1 year prior to administration of the BTK inhibitor. In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor is used in a method of reducing the number of new gadolinium (Gd)-enhanced T1 hyperintense lesions or the number of new or enlarged T2 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the following steps: a) administering to a subject in need thereof a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one; [4,5-c]pyridin-2(3H)-one for at least 12 weeks; and b) discontinuation of administration of the BTK inhibitor, wherein the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject after discontinuation of administration of the BTK inhibitor is equal to or less than the baseline number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or new or enlarging T2 hyperintense lesions measured in the subject during the 4 weeks prior to administration of the BTK inhibitor.In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor is used in a method for reducing the total number of gadolinium (Gd)-enhancing T1 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering to a subject in need thereof a BTK inhibitor comprising (R)-1- a) cessation of administration of the BTK inhibitor, wherein the total number of gadolinium (Gd)-enhancing T1 hyperintense lesions measured in the subject after cessation of administration of the BTK inhibitor is equal to or less than the baseline number of gadolinium (Gd)-enhancing T1 hyperintense lesions measured in the subject before administration of the BTK inhibitor.

[0095] In some embodiments, the BTK inhibitor compound is administered as a monotherapy. In some embodiments, the method comprises administering a BTK inhibitor compound and at least one additional therapeutic agent. The additional therapeutic agent can be administered simultaneously or sequentially with the BTK inhibitor compound.

[0096] The determination of the frequency of administration can be made by a person skilled in the art (e.g., an attending physician) based on consideration of the following factors: the condition to be treated, the age of the subject to be treated, the severity of the condition to be treated, the general health status of the subject to be treated, etc. In some embodiments, the BTK inhibitor compound is administered in a therapeutically effective amount for the treatment of RMS. The therapeutically effective amount generally depends on the weight of the subject to be treated, their physical or health status, the extensiveness of the condition to be treated, or the age of the subject to be treated, the drug formulation method, and / or the administration method (e.g., administration time and administration route).

[0097] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising administering to a subject in need thereof a dose of about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one and / or a pharmaceutically acceptable salt thereof. In some embodiments, administration of the inhibitor reduces the number of new active brain lesions. In some embodiments, the lesions are Gd-enhancing T1 hyperintense lesions. In some embodiments, the number of lesions is detected by magnetic resonance imaging (MRI).

[0098] In some embodiments, a method of treating RMS is provided, comprising administering to a subject in need thereof a dose of about 5-10 mg, 10-15 mg, 15-20 mg, 20-25 mg, 25-30 mg, 30-35 mg, 35-40 mg, 40-45 mg, 45-50 mg, 50-55 mg or 55-60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method of treating RMS is provided, comprising administering to a subject in need thereof a dose of about 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method of treating RMS is provided, comprising administering to a subject in need thereof a dose of about 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method of treating RMS is provided, comprising administering to a subject in need thereof a dose of about 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method of treating RMS is provided, comprising administering to a subject in need thereof a dose of about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one and / or a pharmaceutically acceptable salt thereof. IV. Therapies to Reduce the Risk of Liver Injury

[0099] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of performing an iron status test using the patient's blood or serum, and administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one if the patient has appropriate iron status. In some embodiments, the iron status test measures any one or more of the levels of iron, ferritin, transferrin saturation, and total iron binding capacity (TIBC) in the patient's blood or serum. In some embodiments, suitable iron status includes one or more of the following: (i) an iron level of 60 to 170 μg / dL, (ii) a ferritin level of ≤500 μg / L, (iii) a transferrin saturation level of ≤50% in male patients or a transferrin saturation level of ≤40% in female patients, and (iv) TIBC of 240 to 450 μg / dL.

[0100] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of performing an iron status test in the patient's blood or serum, detecting a level of the iron status test within a normal range, and administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the iron status test measures any one or more of the iron level, ferritin level, transferrin saturation level, and total iron binding capacity (TIBC) level in the patient's blood or serum. In some embodiments, the normal range for an iron status test includes one or more of the following: (i) an iron level of 60 to 170 μg / dL, (ii) a ferritin level of ≤500 μg / L, (iii) a transferrin saturation level of ≤50% in male patients or a transferrin saturation level of ≤40% in female patients, and (iv) a TIBC of 240 to 450 μg / dL.

[0101] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), the BTK inhibitor being used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of performing an iron status test in the patient's blood or serum, detecting a level of the iron status test within a normal range, and administering a therapeutically acceptable amount of the compound to the patient. In some embodiments, the iron status test measures any one or more of the iron level, ferritin level, transferrin saturation level, and total iron binding capacity (TIBC) level in the patient's blood or serum. In some embodiments, the normal range for an iron status test includes one or more of the following: (i) an iron level of 60 to 170 μg / dL, (ii) a ferritin level of ≤500 μg / L, (iii) a transferrin saturation level of ≤50% in male patients or a transferrin saturation level of ≤40% in female patients, and (iv) a TIBC of 240 to 450 μg / dL.

[0102] In some embodiments, a method for treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of determining the transferrin saturation level in the patient's blood or serum, and if the transferrin saturation level is appropriate, administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the appropriate transferrin saturation level in the blood or serum of a male patient is ≤50% transferrin saturation. In some embodiments, the appropriate transferrin saturation level in the blood or serum of a female patient is ≤40% transferrin saturation.

[0103] In some embodiments, a method for treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of detecting a transferrin saturation level within a normal range in the patient's blood or serum, and administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the transferrin saturation level within a normal range in the blood or serum of a male patient is a transferrin saturation of ≤50%. In some embodiments, the transferrin saturation level within a normal range in the blood or serum of a female patient is a transferrin saturation of ≤40%.

[0104] In some embodiments, the present application provides a BTK inhibitor (compound) comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, the BTK inhibitor (compound) being used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the following steps: detecting a transferrin saturation level within a normal range in the patient's blood or serum, and administering a therapeutically effective amount of the compound to the patient. In some embodiments, the transferrin saturation level within a normal range in the blood or serum of a male patient is a transferrin saturation of ≤50%. In some embodiments, the transferrin saturation level within a normal range in the blood or serum of a female patient is a transferrin saturation of ≤40%.

[0105] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of determining a patient's blood or serum ferritin level, and if the ferritin level is appropriate, administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, an appropriate ferritin level in the patient's blood or serum is ≤500 μg / L.

[0106] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of detecting a ferritin level in a patient's blood or serum that is within a normal range, and administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the ferritin level in the patient's blood or serum that is within a normal range is ≤500 μg / L.

[0107] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), the BTK inhibitor being used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: detecting a ferritin level within a normal range in the patient's blood or serum; and administering a therapeutically acceptable amount of the compound to the patient. In some embodiments, the ferritin level within a normal range in the patient's blood or serum is ≤500 μg / L.

[0108] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of performing a liver function test in a patient and, if the patient has adequate liver function, administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the liver function test measures one or more of the following levels in the patient's blood: aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, alkaline phosphatase, total and direct bilirubin, and total protein. In some embodiments, a patient with adequate liver function has one or more of the following: ALT level ≤ 1.5 x upper limit of normal (ULN), AST level ≤ 1.5 x ULN, alkaline phosphatase ≤ 2 x ULN (except when caused by a non-liver-related disorder or explained by a stable chronic liver disorder), and total bilirubin ≤ 1.5 x ULN (except when due to Gilbert's syndrome or a non-liver-related disorder).

[0109] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, the method comprising the steps of performing a liver function test in a patient, detecting adequate liver function, and administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the liver function test measures one or more of the following levels in the patient's blood: aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, alkaline phosphatase, total and direct bilirubin, and total protein. In some embodiments, a patient with adequate liver function has one or more of the following: ALT level ≤ 1.5 x upper limit of normal (ULN), AST level ≤ 1.5 x ULN, alkaline phosphatase ≤ 2 x ULN (except when caused by a non-liver-related disorder or explained by a stable chronic liver disorder), and total bilirubin ≤ 1.5 x ULN (except when due to Gilbert's syndrome or a non-liver-related disorder).

[0110] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), the BTK inhibitor being used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of performing a liver function test in the patient, detecting appropriate liver function, and administering a therapeutically acceptable amount of the compound to the patient. In some embodiments, the liver function test measures one or more of the following levels in the patient's blood: aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, alkaline phosphatase, total and direct bilirubin, and total protein. In some embodiments, patients with adequate liver function have one or more of: ALT levels ≤ 1.5 x upper limit of normal (ULN), AST levels ≤ 1.5 x ULN, and alkaline phosphatase ≤ 2 x ULN (unless caused by a non-liver related disorder or explained by a stable chronic liver disorder), and total bilirubin ≤ 1.5 x ULN (unless due to Gilbert's syndrome or a non-liver related disorder).

[0111] In some embodiments, liver function tests are performed at least about every 6 months, at least about every 5 months, at least about every 4 months, at least about every 3 months, at least about every 2 months, or at least about every month. In some embodiments, liver function tests are performed at least about every 12 weeks, at least about every 11 weeks, at least about every 10 weeks, at least about every 9 weeks, at least about every 8 weeks, at least about every 7 weeks, at least about every 6 weeks, at least about every 5 weeks, at least about every 4 weeks, at least about every 3 weeks, at least about every 2 weeks, or at least about every week.

[0112] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT level >8x upper limit of normal (ULN) detected; d) ceasing administration of the compound to the patient; and optionally e) monitoring ALT levels in said patient; and f) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0113] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), wherein the BTK inhibitor is used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the following steps: a) administering a therapeutically effective amount of a compound to a patient in need thereof; b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT level >8x upper limit of normal (ULN) detected; d) ceasing administration of the compound to the patient; and optionally e) monitoring ALT levels in said patient; and f) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0114] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT levels >5x the upper limit of normal (ULN) detected during a period of at least two weeks; d) ceasing administration of the compound to the patient; and optionally e) monitoring ALT levels in said patient; and f) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0115] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), wherein the BTK inhibitor is used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the following steps: a) administering a therapeutically effective amount of a compound to a patient in need thereof; b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT levels >5x the upper limit of normal (ULN) detected during a period of at least two weeks; d) ceasing administration of the compound to the patient; and optionally e) monitoring ALT levels in said patient; and f) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0116] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT level >3x upper limit of normal (ULN) detected; d) measuring one or more of total bilirubin and international normalized ratio (INR) in the patient; e) One or more of total bilirubin >2x ULN and INR >1.5 was detected; f) ceasing administration of said compound to said patient; and optionally g) monitoring ALT levels in said patient; and h) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0117] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), wherein the BTK inhibitor is used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the following steps: a) administering a therapeutically effective amount of a compound to a patient in need thereof; b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT level >3x upper limit of normal (ULN) detected; d) measuring one or more of total bilirubin and international normalized ratio (INR) in the patient; e) One or more of total bilirubin >2x ULN and INR >1.5 was detected; f) ceasing administration of said compound to said patient; and optionally g) monitoring ALT levels in said patient; and h) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0118] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of: a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT level >3x upper limit of normal (ULN) detected; d) discontinuing administration of the compound to the patient if the patient experiences one or more of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, and eosinophilia >5%; and optionally e) monitoring ALT levels in said patient; and f) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0119] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), wherein the BTK inhibitor is used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the following steps: a) administering a therapeutically effective amount of a compound to a patient in need thereof; b) measuring alanine aminotransferase (ALT) levels in the patient; c) ALT level >3x upper limit of normal (ULN) detected; d) discontinuing administration of the compound to the patient if the patient experiences one or more of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, and eosinophilia >5%; and optionally e) monitoring ALT levels in said patient; and f) resuming administration of the therapeutically effective amount of the compound to the patient when the patient's ALT level is determined to be <1.5 x ULN.

[0120] In some embodiments, the ALT level in a patient is measured at least about every 6 months, at least about every 5 months, at least about every 4 months, at least about every 3 months, at least about every 2 months, or at least about every month. In some embodiments, the ALT level in a patient is measured at least about every 12 weeks, at least about every 11 weeks, at least about every 10 weeks, at least about every 9 weeks, at least about every 8 weeks, at least about every 7 weeks, at least about every 6 weeks, at least about every 5 weeks, at least about every 4 weeks, at least about every 3 weeks, at least about every 2 weeks, or at least about every week.

[0121] In some embodiments, ALT levels are monitored in the patient about every 2 to 3 days, about every 3 days, about every 2 days, or about every day after discontinuation of administration of the compound.

[0122] In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising administering to a patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the patient is not receiving a strong or moderate inducer of cytochrome P450 3A (CYP3A) or a strong inhibitor of the CYP2C8 liver enzyme. In some embodiments, the strong CYP3A inducer is selected from rifampicin, carbamazepine, phenobarbital, St. John's wort extract, avasimibe, lumacato, rifapentine, rifabutin, and phenytoin. In some embodiments, the moderate CYP3A inducer is selected from the group consisting of semacidin, anaprevir, belavuvir, daclatasvir, phenbarate, nafcillin, lecithin, modafinil, bosentan, terostat ethyl, thioridazine, alagrogol sodium, and rifabutin. In some embodiments, the strong CYP2C8 inhibitor is selected from the group consisting of gemfibrozil and clopidogrel.

[0123] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), the BTK inhibitor being used in the treatment of relapsing multiple sclerosis (RMS), the method comprising administering a therapeutically acceptable amount of the compound to a patient, wherein the patient is not receiving a strong and moderate inducer of cytochrome P450 3A (CYP3A) or a strong inhibitor of the CYP2C8 liver enzyme. In some embodiments, the strong CYP3A inducer is selected from rifampicin, carbamazepine, phenobarbital, St. John's wort extract, avasimib, lumacato, rifapentine, rifabutin, and phenytoin. In some embodiments, the moderate CYP3A inducer is selected from the group consisting of semacidin, anaprevir, belavuvir, daclatasvir, phenbarate, nafcillin, lecithin, modafinil, bosentan, terostat ethyl, thioridazine, alagrogol sodium, and rifabutin. In some embodiments, the strong CYP2C8 inhibitor is selected from the group consisting of gemfibrozil and clopidogrel.

[0124] In some embodiments, a method for treating relapsing multiple sclerosis (RMS) is provided, comprising the steps of advising the patient to limit alcohol consumption during treatment and administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the patient is female and is advised to limit alcohol consumption to 1 drink or less per day. In some embodiments, 1 drink is approximately 14 grams of alcohol (e.g., 350 mL of beer, 140 mL of wine, or 40 mL of liquor). In some embodiments, the patient is male and is advised to limit alcohol consumption to 2 drinks or less per day. In some embodiments, 2 drinks are approximately 28 grams of alcohol.

[0125] In some embodiments, the present application provides a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound), the BTK inhibitor being used in a method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of advising the patient to limit alcohol consumption during treatment and administering to the patient a therapeutically acceptable amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, the patient is female and is advised to limit alcohol consumption to 1 unit of alcohol per day or less. In some embodiments, 1 unit of alcohol is approximately 14 grams of alcohol (e.g., 350 mL of beer, 140 mL of wine, or 40 mL of liquor). In some embodiments, the patient is male and is advised to limit alcohol consumption to 2 drinks per day or less. In some embodiments, 2 drinks are approximately 28 grams of alcohol.

[0126] The selection of formulation depends on various factors, such as the mode of drug administration (e.g., for oral administration, formulations in the form of tablets, pills, or capsules are preferred) and the bioavailability of the drug substance. Recently, based on the principle that bioavailability can be increased by increasing surface area (i.e., reducing particle size), pharmaceutical formulations specifically for drugs showing poor bioavailability have been developed. For example, U.S. Patent No. 4,107,288 describes a pharmaceutical formulation having a particle size within the range of 10 to 1,000 nm, wherein the active material is loaded on a cross-linked matrix of macromolecules. U.S. Patent No. 5,145,684 describes the production of a pharmaceutical formulation, wherein in the presence of a surface modifier, the drug substance is crushed into nanoparticles (average particle size of 400 nm) and then dispersed in a liquid medium to obtain a pharmaceutical formulation showing significantly high bioavailability. The bioavailability of drugs decomposed at gastric pH can be increased by administering such drugs with formulations that release the drug in the duodenum.

[0127] The composition is generally composed of a BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof in combination with a pharmaceutically acceptable excipient (e.g., a binder, a surfactant, a diluent, a buffer, an anti-adhesive agent, a glidant, a hydrophilic or hydrophobic polymer, a retardant, a stabilizing agent or stabilizer, a disintegrant or superdisintegrant, an antioxidant, an antifoaming agent, a filler, a flavoring agent, a pigment, a lubricant, an adsorbent, a preservative, a plasticizer or a sweetener, or a mixture thereof) that facilitates processing the BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof into a pharmaceutically acceptable formulation. Any well-known techniques and excipients can be used as understood and appropriate in the art, see, for example, Remington: The Science and Practice of Pharmacy, Twenty-first Edition, (Pharmaceutical Press, 2005); Liberman, HA, Lachman, L. and Schwartz, JB, eds., Pharmaceutical Dosage Forms, Vols. 1-2 Taylor & Francis 1990; and RI Mahato, Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, Second Edition (Taylor & Francis, 2012).

[0128] In certain embodiments, the formulation may include one or more pH adjusters or buffers, for example: acids such as acetic acid, boric acid, citric acid, fumaric acid, maleic acid, tartaric acid, malic acid, lactic acid, phosphoric acid, and hydrochloric acid; bases such as sodium hydroxide, sodium phosphate, sodium borate, sodium citrate, sodium acetate, sodium lactate, and tris; and buffers such as citrate / dextrose, sodium bicarbonate, ammonium chloride, and the like. Such buffers used as bases may have counterions other than sodium, such as potassium, magnesium, calcium, ammonium, or other counterions. Such acids, bases, and buffers are included in amounts necessary to maintain the pH of the composition within an acceptable range.

[0129] In certain embodiments, the formulation may also include one or more salts in an amount required to bring the osmolality of the composition into an acceptable range. Such salts include those having sodium, potassium, or ammonium cations and chloride, citrate, ascorbate, borate, phosphate, bicarbonate, sulfate, thiosulfate, or bisulfite anions; suitable salts include sodium chloride, potassium chloride, sodium thiosulfate, sodium bisulfite, and ammonium sulfate.

[0130] In certain embodiments, the formulation may also include one or more defoaming agents to reduce foaming during processing that may cause coagulation of the aqueous dispersion, the appearance of bubbles in the finished film, or generally impair processing. Exemplary defoaming agents include silicone emulsions or sorbitan sesquioleate.

[0131] In certain embodiments, the formulation may also include one or more antioxidants, such as non-thiol antioxidants, for example, butylated hydroxytoluene (BHT), sodium ascorbate, ascorbic acid or its derivatives, and tocopherol or its derivatives. In certain embodiments, antioxidants enhance chemical stability when needed. Other agents such as citric acid or citrate or EDTA may also be added to slow oxidation.

[0132] In certain embodiments, the formulation may also include one or more preservatives to inhibit microbial activity. Suitable preservatives include mercury-containing substances such as merfen and thimerosal; stabilized chlorine dioxide; and quaternary ammonium compounds such as benzalkonium chloride, cetyltrimethylammonium bromide, and cetylpyridinium chloride.

[0133] In certain embodiments, the formulation may also include one or more binders. Binders impart cohesiveness and include, for example, alginic acid and its salts; cellulose derivatives such as carboxymethyl cellulose, methyl cellulose (e.g., ), hydroxypropyl methylcellulose, hydroxyethyl cellulose, hydroxypropyl cellulose (e.g., ), ethyl cellulose (e.g., ) and microcrystalline cellulose (e.g., ); microcrystalline dextrose; amylose; magnesium aluminum silicate; polysaccharide acid; bentonite; gelatin; polyvinyl pyrrolidone / vinyl acetate copolymer; cross-linked polyvinylpyrrolidone; povidone; starch; pregelatinized starch; tragacanth gum; dextrin; sugars such as sucrose (e.g., ), glucose, dextrose, molasses, mannitol, sorbitol, xylitol (e.g., ) and lactose; natural or synthetic gums, such as gum arabic, gum tragacanth, and the mucilage of the bark of the isapol tree; polyvinylpyrrolidone (e.g., CL, CL, XL-10); larch arabinogalactan; Polyethylene glycol; polyethylene oxide; wax; sodium alginate, etc.

[0134] In certain embodiments, the formulation may also include a dispersant and / or viscosity modifier. Dispersants and / or viscosity modifiers include materials that control the diffusion and uniformity of the drug through the liquid medium or granulation method or blending method. In some embodiments, these agents also contribute to the effectiveness of the coating or dissolution matrix. Exemplary diffusion enhancers / dispersants include, for example, hydrophilic polymers, electrolytes, 60 or 80, PEG, polyvinylpyrrolidone (PVP; commercially known as ), and carbohydrate-based dispersants such as hydroxypropyl cellulose (e.g., HPC, H-PC-SL, and HPC-L), hydroxypropyl methylcellulose (e.g., HPMC K100, RPMC K4M, HPMC K15M, and HPMC K100M), sodium carboxymethylcellulose, methylcellulose, hydroxyethyl cellulose, hydroxypropyl cellulose, hydroxypropyl methylcellulose phthalate, hydroxypropyl methylcellulose acetate stearate (HPMCAS), non-crystalline cellulose, polyethylene oxide, magnesium aluminum silicate, triethanolamine, polyvinyl alcohol (PVA), vinylpyrrolidone / vinyl acetate copolymer (S630), 4-(1,1,3,3-tetramethylbutyl)-phenol polymer with ethylene oxide and formaldehyde (also known as tyloxapol), poloxamers (e.g., Pluronic and 8, which is a block copolymer of ethylene oxide and propylene oxide), and poloxamines (e.g., Tetronic Also known as Poloxamine which is a tetrafunctional block copolymer derived from the sequential addition of propylene oxide and ethylene oxide to ethylenediamine (BASF Corporation, Parsippany, NJ), polyvinyl pyrrolidone K12, polyvinyl pyrrolidone K17, polyvinyl pyrrolidone K25, or polyvinyl pyrrolidone K30, polyvinyl pyrrolidone / vinyl acetate copolymer (S-630), polyethylene glycol (e.g., the polyethylene glycol can have a molecular weight of about 300 to about 6000, or about 3350 to about 4000, or about 7000 to 5400), sodium carboxymethyl cellulose, methyl cellulose, polysorbate 80, sodium alginate, gums (e.g., gum tragacanth and gum arabic), guar gum, xanthan gum (including xanthan gum gum), sugars, cellulose (e.g., sodium carboxymethylcellulose, methylcellulose, sodium carboxymethylcellulose), polysorbate 80, sodium alginate, polyethoxylated sorbitan monolaurate, polyethoxylated sorbitan monolaurate, povidone, carbomer, polyvinyl alcohol (PVA), alginates, chitosan, and combinations thereof. Plasticizers such as cellulose or triethylcellulose may also be used as dispersants. Dispersants particularly useful for liposomal dispersions and self-emulsifying dispersions are dimyristoylphosphatidylcholine, natural phosphatidylcholine from egg, natural phosphatidylglycerol from egg, cholesterol, and isopropyl myristate. Typically, a binder content of about 10% to about 70% is used in powder-filled gelatin capsule formulations. The amount of binder used in tablet formulations varies, whether direct compression, wet granulation, roller compaction, or the use of other excipients (e.g., fillers, which themselves can act as moderate binders). The formulator skilled in the art can determine the binder content of the formulation, but binder levels of up to 90%, more typically up to 70%, are common in tablet formulations.

[0135] In certain embodiments, the formulation may also include one or more diluents, which refers to chemical compounds used to dilute the compound of interest prior to delivery. Diluents can also be used to stabilize the compound because they can provide a more stable environment. Salts dissolved in buffered solutions (which can also provide pH control or maintenance) are used as diluents in the art, including but not limited to phosphate buffered saline solutions. In certain embodiments, the diluent increases the volume of the composition to aid compression or to create enough homogenous blend volume for capsule filling. Such compounds include, for example: lactose; starch; mannitol; sorbitol; dextrose; microcrystalline cellulose, such as Calcium dihydrogen phosphate; dicalcium hydrogen phosphate dihydrate; tricalcium phosphate; calcium phosphate; anhydrous lactose; spray-dried lactose; pregelatinized starch; compressible sugars, such as (Amstar); hydroxypropyl methylcellulose; hydroxypropyl methylcellulose acetate stearate; sucrose-based diluents; confectioners' sugar; calcium hydrogen sulfate monohydrate; calcium sulfate dihydrate; calcium lactate trihydrate; dextrates; hydrolyzed cereal solids; amylose; powdered cellulose; calcium carbonate; glycine; kaolin; mannitol; sodium chloride; inositol; bentonite, etc.

[0136] In certain embodiments, the formulation may also include one or more disintegrants, which include dissolution and dispersion of the dosage form upon contact with gastrointestinal fluids. A disintegration agent or disintegrant aids in the breakdown or disintegration of a substance. Examples of disintegrants include starches, for example, natural starches (such as corn starch or potato starch), pregelatinized starches (such as National 1551), or sodium starch glycolate (such as or ); cellulose, such as wood products, methyl crystalline cellulose (e.g., PH101, PH 102, PH105, P100, and ), methylcellulose, cross-linked carboxymethylcellulose or cross-linked cellulose (such as cross-linked carboxymethylcellulose sodium Cross-linked carboxymethyl cellulose or cross-linked carboxymethyl cellulose); cross-linked starch (such as sodium starch glycolate); cross-linked polymers such as cross-linked polyvinyl pyrrolidone; alginates such as alginic acid or salts of alginic acid such as sodium alginate; clays such as HV (magnesium aluminum silicate); gums such as agar, guar gum, locust bean gum, karaya gum, pectin, or tragacanth gum; sodium starch glycolate; bentonite; natural sponge; surfactants; resins such as cation exchange resins; citrus pulp; sodium lauryl sulfate; a combination of sodium lauryl sulfate and starch, etc.

[0137] In certain embodiments, the formulation may further include an erosion promoter. Erosion promoters include materials that control the erosion of a particular material in gastrointestinal fluids. Erosion promoters are generally known to those skilled in the art. Exemplary erosion promoters include, for example, hydrophilic polymers, electrolytes, proteins, peptides, and amino acids.

[0138] In certain embodiments, the formulation may further include one or more fillers, including compounds such as lactose, calcium carbonate, calcium phosphate, monocalcium phosphate, calcium sulfate, microcrystalline cellulose, cellulose powder, dextrose, dextrates, dextran, starch, pregelatinized starch, sucrose, xylitol, lactitol, mannitol, sorbitol, sodium chloride, polyethylene glycol, and the like.

[0139] In certain embodiments, the formulations may further include one or more flavoring agents and / or sweeteners, such as acacia syrup, acesulfame K, alitame, anise, apple, aspartame, banana, Bavarian cream berry, black currant, butterscotch, calcium citrate, camphor, caramel, cherry, cherry cream chocolate, cinnamon, bubble gum, citrus, citrus punch, citrus cream, cotton candy, cocoa, cola, cool cherry, cool citrus, cyclamate, cyclamate, dextrose, eucalyptus, eugenol, fructose, fruit punch, ginger, glycyrrhizate, glycyrrhiza / licorice syrup, grape, grapefruit, honey, isomalt, lemon, lime, lemon cream, monoammonium glycyrrhizate, maltol, mannitol, maple, marshmallow, menthol, mint cream, Cream), Mixed Berries, Neohesperidin DC, Neotame, Orange, Pear, Peach, Peppermint, Peppermint Cream, Powder, Raspberry, Root Beer, Rum, Saccharin, Safrole, Sorbitol, Spearmint, Spearmint Cream, Strawberry, Strawberry Cream, Stevia, Sucralose, Sucrose, Sodium Saccharin, Saccharin, Aspartame, Acesulfame Potassium, Mannitol, Talin, Xylitol, Sucralose, Sorbitol, Swiss Cream, Tagatose, Tangerine, Thaumatin, Tutti The present invention also provides flavoring ingredients such as anise-menthol, cherry-anise, cinnamon-orange, cherry-cinnamon, chocolate-mint, honey-lemon, lemon-lime, lemon-mint, menthol-eucalyptus, orange-cream, vanilla-mint, and mixtures thereof.

[0140] In certain embodiments, the formulation may also include one or more lubricants and glidants, which are compounds that prevent, reduce, or inhibit adhesion or friction of the material. Exemplary lubricants include, for example, stearic acid, calcium hydroxide, talc, sodium stearyl lumerate, hydrocarbons (such as mineral oil), or hydrogenated vegetable oils (such as hydrogenated soybean oil), higher fatty acids and alkali metal and alkaline earth metal salts thereof (such as aluminum, calcium, magnesium, zinc), stearic acid, sodium stearate, glycerol, talc, wax, boric acid, sodium benzoate, sodium acetate, sodium chloride, leucine, polyethylene glycol (e.g., PEG4000) or methoxy polyethylene glycol (e.g., ), sodium oleate, sodium benzoate, glyceryl behenate, polyethylene glycol, magnesium lauryl sulfate or sodium lauryl sulfate, colloidal silicon dioxide (such as ), starch (such as corn starch), silicone oil, surfactants, etc.

[0141] In some embodiments, preparation can also include one or more plasticizers, and described plasticizer is for softening enteric or delayed release coating so that it is not fragile compound.Suitable plasticizer includes for example polyethylene glycol (as PEG300, PEG 400, PEG 600, PEG 1450, PEG 3350 and PEG 800), stearic acid, propylene glycol, oleic acid, triethyl citrate, dibutyl sebacate, triethyl cellulose and triacetin.In some embodiments, plasticizer also can play the effect of dispersant or wetting agent.

[0142] In certain embodiments, the formulation may further include one or more solubilizing agents, such as triacetin, triethyl citrate, ethyl oleate, ethyl caprylate, sodium lauryl sulfate, docusate sodium, vitamin E TPGS, dimethylacetamide, N-methylpyrrolidone, N-hydroxyethylpyrrolidone, polyvinylpyrrolidone, hydroxypropyl methylcellulose, hydroxypropyl cyclodextrin (e.g., ), ethanol, n-butanol, isopropanol, cholesterol, bile salts, polyethylene glycol 200-600, tetrahydrofuran glycol ether, diethylene glycol monoethyl ether, propylene glycol and isosorbide dimethyl ether and the like. In one embodiment, the solubilizing agent is vitamin E TPGS and / or or β-hydroxypropyl cyclodextrin.

[0143] In certain embodiments, the formulation may further include one or more suspending agents, including, for example, polyvinyl pyrrolidone (e.g., polyvinyl pyrrolidone K112, polyvinyl pyrrolidone K17, polyvinyl pyrrolidone K25, or polyvinyl pyrrolidone K30), vinyl pyrrolidone / vinyl acetate copolymer (S630), polyethylene glycol (e.g., the polyethylene glycol may have a molecular weight of about 300 to about 6000, or about 3350 to about 4000, or about 7000 to about 5400), sodium carboxymethyl cellulose, methyl cellulose, hydroxypropyl methyl cellulose, hydroxymethyl cellulose acetate stearate, polysorbate 80, hydroxyethyl cellulose, sodium alginate, gums (e.g., gum tragacanth and gum arabic), guar gum, xanthan gum (including xanthan gum), guar gum, and xanthan gum. gum), sugars, cellulose (e.g., sodium carboxymethylcellulose, methylcellulose, sodium carboxymethylcellulose, hydroxypropyl methylcellulose, hydroxyethyl cellulose), polysorbate 80, sodium alginate, polyethoxylated sorbitan monolaurate, polyethoxylated sorbitan monooleate, povidone and the like compounds.

[0144] In certain embodiments, the formulation may further include one or more surfactants, including surfactants such as sodium lauryl sulfate, sodium docusate, Tween 20, Tween 60, or Tween 80, triacetin, vitamin E TPGS, sorbitan monooleate, polyoxyethylene sorbitan monooleate, polyoxyethylene sorbitan monolaurate, polysorbates, poloxamers, bile salts, glyceryl monostearate, copolymers of ethylene oxide and propylene oxide (e.g., (BASF) and other compounds. Some other surfactants include polyoxyethylene fatty acid glycerides and vegetable oils (e.g., polyoxyethylene (60) hydrogenated castor oil) and polyoxyethylene alkyl ethers and alkylphenyl ethers (e.g., octoxynol 10, octoxynol 40). In some embodiments, surfactants can be included to enhance physical stability or for other purposes.

[0145] In certain embodiments, the formulation may further include one or more viscosity enhancers including, for example, methylcellulose, xanthan gum, carboxymethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, hydroxypropylmethylcellulose acetate stearate, hydroxypropylmethylcellulose phthalate, carbomer, polyvinyl alginate, gum arabic, chitosan, and combinations thereof.

[0146] In certain embodiments, the formulation may further include one or more wetting agents, including compounds such as oleic acid, glyceryl monostearate, sorbitan monooleate, sorbitan monolaurate, triethanolamine oleate, polyoxyethylene sorbitan monooleate, polyoxyethylene sorbitan monolaurate, docusate sodium, sodium oleate, sodium lauryl sulfate, docusate sodium, triacetin, Tween 80, vitamin E TPGS, ammonium salts, and the like.

[0147] The pharmaceutical preparations disclosed herein can be obtained by mixing one or more solid excipients (such as carriers, binders, fillers, suspending agents, flavoring agents, sweeteners, disintegrants, dispersants, surfactants, lubricants, colorants, diluents, solubilizers, wetting agents, plasticizers, stabilizers, penetration enhancers, wetting agents, defoaming agents, antioxidants, preservatives, or one or more combinations thereof) with one or more compounds described herein, optionally grinding the resulting mixture, and processing the granule mixture after adding suitable excipients (if necessary) to obtain tablets.

[0148] Pharmaceutical preparations disclosed in the present application also include capsules made of gelatin and soft sealed capsules made of gelatin and plasticizers (such as glycerol or sorbitol).Capsules can also be made of polymers (such as hypromellose).Capsules can contain a mixture of active ingredients and fillers (such as lactose), adhesives (such as starch) and / or lubricants (such as talc or magnesium stearate) and optional stabilizers.In soft capsules, active compounds can be dissolved or suspended in suitable liquids (such as fatty oils, liquid paraffin, lipids, solubilizers or liquid polyethylene glycol).In addition, stabilizers can be added.The dosage of all preparations for oral administration should all be applicable to this administration.

[0149] These formulations can be manufactured by conventional pharmacological techniques. Conventional pharmacological techniques include, for example, one or a combination of the following methods: (1) dry blending, (2) direct compression, (3) milling, (4) dry or non-aqueous granulation, (5) wet granulation, (6) fusion, or (7) extrusion. See, for example, Lachman et al., The Theory and Practice of Industrial Pharmacy, 3rd edition (1986). Other methods include, for example, spray drying, pan coating, melt granulation, granulation, fluidized bed spray drying or coating (e.g., wurster coating), tangential coating, top spraying, tableting, extrusion, extrusion / spheronization, etc.

[0150] It should be understood that there is considerable overlap between the excipients used in the solid dosage forms described herein. Therefore, the additives listed above should be considered as merely exemplary, non-restrictive, types of excipients that may be included in the solid dosage forms described herein. The type and amount of such excipients can be easily determined by those skilled in the art according to the desired specific characteristics.

[0151] In some embodiments, solid dosage form described herein is an enteric coated oral dosage form, i.e., as an oral dosage form of pharmaceutical composition as described herein, which utilizes enteric coating to affect the release of compound in the intestine of the gastrointestinal tract." enteric coating " medicine and / or tablet refer to medicine and / or tablet that are kept intact in the stomach but once arrive in the intestine (small intestine in one embodiment) and just dissolve and release the material coating of medicine. As used in this application, "enteric coating " is as dosage form or as the material of particle package therapeutic active agent core, such as one or more polymeric materials. Typically, before therapeutic active agent is released from dosage form, significant amount or all enteric coating materials are dissolved, thereby realizing the delayed dissolution of therapeutic active agent core or particles in the small intestine and / or large intestine. Enteric coatings are discussed, for example, in Loyd, V. Allen, Remington: The Science and Practice of Pharmacy, Twenty-first Edition, (Pharmaceutical Press, 2005; and PJ Tarcha, Polymers for Controlled Drug Delivery, Chapter 3, CRC Press, 1991. Methods for applying enteric coatings to pharmaceutical compositions are well known in the art and include, for example, U.S. Patent Publication No. 2006 / 0045822.

[0152] Enteric coated dosage forms can be compressed or molded or extruded tablets (coated or uncoated) containing granules, powders, pellets, beads or particles of a BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof and / or other excipients, which themselves are coated or uncoated, provided that at least the tablet or the BTK inhibitor compound is coated. Enteric coated oral dosage forms can also be capsules (coated or uncoated) containing pellets, beads or granules of a BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof and / or other excipients, which themselves are coated or uncoated, provided that at least one of them is coated. Some examples of coatings originally used as enteric coatings are beeswax and glyceryl monostearate; beeswax, shellac and cellulose; and cetyl alcohol, frankincense and shellac and shellac and stearic acid (U.S. Patent No. 2,809,918); polyvinyl acetate and ethylcellulose (U.S. Patent No. 3,835,221). More recently, coatings used have been neutral copolymers of polymethacrylates (Eudragit L30D) (FW Goodhart et al., Pharm. Tech., pp. 64-71, April 1984); copolymers of methacrylic acid and methyl methacrylate (Eudragit S), or neutral copolymers of polymethacrylates containing metal stearates (U.S. Pat. Nos. 4,728,512 and 4,794,001 to Mehta et al.); cellulose acetate succinate and hypromellose phthalate.

[0153] In the methods and compositions described herein, any anionic polymer that exhibits a pH-dependent solubility profile can be used as an enteric coating to achieve intestinal delivery. In one embodiment, delivery can be to the small intestine. In another embodiment, delivery can be to the duodenum. In some embodiments, the polymers described herein are anionic carboxylic acid polymers. In other embodiments, the polymers and compatible mixtures thereof, and some of their properties include, but are not limited to:

[0154] Shellac: Also known as purified lac, it is a refined product obtained from the resinous secretions of insects. This coating dissolves in media with a pH > 7;

[0155] Acrylic polymers: The properties of acrylic polymers (primarily their solubility in biological fluids) can vary depending on the degree and type of substitution. Examples of suitable acrylic polymers include methacrylic acid copolymers and ammonium methacrylate copolymers. Eudragit series L, S and RS (manufactured by Rohm Pharma and known as ) are available as dissolved in organic solvents, aqueous dispersions, or dry powders. Eudragit series RL, NE, and RS are insoluble in the gastrointestinal tract, but permeable, and are primarily used for colon targeting. Eudragit series L, L-30D, and S are insoluble in the stomach, soluble in the intestine, and can be selected and formulated to dissolve at pH values greater than 5.5, as low as greater than 5, or as high as greater than 7;

[0156] Cellulose derivatives: Examples of suitable cellulose derivatives are: ethyl cellulose; reaction mixtures of cellulose acetate esters with phthalic anhydride. The properties may vary depending on the degree and type of substitution. Cellulose acetate phthalate (CAP) dissolves at pH > 6. Aquateric (FMC) is a water-based system and is a spray-dried CAP pseudolatex with particles < 1 μm. Other components in Aquateric may include pluronic, Tween, and acetylated monoglycerides. Other suitable cellulose derivatives include cellulose acetate tritnellitate (Eastman); methylcellulose (Pharmacoat, Methocel); hydroxypropyl methylcellulose phthalate (HPMCP); hydroxypropyl methylcellulose succinate (HPMCS); and hydroxypropyl methylcellulose acetate succinate (HPMCAS, such as AQOAT (Shin Etsu)). The properties may vary depending on the degree and type of substitution. For example, HPMCP grades such as HP-50, HP-55, HP-55S, and HP-55F are suitable. The properties may vary depending on the degree and type of substitution. For example, suitable grades of hydroxypropylmethylcellulose acetate succinate include, but are not limited to, AS-LG (LF), which dissolves at pH 5, AS-MG (MF), which dissolves at pH 5.5, and AS-HG (HF), which dissolves at higher pH. These polymers are provided as granules or as a fine powder for aqueous dispersion;

[0157] Polyvinyl acetate phthalate (PVAP): PVAP dissolves at pH > 5 and is much less permeable to water vapor and gastric fluid. A detailed description of these polymers and their pH-dependent solubility can be found in the article by Professors Karl Thoma and Karoline Bechtold, entitled "Enteric coated hard gelatin capsules," available at http: / / pop.www.capsugel.com / media / library / enteric-coated-hard-gelatin-capsules.pdf. In some embodiments, the coating can and typically does contain a plasticizer and possibly other coating excipients, such as a colorant, talc, and / or magnesium stearate, as are well known in the art. Suitable plasticizers include triethyl citrate (Citroflex 2), triacetin (glycerol triacetate), acetyl triethyl citrate (Citroflec A2), Carbowax 400 (polyethylene glycol 400), diethyl phthalate, tributyl citrate, acetylated monoglycerides, glycerol, fatty acid esters, propylene glycol, and dibutyl phthalate. Specifically, anionic carboxylic acid acrylic polymers typically contain 10% to 25% by weight of plasticizers, especially dibutyl phthalate, polyethylene glycol, triethyl citrate, and triacetin. The coating is applied using conventional coating techniques (e.g., fluidized bed or Wurster coaters, or spray coating or pan coating). The coating thickness must be sufficient to ensure that the oral dosage form remains intact until it reaches the desired local delivery site in the intestinal tract.

[0158] In addition to plasticizers, colorants, surfactants, anti-sticking agents, defoaming agents, lubricants (e.g., carnauba wax or PEG), and other additives can be added to the coating to dissolve or disperse the coating material and improve coating properties and the coated product.

[0159] To accelerate the dissolution of the enteric coating, a half-thick double layer of an enteric polymer (e.g., Eudragit L30 D-55) can be applied, and the inner enteric coating can be buffered up to pH 6.0 in the presence of 10% citric acid, followed by a final layer of standard Eudragit L 30 D-55. Liu and Basit applied two layers of enteric coating (each half the thickness of a typical enteric coating) and were able to accelerate the dissolution of the enteric coating compared to a similar coating system applied as a single layer without buffering (Liu, F. and Basit, A. Journal of Controlled Release. 147 (2010) 242-245).

[0160] The integrity of the enteric coating can be measured, for example, by degradation of the drug within the pellets. As described in the USP, enteric coated dosage forms or pellets can be tested in dissolution tests first in gastric fluid and then separately in intestinal fluid to determine their functionality.

[0161] Enteric coated tablets and capsule formulations containing the disclosed compounds can be prepared by methods known in the art. For example, tablets containing the compounds disclosed herein can be coated using a side vented coating pan (Freund Hi-Coater) with a coating containing Enteric coating is performed with a coating solution of diethyl phthalate, isopropyl alcohol, talc and water.

[0162] Alternatively, multiple unit dosage forms comprising enteric-coated pellets that can be incorporated into tablets or capsules can be prepared as follows.

[0163] Core material: The core material of the enteric coating layered pellets can be composed according to different principles. The seeds layered with an active agent (i.e., a BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof) optionally mixed with an alkaline substance or a buffer can be used as the core material for further processing. The seeds layered with the active agent can be water-insoluble seeds comprising different oxides, cellulose, organic polymers and other materials alone or in a mixture, or water-soluble seeds comprising different inorganic salts, sugar, sucrose pellets (non-pareil) and other materials alone or in a mixture. In addition, the seeds can include active agents in the form of crystals, agglomerates, briquette, etc. The size of the seeds is not critical for this application, but can vary between approximately 0.1 and 2 mm. The seeds layered with the active agent are produced by layering with a powder or solution / suspension using, for example, granulation or spraying layering equipment.

[0164] Before seed layering, activating agent can be mixed with other components.This type of component can be binding agent, surfactant, filler, disintegrant, alkaline additive or other compositions or pharmaceutically acceptable composition separately or in mixture form.Binder is for example polymer such as hydroxypropyl methylcellulose (HPMC), hydroxypropyl cellulose (HPC), sodium carboxymethyl cellulose, polyvinylpyrrolidone (PVP), or sugar, starch or other pharmaceutically acceptable substances with cohesive properties.Suitable surfactant is found in lower group: pharmaceutically acceptable nonionic or ionic surfactant, for example sodium lauryl sulfate.

[0165] Alternatively, the activating agent optionally mixed with the appropriate ingredients can be mixed with core material. Said core material can utilize conventional processing equipment to produce by extruding / spheronization, spheronization or compression. The size of the prepared core material is between about 0.1 and 4mm, and for example between 0.1 and 2mm. The core material manufactured can be further layered with the other composition that comprises the activating agent, and / or can be used for further processing.

[0166] The active agent is mixed with the pharmaceutical ingredients to obtain preferred handling and processing characteristics and the appropriate concentration of the active agent in the final formulation. Pharmaceutical ingredients such as fillers, binders, lubricants, disintegrants, surfactants and other pharmaceutically acceptable additives may be used.

[0167] Alternatively, the aforementioned core material may be prepared by using spray drying or spray congealing techniques.

[0168] Enteric coating layer(s): Before applying the enteric coating layer(s) to the core material as individual pellets, the pellets may optionally be coated with one or more separating layers comprising pharmaceutical excipients, optionally including alkaline compounds such as pH buffering compounds. This separating layer(s) separates the core material from the outer layer(s) serving as the enteric coating layer(s). The separating layer(s) protecting the core material of the active agent should be water-soluble or rapidly disintegrate in water.

[0169] Can optionally by coating or layering process in suitable equipment (as coating pan, coating granulator) or in the fluidized bed instrument that uses water and / or organic solvent for coating process, one and / or multiple separating layers are applied to core material.As an alternative, can by using powder coating technology, described one or more separating layers are applied to core material.The material that is used for separating layer is pharmaceutically acceptable compound that uses separately or in mixture form, for example sugar, Polyethylene Glycol, Polyvinyl Pyrrolidone, Polyvinyl Alcohol, Polyvinyl Acetate, hydroxypropyl cellulose, methylcellulose, ethylcellulose, hydroxypropyl methylcellulose, sodium carboxymethyl cellulose, enteric coating polymer water-soluble salt etc.Additive (as plasticizer, coloring agent, pigment, filler, antitack agent and antistatic agent, for example magnesium stearate, titanium dioxide, talcum and other additives) also can be included in described one or more separating layers.

[0170] When an optional separating layer is applied to the core material, it can constitute a variable thickness. The maximum thickness of the one or more separating layers is usually only limited by processing conditions. The separating layer can be used as a diffusion barrier and can be used as a pH buffer. The one or more separating layers optionally applied are not critical for the embodiments of the present application. However, the one or more separating layers can improve the chemical stability of the active substance and / or the physical properties of the novel multiple unit tablet dosage form.

[0171] Alternatively, the separating layer may be formed in situ by a reaction between an enteric coating polymer layer applied to the core material and an alkaline reacting compound in the core material. Thus, the separating layer formed comprises a water-soluble salt formed between the one or more enteric coating layer polymers and the alkaline reacting compound in a position to form the salt.

[0172] In some embodiments, the enteric coating layer can be applied to the core material or to the core material covered with one or more separating layers.The enteric coating layer material can be dispersed in or dissolved in water or a suitable organic solvent.As the enteric coating layer polymer, one or more of the following can be used alone or in combination, for example, solution or the dispersion of methacrylic acid copolymer, cellulose acetate phthalate, hydroxypropyl methylcellulose phthalate, hydroxypropyl methylcellulose acetate succinate, polyvinyl acetate phthalate, cellulose acetate trimellitate, carboxymethyl ethyl cellulose, shellac or one or more other suitable enteric coating polymers.

[0173] The enteric coating layer contains a pharmaceutically acceptable plasticizer to obtain the desired mechanical properties, such as flexibility and hardness of the enteric coating layer. Such plasticizers are, for example, but not limited to, triacetin, citrate, phthalate, dibutyl sebacate, cetyl alcohol, polyethylene glycol, polysorbate or other plasticizers.

[0174] About the one or more enteric coating polymers selected, the one or more plasticizers selected and the applied amount of the one or more polymers, the amount of plasticizer is optimized in the following manner for each enteric coating formulation, the manner makes it possible to adjust the mechanical properties (i.e., the toughness and hardness of the one or more enteric coating layers, for example, taking Vickers hardness as an example) so that if tablets are required, the acid resistance of the pellets covered with the one or more enteric coating layers will not be significantly reduced during the process of compressing the pellets into tablets. By the weight of the one or more enteric coating polymers, the amount of plasticizer is generally higher than 5%, such as 15%-50%, and further such as 20%-50%. Additives such as dispersants, colorants, pigment polymers such as poly (ethyl acrylate, methyl methacrylate), anti-adhesives and defoamers can also be included in the one or more enteric coating layers. Other compounds can be added to increase film thickness and reduce the diffusion of acidic gastric juice into acid-sensitive materials. The maximum thickness of the enteric coating applied is generally only limited by processing conditions and the desired dissolution curve.

[0175] Outer coating layer: The pellets covered with one or more enteric coating layers may optionally be further covered with one or more over-coating layers. The one or more over-coating layers should be water-soluble or rapidly disintegrate in water. The one and / or more over-coating layers may be applied to the enteric coated pellets by a coating or layering process in a suitable device (such as a coating pan, a coating granulator) or in a fluidized bed apparatus using water or an organic solvent for the coating or layering process. The materials used for the over-coating layer are selected from pharmaceutically acceptable compounds used alone or in mixtures, such as sugars, polyethylene glycol, polyvinyl pyrrolidone, polyvinyl alcohol, polyvinyl acetate, hydroxypropyl cellulose, methyl cellulose, ethyl cellulose, hydroxypropyl methyl cellulose, sodium carboxymethyl cellulose, and the like. Additives (such as plasticizers, colorants, pigments, fillers, anti-adhesives and antistatic agents, such as magnesium stearate, titanium dioxide, talc, and other additives) may also be included in the one or more over-coating layers. The outer coating layer can further prevent the potential agglomeration of the enteric coated layered pellets. It can also protect the enteric coating layer from rupture during the compression process and enhance the tableting process. The maximum thickness of the applied one or more outer coating layers is usually limited by the processing conditions and the desired dissolution profile. The outer coating layer can also be used as a tablet film coating layer.

[0176] Enteric coatings for soft gelatin capsules can contain emulsions, oils, microemulsions, self-emulsifying systems, lipids, triglycerides, polyethylene glycol, surfactants, other solubilizing agents, etc., and combinations thereof, to dissolve active agents. The pliability of soft gelatin capsules is maintained by residual water and plasticizers. In addition, for gelatin capsules, gelatin can be dissolved in water so that spraying must be completed with a speed with relatively low relative humidity, as can be completed in a fluidized bed or Wurster. In addition, drying should be completed without removing residual water or plasticizer, thereby causing the capsule shell to crack. Commercially available blends optimized for enteric coatings for soft gelatin capsules are available, such as Instamodel EPD (enteric polymer dispersions), available from Ideal Cures, Pvt. Ltd. (Mumbai, India). On a laboratory scale, enteric coated capsules can be prepared by a) swirling the capsules in a flask or dipping the capsules into a mildly heated solution of the enteric coating material and plasticizer at the lowest possible temperature, or b) in a laboratory scale sprayer / fluid bed followed by drying.

[0177] For aqueous active agents, it may be particularly desirable to incorporate the drug into the aqueous phase of the emulsion. This "water-in-oil" emulsion provides a suitable biophysical environment for the drug and can provide an oil-water interface that can protect the drug from the adverse effects of pH or enzymes that may degrade the drug. In addition, such water-in-oil formulations can provide a lipid layer that can interact favorably with lipids in body cells and increase the distribution of the formulation to cell membranes. This distribution can increase the absorption of the drug in such formulations into the circulation, thereby increasing the bioavailability of the drug.

[0178] In some embodiments, the water-in-oil emulsion contains: an oil phase composed of a medium-chain or long-chain carboxylic acid or its ester or alcohol, a surfactant (surfactant or surface-active agent), and an aqueous phase mainly containing water and an active agent.

[0179] Medium and long chain carboxylic acids are in the range of C8 to C 22 Those carboxylic acids of the type having up to three unsaturated bonds (also branched). Examples of saturated straight-chain acids are dodecanoic acid, tetradecanoic acid, hexadecanoic acid, caproic acid, caprylic acid, capric acid, lauric acid, myristic acid, palmitic acid, stearic acid, arachidic acid, behenic acid, montanic acid, and melissic acid. Unsaturated monoolefin straight-chain monocarboxylic acids may also be used. Examples of these carboxylic acids are oleic acid, gadoleic acid, and erucic acid. Unsaturated (polyolefin) straight-chain monocarboxylic acids may also be used. Examples of these carboxylic acids are linoleic acid, ricinoleic acid, linolenic acid, arachidonic acid, and docos-13-ynoic acid. Useful branched-chain acids include, for example, diacetyltartaric acid. The unsaturated olefin chains may also be hydroxylated or ethoxylated to prevent oxidation or alter surface properties.

[0180] Examples of long chain carboxylic acid esters include, but are not limited to, those from the group consisting of glyceryl monostearate; glyceryl monopalmitate; a mixture of glyceryl monostearate and glyceryl monopalmitate; glyceryl monolinoleate; glyceryl monooleate; a mixture of glyceryl monopalmitate, glyceryl monostearate, glyceryl monooleate, and glyceryl monolinoleate; glyceryl monolinolenate; glyceryl monocodone; a mixture of glyceryl monopalmitate, glyceryl monostearate, glyceryl monooleate, glyceryl monolinoleate, glyceryl monocodone, and glyceryl monocodone; acetylated glycerides, such as distilled acetylated monoglycerides; propylene glycol monoesters, distilled monoglycerides, sodium steroyl lactylate, mixtures of mono- and diglycerides such as Atmul; calcium stearoyl lactylate; ethoxylated mono- and diglycerides; lactic acid mono- and diglycerides; lactic acid carboxylic acid esters of glycerol and propylene glycol; lactic acid esters of long-chain carboxylic acids; polyglycerol esters of long-chain carboxylic acids; propylene glycol mono- and di-esters of long-chain carboxylic acids; sodium stearoyl lactylate; sorbitan monostearate; sorbitan monooleate; other sorbitan esters of long-chain carboxylic acids; succinylated monoglycerides; stearoyl citrate monoglyceride; stearoyl heptanoate; cetyl esters of waxes; stearoyl caprylate; C8-C 30 Cholesterol / lanosterol esters; and sucrose long chain carboxylates. Examples of self-emulsifying long chain carboxylates include those from the group consisting of stearate, palmitate, ricinoleate, oleate, behenate, ricinolenate, myristate, laurate, caprylate, and caproate. In some embodiments, the oil phase may comprise a combination of two or more long chain carboxylic acids or their esters or alcohols. In some embodiments, a medium chain surfactant may be used, and the oil phase may comprise caprylic / capric triglycerides and caprylic C8 / C8 10 Mono / diglyceride mixtures, glyceryl caprylate or propylene glycol monocaprylate or mixtures thereof.

[0181] Alcohols that can be used are exemplified by the hydroxyl forms of the above-exemplified carboxylic acids and stearyl alcohol.

[0182] Surfactants are long chain molecules that accumulate at hydrophilic / hydrophobic (water / oil) interfaces and reduce the surface tension at the interface. Thus, they can stabilize emulsions. In some embodiments, surfactants can include: (polyoxyethylene sorbate) family of surfactants, (sorbitan long-chain carboxylate) family of surfactants, (ethylene oxide or propylene oxide block copolymer) family of surfactants, and (each a polyglycolyzed glyceride) family of surfactants, sorbitan esters of oleic acid, stearic acid, lauric acid or other long-chain carboxylic acids, poloxamers (polyethylene glycol-polypropylene glycol block copolymers or ), other sorbitan or sucrose long chain carboxylates, mono- and di-glycerides, PEG derivatives of caprylic / capric triglycerides, and mixtures thereof or mixtures of two or more of the above. In some embodiments, the surfactant phase may comprise polyoxyethylene (20) sorbitan monooleate (Tween ) and sorbitan monooleate (Span ).

[0183] The aqueous phase may optionally contain the active agent suspended in water and a buffer.

[0184] In some embodiments, such emulsions are macroemulsions, microemulsions, and liquid crystal emulsions. In other embodiments, such emulsions may optionally contain a penetration enhancer. In other embodiments, spray-dried dispersions or microparticles or nanoparticles containing encapsulated microemulsions, macroemulsions, or liquid crystals may be used.

[0185] In some embodiments, solid dosage form described herein is a non-enteric delayed release dosage form. As used herein, the term "non-enteric delayed release" refers to such delivery that the release of the drug can be completed at a certain usually predictable position in the intestinal tract, further away than the position that would be completed if the release were not delayed. In some embodiments, the method for delayed release is to become permeable, dissolve, rupture and / or no longer complete coating after the designed duration. The coating in the extended-release dosage form can have a fixed dissolution time after which the drug is released (suitable coatings include polymer coatings such as HPMC, PEO, etc.), or have a core composed of one or more superdisintegrants or one or more osmotic agents or water attractants, such as salts, hydrophilic polymers (typically polyethylene oxide or alkylcellulose), salts (such as sodium chloride, magnesium chloride, sodium acetate, sodium citrate), sugars (such as glucose, lactose, or sucrose) that draw water out through a semipermeable membrane, or gas generating agents (such as citric acid and sodium bicarbonate) with or without an acid (such as citric acid or any of the aforementioned acids incorporated into the dosage form). The semipermeable membrane, while largely impermeable to the drug and osmotic agent, is permeable to water, which penetrates the dosage form at a near-constant rate to increase pressure and ruptures after the swelling pressure exceeds a certain threshold for a desired delay time. The permeability of the drug through this membrane should be less than 1 / 10 that of water, and in one embodiment, less than 1 / 100 that of water. Alternatively, the membrane can be made porous by leaching an extractable aqueous solution for a desired delay time.

[0186] Osmotic dosage forms have been described in U.S. Pat. No. 3,760,984 to Theeuwes, and osmotic burst dosage forms are described in U.S. Pat. No. 3,952,741 to Baker. Such osmotic burst dosage forms can provide a single release pulse or multiple release pulses if different devices with different timings are employed. The timing of the osmotic burst can be controlled by selecting the polymer and the thickness or area of the semipermeable membrane surrounding the core containing both the drug and the osmotic agent or attractant. As the pressure in the dosage form increases with the additional osmotic water, the membrane stretches until it breaks, and the drug is then released. Alternatively, specific rupture zones can be created in the membrane by having thinner, weaker areas in the membrane, or by adding weaker materials to areas of the coating membrane. Some preferred polymers with high water permeability that can be used as semipermeable membranes are cellulose acetate, cellulose acetate butyrate, cellulose nitrate, cross-linked polyvinyl alcohol, polyurethane, nylon 6, nylon 6.6, and aromatic nylon. Cellulose acetate is a particularly preferred polymer.

[0187] In another embodiment, the time-delayed coating that begins to delay the release of the drug after the enteric coating is at least partially dissolved is composed of a hydrophilic, erodible polymer that begins to gradually erode over time when in contact with water. Examples of such polymers include cellulosic polymers and their derivatives, including but not limited to hydroxyalkyl cellulose, hydroxymethyl cellulose, hydroxyethyl cellulose, hydroxypropyl cellulose, hydroxypropyl methyl cellulose, carboxymethyl cellulose, microcrystalline cellulose; polysaccharides and their derivatives; polyalkylene oxides, such as polyethylene oxide or polyethylene glycol, particularly high molecular weight polyethylene glycol; chitosan; poly(vinyl alcohol); xanthan gum; maleic anhydride copolymers; poly(vinyl pyrrolidone); starch and starch-based polymers; maltodextrin; poly(2-ethyl-2-oxazoline); poly(ethyleneimine); polyurethanes; hydrogels; cross-linked polyacrylic acids; and combinations or blends of any of the foregoing.

[0188] Some preferred erodible hydrophilic polymers suitable for forming the erodible coating are poly(ethylene oxide), hydroxypropyl methylcellulose, and combinations of poly(ethylene oxide) and hydroxypropyl methylcellulose. Poly(ethylene oxide) is used herein to refer to linear polymers of unsubstituted ethylene oxide. The molecular weight of the poly(ethylene oxide) polymer can be about 10 5 Dalton to about 10 7 The preferred molecular weight range of the poly(ethylene oxide) polymer is about 2x10 5 Up to 2x10 6 Daltons and is commercially available from Dow Chemical Company (Midland, Mich.) as SENTRYR POLYOX TM Water-soluble resin, NF (National Formulary) grade. When higher molecular weight polyethylene oxides are used, other hydrophilic agents such as salts or sugars (eg, glucose, sucrose, or lactose) that promote erosion or disintegration of the coating may also be included.

[0189] Delayed dosage forms can be mechanical pellets (e.g. capsules or pH-sensitive capsules) that can release the drug after a pre-programmed time or when it receives a signal that can be transmitted or once it leaves the stomach.

[0190] The amount of the compound of the present application in the formulation can vary within the full range used by those skilled in the art. Typically, based on the weight percentage (wt%) of the total formulation, the formulation will contain about 0.01-99.99wt% of the BTK inhibitor compound, with the remainder being one or more suitable pharmaceutical excipients. In one embodiment, the compound is present in an amount of about 1-80wt%.

[0191] The foregoing disclosure has been described in some detail by way of illustration and example for purposes of clarity and understanding. It should therefore be understood that the foregoing description is intended to be illustrative and not restrictive. The scope of this application, therefore, should not be determined with reference to the foregoing description, but rather with reference to the following appended claims, along with the full scope of equivalents to which such claims are entitled. Example

[0192] The following examples are provided to illustrate certain disclosed embodiments and should not be construed as limiting the scope of the present application in any way.In the examples discussed below, BTK inhibitors as defined above may also be referred to interchangeably as "compounds" or "drugs." Example 1 - Dose-finding Study of a BTK Inhibitor in Relapsing Multiple Sclerosis Example 1.1 - Introduction and Summary

[0193] The goal of this 2b phase study is to define the safety and optimal dose of BTK inhibitors. The mechanism of action of the proposed BTK inhibitor is to suppress the formation of new active brain lesions of MS as measured by MRI, and therefore it is expected to show clinical efficacy in further trials in MS patients. This study evaluates the dose response by measuring the change in the number of gadolinium (Gd) enhanced T1 high signal lesions associated with inflammation. This radiographic result has been established as a highly reliable predictive biomarker of clinical efficacy in key studies of MS, and has been shown to be a predictive biomarker of clinical efficacy (ARR reduction) in Phase 3 registration studies (Sormani et al., Ann Neurol.2009; 65 (3): 268-75; Sormani et al., Neurology, 2010; 75 (4): 302-9). Based on 4 dose levels and a short placebo period, the dose response of lesion inhibition was evaluated with a 2-step statistical method. The efficacy of BTK inhibitors relative to placebo was evaluated by evaluating the inhibition of the formation of new active brain lesions as measured by MRI. The study will also characterize the safety and tolerability of the BTK inhibitor in participants with RMS.

[0194] To gather additional data on the potential benefits of BTK inhibitors in neuroinflammation, the study employed multiple secondary outcome measures.

[0195] Exploratory assessments, such as analysis of serum NfL (neurofilament light chain) levels and advanced imaging approaches, are expected to begin to build evidence for the activity of BTK inhibitors on neuroinflammation and neurodegeneration, as well as potential effects on myelin regeneration and tissue preservation. Figure 1 A figure shows the overall design of the study and Table 1 shows the Schedule of Activities (SOA). Table 1: Schedule of Activities (SOA) Abbreviations: β-HCG: human chorionic gonadotropin beta; BTK: Bruton's tyrosine kinase; C-SSRS: Columbia-Suicide Severity Rating Scale; CHI3L1: chitinase 3-like protein 1; D: day; DME: drug-metabolizing enzyme; DNA: deoxyribonucleic acid; ECG: electrocardiogram; EDSS: Expanded Disability Status Scale; FSH: follicle-stimulating hormone; Ig: immunoglobulin; MRI: magnetic resonance imaging; NfL: neurofilament light chain; PBMC: peripheral blood mononuclear cell; TB: tuberculosis; W: perioperative aParticipants should return for a follow-up visit 2 to 4 weeks after prematurely ending treatment. bScreening activities can be completed anytime from 4 weeks before the intervention to Day 1. cOnly participants not enrolled in the LTS study should have a follow-up visit at weeks 18 to 20 d. A comprehensive physical examination is performed at screening; a simple physical examination is sufficient thereafter. If any new findings emerge, the simple physical examination will need to be extended as needed at the investigator's discretion. eSamples or measurements obtained before treatment. fFor a detailed list of laboratory tests, refer to Example 1.16. Pre-study testing is acceptable if performed during the time period from Week -4 to Day -1. gHematology only hTest serum beta-hCG at screening; thereafter, urine beta-hCG is sufficient unless pregnancy is detected or the urine test result is inconclusive and serum testing is needed for confirmation. iBaseline EDSS can be completed within 3 days prior to Day 1. jMRI can be performed within a ±5 day window. Screening MRI should be performed as close to Day 1 as possible. k Participant consented to pharmacogenetic sampling. On site visit days, participants should not take the IMP prior to the visit but should bring their medication bag to the visit so that the time of dosing can be recorded for PK sampling. Treatment adherence diaries were distributed over 4-week periods, collected, and collated at subsequent visits. Treatment adherence was reported using diary data.

[0196] The goals and endpoints of treatment are shown in Table 2 . Table 2: Objectives and endpoints

[0197] Appropriateness of measurement

[0198] As in most RMS clinical trials, magnetic resonance imaging (MRI) markers of inflammatory activity in the brain are collected. The number of new Gd-enhanced T1 high-signal lesions is used as the primary endpoint for evaluating the efficacy of BTK inhibitors. Since MS causes blood-brain barrier leakage, the accumulation of Gd contrast agents in brain tissue is associated with inflammatory activity in MS patients. This radiographic result has been established as a highly reliable predictive biomarker of clinical efficacy in pivotal studies of MS. Central review is used to identify new Gd-enhanced T1 high-signal lesions that did not appear in previous MRI. The total count of Gd-enhanced T1 high-signal lesions is also used as a secondary endpoint for detecting any effect on pre-existing inflammatory lesions. The number of new and enlarged T2 lesions (markers of inflammatory activity and brain tissue destruction in RMS) is also evaluated in the central review to collect additional data on the efficacy of BTK inhibitors. The total volume of T2 lesions (MS burden) and the number of T1 low-signal lesions (black holes) are also assessed as supportive data on efficacy.

[0199] Magnetic resonance imaging (MRI) measurements include changes in brain volume, which is considered a marker of CNS degeneration but is also associated with inflammatory events in patients with RMS. Several MS drugs, known for their ability to slow brain shrinkage, were evaluated for possible signals.

[0200] Clinical relapse is the main clinical manifestation of RMS. Relapse-related endpoints (ARR, proportion of relapse-free participants) are widely used as endpoints in clinical trials. Although the short duration of the trial does not allow for significant differences in the incidence of relapse between the expected dose groups, and relapse is considered rare in PPMS, it is evaluated due to its clinical importance and attempts are made to collect additional efficacy data.

[0201] The EDSS is widely used to measure neurological disability in clinical trials and routine settings (Kurtzke JF, Neurology. 1983; 33(11): 1444-52). Large changes were not expected during the study period, but it was used as supportive data for efficacy. Example 1.2 - Study Design

[0202] Overall Design: A Phase 2b, randomized, double-blind, placebo-controlled, crossover, dose-ranging study to investigate the MRI efficacy and safety of a 12-week dosing regimen of a BTK inhibitor. Individuals diagnosed with RMS were eligible if they met all inclusion criteria and had no exclusion criteria.

[0203] All participants were centrally assigned in equal ratios to 1 of 8 groups (4 dose groups within each of 2 cohorts) using an interactive voice / web response system (IVRS / IWRS) to start the BTK inhibitor (in cohort 1) or placebo (in cohort 2) period and then cross over. Within each cohort, participants were randomly assigned in a blinded manner to 1 of 4 BTK inhibitor doses (5 mg, 15 mg, 30 mg, or 60 mg once daily). ● Cohort 1: Participants received 1 dose of a BTK inhibitor for the first 12 weeks and then crossed over to the placebo group for 4 weeks. Cohort 2: Participants received placebo for the first 4 weeks and then crossed over to 1 BTK inhibitor dose group for 12 weeks.

[0204] After completing the double-blind treatment period, participants were given the option to enroll in a long-term safety (LTS) follow-up study to evaluate the safety and tolerability of the BTK inhibitor.

[0205] Number of participants: Approximately 160 people were screened to randomize approximately 120 participants (based on a 25% screening failure rate) to the study intervention, so that approximately 105 evaluable participants (based on an approximately 15% dropout rate, providing at least 26 participants for each dose level of the BTK inhibitor) completed 12 weeks of BTK inhibitor treatment. Participants from Cohort 2 (n=60) received 4 weeks of placebo and then crossed over to the BTK inhibitor group, providing data that can be used to estimate the dose-response curve and compare with placebo. This approach is based on the assumption of a theoretical constant rate of new Gd-enhancing T1 hyperintense lesions within 12 weeks of placebo treatment. This approach minimizes placebo exposure to study participants. A brief description of the processing of placebo data and analysis, as well as additional details including sample size determination, is provided in Example 1.14.

[0206] Intervention Groups and Duration: A 4-week placebo period was introduced after or before 12 weeks of BTK inhibitor treatment (cohorts 1 and 2, respectively). Participants were randomly assigned to each of the 8 groups (4 dose groups in each of the 2 cohorts) in equal proportions. See Table 5 for an overview of the study interventions.

[0207] Rationale: This study was blinded to dose and order of administration. It focused on dose exploration, but also took into account the need to minimize participant exposure to placebo. Therefore, a dose range was evaluated using four doses: 5 mg, 15 mg, 30 mg, and 60 mg once daily. Furthermore, to minimize exposure to placebo while blinding investigators and participants, each participant was assigned to a 4-week placebo period occurring during the first or last 4 weeks of the study. A 4-week placebo period was introduced after or before 12 weeks of BTK inhibitor treatment (Cohorts 1 and 2, respectively). Participants were randomly assigned to one of eight groups (with equal allocation to four dose groups in each of two cohorts). The duration of placebo administration was limited to four weeks to minimize placebo exposure; the crossover design allowed all participants to be treated with the BTK inhibitor. This crossover design was blinded to the intervention administered and allowed for a more objective assessment of safety events and efficacy endpoints at study entry. The duration of the 12-week BTK inhibitor treatment period should allow for detection of its effect on inhibiting the formation of new Gd-enhancing T1 lesions. A recent communication on the study of Evobrutinib in patients with RMS confirmed that a meaningful reduction in such lesions could be observed starting from week 12 (Merck Press release - Merck KGaA, Darmstadt, Germany, Announces Positive Phase IIB Results for Evobrutinib in Relapsing Multiple Sclerosis. March 7, 2018).

[0208] Dosing regimen: The dose range selected for this study was derived from several assessments. First, allometric modeling aims to convert the BTK occupancy produced by BTK inhibitors in preclinical animals (mice, rats and dogs) to predict the optimal dose range of 1 mg to 100 mg once daily in humans. Secondly, a phase 1 multiple dose escalation measurement of BTK occupancy in human peripheral blood mononuclear cells (PBMCs) showed that at a dose of 7.5 mg once daily, BTK inhibitors progressively approached receptor saturation, while approaching saturation more rapidly at higher doses. Finally, measurements of absolute CD19+ B cell counts showed a dose-dependent increase (maximum observed on day 4) relative to baseline of up to 80%. The increase in BTK-induced circulating B cells was predicted by the literature because BTK inhibition changes the expression of cell surface adhesion molecules, leading to discharge from lymph nodes (Burger JA et al., Nat Rev Cancer. 2018; 18 (3): 148-67). The dose-response relationship of this effect is maximum at approximately 30 mg once daily. Taking all of these factors into account, a dose range of 5 mg to 60 mg once daily was set to provide the best chance of capturing the optimal dose of a BTK inhibitor in RMS.

[0209] Study End Definition: A participant is considered to have completed the study if he / she has completed all phases of the study, including the final visit. Study end is defined as the date of the final visit of the last participant in the study. Example 1.3 - Study Population Example 1.3A - Inclusion Criteria

[0210] Participants were eligible for inclusion in the study only if all of the following criteria, as shown in Table 3, were met. Table 3 - Inclusion criteria Example 1.3B - Exclusion Criteria

[0211] Participants were excluded from this study if any of the following criteria as shown in Table 4 applied. Table 4 - Exclusion criteria Example 1.4 - Study Intervention

[0212] A study intervention was defined as any investigational intervention(s), commercially available product(s), placebo, or medical device(s) intended to be administered to participants according to the study protocol. Example 1.4A - One or more study interventions administered

[0213] The study interventions included an IMP and a non-investigational product (NIMP). To maintain blinding, participants received four tablets of a BTK inhibitor and / or placebo once daily in a blinded manner. Details of the interventions are provided in Table 5. Table 5 - Summary of Study Interventions Administered

[0214] NIMP: Radiological, signal-enhancing, intravenous (IV) contrast agents for T1 contrast-enhanced MRI sequences. Use locally approved contrast agents. Example 1.4A1 - Measures to Minimize Bias: Randomization and Blinding

[0215] All participants were centrally assigned to 1 of 8 groups (4 dose groups in each of 2 cohorts) in equal proportions using IVRS / IWRS to start the BTK inhibitor (in cohort 1) or placebo (in cohort 2) period and then crossover. Participants could not be randomized more than once during the study. Before the start of the study, each site was provided with a telephone number and call-in instructions for the IVRS and / or login information and instructions for the IWRS. The study interventions were assigned at the study visit summarized in the activity schedule (Table 1). Withdrawn study interventions should not be reassigned to participants.

[0216] Unblinding (IVRS / IWRS): The IVRS / IWRS is programmed with unblinding instructions. In an emergency situation, the investigator's sole responsibility is to determine whether it is necessary to unblind a participant's treatment assignment. The safety of the participant must always be the primary consideration in making such a decision. If the investigator determines that unblinding is necessary, the investigator should make every effort to contact the sponsor before unblinding the participant's treatment assignment, unless this may delay the participant's emergency treatment. If a participant's treatment assignment is unblinded, the sponsor must be notified within 24 hours of unblinding. The date and reason for unblinding must be recorded in the source document and case report form (if applicable).

[0217] The study was blinded to dose and BTK inhibitor-placebo administration sequence. Tablets and placebo were identical across the different BTK inhibitor dose levels. Due to ethical considerations, the placebo duration was limited to 4 weeks, which allowed for a more objective assessment of safety events at the beginning of the study period and also increased the objectivity of the clinical endpoint assessments.

[0218] The investigators will not have access to the MRI data, except for any non-MS-related findings that need to be communicated for the purpose of evaluating the participant's safety. The on-site radiology department will be responsible for reporting any non-MS findings on the MRI to the investigators in a timely manner.

[0219] An independent data monitoring committee (IDMC) regularly monitored the safety of this study. Unblinded data were provided to the IDMC for review by an independent statistician who performed the unblinding. Unblinded data were not accessible to study team members, investigators, or study participants. Example 1.4B - Concomitant Therapy

[0220] Any medications or vaccines (including over-the-counter or prescription medications, vitamins, and / or herbal supplements) that participants were receiving at enrollment or received during the study were recorded along with the reason for use, dates of administration (including start and end dates), and dosing information (including dose and frequency).

[0221] Identical data were collected for all prior medications received during the 4 weeks prior to enrollment, as well as for all prior MS therapies and treatments considered clinically relevant for the assessment of MS or concomitant conditions. Standard treatment for MS relapses with high-dose glucocorticoids was permitted. Such treatment should follow local guidelines.

[0222] In addition to the drugs excluded in Table 4, the following drugs were prohibited throughout the study: -Other MS disease-modifying treatments -Acetylsalicylic acid (aspirin) -Antiplatelet drugs (eg, clopidogrel) - Anticoagulants, including warfarin, heparin (including low molecular weight heparin), dabigatran, apixaban, edoxaban, and rivaroxaban.

[0223] The use of paracetamol / acetaminophen at a dose of ≤3 g / day was permitted at any time during the study. Short-term (up to 5 days) NSAIDs (except acetylsalicylic acid) at recommended doses were allowed during the study if clinically indicated for treatment of an existing medical condition or a new event. The investigator recorded the use of NSAIDs (and any other concomitant medications) in the CRF.

[0224] In vitro experiments and computer simulations have demonstrated the potential for gastric acid reducers to reduce the plasma exposure of BTK inhibitors. Proton pump inhibitors (such as omeprazole) should be avoided. The use of antacids (such as calcium carbonate) should be staggered with BTK inhibitor medication, and antacid administration occurs no less than 2 hours before or after 2 hours of BTK inhibitor administration. The use of H2 receptor antagonists (such as ranitidine) should also be staggered with BTK inhibitor medication, and H2 receptor antagonists are administered no less than 10 hours before or after 2 hours of BTK inhibitor administration. There is a list of exemplary drugs with the potential for the plasma exposure of BTK inhibitors via reducing gastric acid.

[0225] Based on preclinical drug metabolism studies, BTK inhibitors are substrates of CYP3A and CYP2C8 isoenzymes, so the plasma exposure of BTK inhibitors may be altered if co-administered with other drugs that induce or inhibit CYP3A and / or CYP2C8 metabolism. This has not been studied in humans to date, so if possible, drugs that strongly inhibit or induce CYP3A or CYP2C8 should be avoided. See Table 12 for a list of drugs that should not be used. Example 1.4C - Dosage Modification

[0226] No dose reductions are anticipated in this study. Participants, investigators, and the sponsor's team were blinded to the assigned dose level. Interruption or permanent discontinuation of treatment may be necessary if deemed necessary due to AEs (Examples 1.4E and 1.8). Example 1.4D - Post-Study Intervention

[0227] Participants who completed the study's Week 16 visit were offered a separate, open-label LTS study. After completing the double-blind treatment period, participants already enrolled in the DRI study and all subsequent participants had the option to enroll in the LTS follow-up study to evaluate the safety and tolerability of the BTK inhibitor. Example 1.4E - Discontinuation of Study Intervention and Participant Discontinuation / Withdrawal

[0228] Withdrawal of consent for treatment should be distinguished from (additional) withdrawal of consent follow-up visits and follow-up visits for contact with non-participants who have withdrawn consent (e.g., medical record review). Any circumstances in which consent is withdrawn should be recorded on site. Example 1.4E1 - Discontinuation of Study Intervention

[0229] Definitive Discontinuation: The IMP should be continued whenever possible. In the event that the IMP is discontinued, a determination should be made as to whether such discontinuation can be temporary; a definitive IMP discontinuation should be a last resort. Any IMP discontinuation should be fully documented in the eCRF. In all cases, participants should remain in the study for as long as possible. A definitive intervention discontinuation is any discontinuation of the intervention associated with the investigator's definitive decision not to re-expose the participant to the IMP at any time during the study, or for any reason, to discontinue the participant's exposure to the IMP. The investigator should consider discontinuing the study intervention for abnormal liver function when the participant meets one of the criteria outlined in Section 10.6 or if the investigator determines that it is in the best interest of the participant. If a clinically significant finding is identified on the ECG after enrollment (including but not limited to a change from baseline in the QT interval corrected using the Fridericia formula [QTcF]), the investigator or a qualified designee will determine whether the participant can continue to participate in the study and whether a change in participant management is warranted. Due to ECG changes, consideration should be given to a review of the ECG findings by a cardiologist to determine the definitive discontinuation of the study intervention. This review should be documented on the printed ECG at the time of collection. Any new clinically relevant findings were reported as AEs.

[0230] See the SoA (Table 1) for data to be collected at intervention discontinuation (end-of-treatment visit) and follow-up, as well as any further evaluations that need to be completed. Immediately recheck after 24 hours to confirm any abnormal laboratory values or ECG parameters before making a definitive discontinuation of the intervention for the relevant participant. In the event of premature discontinuation of the intervention, an end-of-treatment visit will be conducted.

[0231] Participants were followed according to the study procedures specified in this protocol until study completion or until recovery or stabilization of any AE to be followed as specified in this protocol, whichever occurred last. If possible, and after a definitive discontinuation of the intervention, participants were assessed using the procedures typically planned for the last treatment day of the IMP (including PK samples). Details are provided in the SoA (Table 1). When considered confirmed, all definitive discontinuations of the intervention were recorded by the investigator on the appropriate pages of the eCRF.

[0232] The investigator may consider a temporary discontinuation of the intervention due to suspected AEs and / or laboratory abnormalities and / or ECG abnormalities. For all temporary discontinuations of the intervention, the investigator should record the duration of the discontinuation on the appropriate page of the eCRF. A temporary discontinuation of the intervention determined by the investigator corresponds to >1 dose not being administered to the participant.

[0233] After the investigator, in his or her best medical judgment, determines that one or more IMPs are unlikely to be responsible for the occurrence of the relevant event and if the study selection criteria (see Table 3) are still met, reinitiation of IMP intervention will be performed under close and appropriate clinical and / or laboratory monitoring. Example 1.4E2 - Participant Suspension / Withdrawal:

[0234] A participant may withdraw from the study at any time at his / her own request or at the investigator's discretion for safety, behavioral, compliance, or medication reasons. - If a participant withdraws consent for future disclosure of information, the sponsor may retain and continue to use any data collected before such withdrawal of consent. -If a participant withdraws from the study, he / she may request that any samples collected but not tested be destroyed, and the investigator must record this in the study records at the site. - See SoA (Table 1) for data to be collected at study discontinuation and follow-up, and any further evaluations that need to be completed. - If participants no longer wish to take the IMP, they are encouraged to remain in the study.

[0235] Researchers should discuss key visits with participants and emphasize the importance of all study data to the public health value of the research.

[0236] Participants withdrawing from a study intervention should be explicitly asked about the impact of possible AEs on their decision, and any AE information elicited must be recorded.

[0237] The investigator should record all study withdrawals in the appropriate screen of the eCRF and in the participant's medical record. In the medical record, at a minimum, the date of withdrawal and the reason for withdrawal should be recorded.

[0238] In addition, participants may withdraw their consent to participate in the study. Withdrawal of consent for an intervention should be distinguished from withdrawal of consent for follow-up visits and withdrawal of consent for non-participant contact (e.g., medical record review). Any withdrawal of consent should be recorded on-site.

[0239] Participants who have withdrawn from the study cannot be re-randomized (to treatment) in the study. Their participant and kit number will not be used again. Example 1.4E3—Lost to Follow-up

[0240] If a participant failed to return for scheduled visits multiple times and could not be contacted with the study site, he or she was considered lost to follow-up.

[0241] If a participant fails to return to the clinic for a required study visit, take the following actions: -The site must attempt to contact the participant and reschedule missed visits as quickly as possible, counsel the participant on the importance of maintaining the assigned visit schedule, and determine whether the participant wishes and / or should continue in the study. - Before a participant is considered lost to follow-up, the investigator or designee must make every effort to restore contact with the participant (three telephone calls, if possible, and, if necessary, registered mail to the participant's last known mailing address or local equivalent). These attempts to contact the participant should be documented in the participant's medical record. - Participants who could not be contacted were considered to have withdrawn from the study. Example 1.5 - Study Assessment and Procedures

[0242] Study procedures and their timing are summarized in the SoA (Table 1). No waivers or exemptions from the protocol will be permitted. Procedures performed as part of routine clinical management of potential participants (e.g., blood counts) and obtained prior to signing the Informed Consent Form (ICF) may be used for screening or baseline purposes, provided that the procedure meets the protocol-specified criteria and is performed within the timeframe defined in the SoA (Table 1). In the event of premature discontinuation of the study intervention, an end-of-treatment visit will be conducted. Participants will return 2 to 4 weeks after the premature end-of-treatment visit. Example 1.6 - Efficacy Evaluation Example 1.6A - Magnetic Resonance Imaging Assessment

[0243] Cranial (brain) MRI with and without Gd contrast agent was performed. A basic MRI was performed on all participants at all study sites and consisted of T2- and T1-weighted sequences without and with Gd contrast agent. Due to the potential safety risks associated with the deposition of certain IV Gd contrast agents in the brain, these agents should be used according to local recommendations / regulations (Fischer JS et al. "The Multiple Sclerosis Functional Composite Measure (MSFC): an integrated approach to MS clinical outcome assessment," National MS Society Clinical Outcomes Assessment Task Force. Mult Scler. 1999; 5(4): 244-50).

[0244] New T1 Gd-enhancing hyperintensities and new and enlarging T2 lesions were assessed at each visit according to SoA (Table 1), and lesion counts were compared with the previous MRI scan. Unless otherwise specified, the baseline brain MRI was used as the reference for assessing all MRI-derived endpoints. The baseline MRI was the last MRI performed before the randomization visit. Standardized endpoint assessment was ensured by central review of brain MRI scans. Blinded central review was performed for all MRI-derived endpoints. The MRI reviewer was blinded to treatment allocation and was also blinded to other participant data. If the investigator suspected spinal MS lesions, a spinal MRI could be requested. Spinal cord MRI was evaluated locally and reported in the eCRF. No central review of spinal cord MRI was performed.

[0245] Magnetic resonance imaging for exploratory efficacy evaluation employed regional and whole-brain volume assessments, additional analyses of T1 and T2 imaging, and sequences such as magnetic transmissibility and susceptibility-weighted imaging. Example 1.6B - Multiple Sclerosis Relapse

[0246] Unplanned Assessment Visit for Suspected MS Relapse: Participants are instructed to report new neurological symptoms and recurrence or worsening of previous symptoms to the Investigator immediately. Any reported symptoms are collected. If a participant reports symptoms that may be consistent with a relapse, an unplanned assessment visit with the Investigator must be arranged as soon as possible (within 7 days of symptom onset if possible). The Investigator assesses whether the reported episode is consistent with the definition of an MS relapse (see Example 1.6B). If consistent with the definition of an MS relapse, or if there is any doubt and a relapse cannot be ruled out, an EDSS assessment should be performed. Unplanned visit activities are detailed in the SoA (Table 1) and need to be adjusted if a pathology other than MS is the cause, and additional examinations or laboratory tests need to be performed for safety follow-up and optimal treatment decisions.

[0247] Multiple Sclerosis Relapse: For the purposes of this study, an MS relapse is defined as an acute onset of new neurologic symptoms, or worsening of previous neurologic symptoms, with objective changes on neurologic examination. Symptoms must: Attributed to MS Lasts ≥24 hours, and Presents at normal body temperature (ie, in the absence of infection, excessive exercise, or elevated ambient temperature)

[0248] NOTE: Exacerbation or recurrence of symptoms and signs that can reasonably be attributed to transient conduction disturbances in previously demyelinating pathways caused by the drug (eg, rarely occurring a few hours after interferon beta injection), increased core body temperature (Uhthoff phenomenon), or systemic cytokine release (eg, occurring with alemtuzumab administration) are not considered relapses. Example 1.6C - Expanded Disability Status Scale Assessment

[0249] The investigators performed EDSS assessments (Kurtzke JF, Neurology. 1983; 33(11): 1444-52) as indicated in the SoA (Table 1).

[0250] Functional systems were assessed by the investigator in the context of a standard neurological examination and reported according to the EDSS reporting instructions along with information on the participant's mobility, gait, and use of assistive devices. Standard EDSS assessments were performed for neurological symptoms in each of the seven functional domains (vision, brainstem, pyramidal [motor], cerebellar [coordination], sensory, cerebral, and bowel / bladder). Movement was also scored as part of the assessment. Fatigue could optionally be assessed, but it did not contribute to the EDSS score. Example 1.7 - Safety Assessment

[0251] The time points for all safety assessments are provided in the SoA (Table 1). The definitions of AEs and SAEs can be found in Example 1.8B. For the purposes of this protocol, MS relapses (Example 1.6B) were waived as AE reports unless they met the criteria for an SAE. Non-severe MS relapses were collected on a dedicated eCRF page and analyzed as efficacy endpoints. After the MS relapse assessment (Example 1.6B), events that were inferred not to meet the MS relapse criteria were reported as AEs. Example 1.7A - Physical Examination

[0252] A complete physical examination includes, at a minimum, an assessment of the general appearance, head and neck, abdomen, lymph nodes, skin (including signs of bleeding such as bruises, petechial rashes), cardiovascular system, respiratory system, gastrointestinal system, musculoskeletal system, and nervous system. Height and weight are also measured and recorded. A brief physical examination includes, at a minimum, an assessment of the skin, lungs, cardiovascular system, and abdomen (liver and spleen). Investigators should pay particular attention to clinical signs associated with pre-existing serious illness. Any new findings or worsening of previously found findings should be reported as a new AE. The SoA (Table 1) provides a schedule for physical examinations. Example 1.7B - Vital Signs

[0253] Assess temperature, pulse rate, respiratory rate, and blood pressure. The same method of measuring temperature should be used throughout the study. Blood pressure and pulse measurements should be assessed in the sitting or supine position using a fully automated device. Measurements should be made using the same position for the same participant throughout the study. Manual techniques should be used only when an automated device is not available. Avoid consuming caffeinated beverages before measuring blood pressure. Before blood pressure and pulse measurements, participants should rest in a quiet environment free from distractions (e.g., television, cell phones) for at least 5 minutes. Vital signs (obtained before blood collection for laboratory testing) consist of one pulse measurement, three blood pressure measurements (three consecutive blood pressure readings recorded at least 1 minute apart), and respiratory rate. The average of the three blood pressure readings should be recorded. Example 1.7C - Electrocardiogram

[0254] A single 12-lead ECG is obtained as outlined in the SOA (Table 1) using an ECG machine that automatically calculates heart rate and measures PR, QRS, QT, and QTc intervals. At least one long rhythm monitoring recording needs to be part of each ECG test. The ECG is reviewed by a cardiologist to confirm abnormalities and clinical evaluation. QTc exit criteria and any additional QTc readings that may be needed are referenced in Example 1.4E. Example 1.7D - Clinical Safety Laboratory Assessment

[0255] A list of clinical laboratory tests to be performed is provided in Example 1.16, and the timing and frequency are provided in the SoA (Table 1). The Investigator will review the laboratory reports, document this review, and record any clinically relevant changes that occur during the study in the AE section of the eCRF. Clinically significant abnormal laboratory results are those not related to the underlying disease, unless the Investigator judges that the condition is more severe than expected for the participant. All laboratory tests with values considered to be clinically significant abnormal during study participation or within 4 weeks after the last dose of the study intervention should be repeated until the value returns to normal or baseline or is no longer considered clinically significant by the Investigator or Medical Monitor. If such values do not return to normal / baseline within a reasonable period of time as determined by the Investigator, the cause should be identified and the Sponsor notified. All protocol-required laboratory evaluations as defined in Example 1.16 will be performed in accordance with the laboratory manual and SoA (Table 1). If laboratory values from non-protocol-required laboratory evaluations performed at the institution's local laboratory require a change in the participant's management or are considered clinically significant by the Investigator (e.g., SAE or AE or dose modification), the results will be recorded in the eCRF. Example 1.7E - Suicide Risk Monitoring

[0256] BTK inhibitors are considered CNS active, so routine suicide risk monitoring is performed. The Columbia-Suicide Severity Rating Scale (C-SSRS) and a thorough clinical evaluation of complaints are used for suicide risk assessment. Any clinically important observation or event is reported as an AE. The C-SSRS is a tool used to assess participants' lifetime suicidality and track suicide events through the study. A structured interview prompts recall of suicidal ideation, including the intensity of the ideation, behavior, and actual / potentially lethal attempts. The scale is administered by the investigator or qualified designee at the time points specified in the SoA (Table 1). Example 1.8 - Adverse Events and Serious Adverse Events Example 1.8A - Adverse Events of Special Interest

[0257] AESIs are AEs (serious or nonserious) of scientific and medical concern specific to the sponsor's product or procedure that require ongoing monitoring by the investigator and immediate notification to the sponsor. Such events may require further investigation to characterize and understand them. Adverse events of particular interest may be added, modified, or removed during the study through protocol amendments. - Acute hypersensitivity / anaphylactic reaction - pregnancy in female participants entering the study and pregnancy in the female partners of male participants entering the IMP / NIMP study; o Pregnancy occurring in a female participant entering a clinical study or in the female partner of a male participant entering a clinical study. It is considered an SAE only if it meets one of the severity criteria (see Example 1.8B). In the event of pregnancy in a female participant, the IMP should be discontinued. Follow-up of pregnancy in a female participant or in the female partner of a male participant is mandatory until the outcome has been determined (see Example 1.17). - Symptomatic IMP / NIMP overdose (serious or nonserious): An IMP / NIMP overdose (accidental or intentional) is an event suspected by the investigator or spontaneously notified by the participant (not based on systematic pill counts) and is defined as at least two times the scheduled dose within the scheduled treatment interval, adjusted for test drug. Of note, asymptomatic overdose is reported as a standard AE. - ALT increase: Any increase in ALT > 3x ULN. Other project-specific AESIs

[0258] ECG-observed QTc ≥ 500 ms or clinically significant arrhythmia (e.g., atrial fibrillation, atrial flutter) confirmed by a cardiologist, including serious infection, particularly any opportunistic infection; major bleeding events, including symptomatic bleeding into critical areas or organs, such as CNS or intraocular hemorrhage, resulting in a SAE; thrombocytopenia with a platelet count < 100 x 10 9 / L.

[0259] AEs were reported by the participant (or, when appropriate, by a caregiver, surrogate, or the participant's legally authorized representative).

[0260] The Investigator and any qualified designees are responsible for detecting, documenting, and recording events that meet the definition of an AE or SAE, and for ongoing follow-up of AEs that are serious, considered related to the study intervention or study procedures, or that lead to participant discontinuation of the study intervention (see Example 1.4E).

[0261] The definition of AE or SAE can be found in Example 1.8B. Example 1.8B - Adverse Events: Definition and Procedures for Recording, Evaluation, Follow-up, and Reporting

[0262] Adverse Event (AE): An AE is any untoward medical occurrence in a participant or clinical study participant that is temporally associated with the use of an investigational intervention (whether or not considered to be related to the investigational intervention). An AE may therefore be any unfavorable and unspecified sign (including abnormal laboratory results), symptom, or disease (new or worsening) that is temporally related to the use of an investigational intervention.

[0263] Events that meet the definition of AE: - Any abnormal laboratory test results (e.g., hematology, clinical chemistry, or urinalysis) or other safety assessments (e.g., ECG, radiology scan, vital sign measurements) that are considered clinically significant (i.e., not related to progression of the underlying disease) based on the medical and scientific judgment of the investigator, including those that worsen from baseline. - Exacerbation of a chronic or intermittent pre-existing condition, including an increase in the frequency and / or intensity of the condition. - Detection or diagnosis of a new condition after administration of the study intervention, even if it may have existed before the start of the study. - Signs, symptoms, or clinical sequelae of suspected drug interaction. - Suspected signs, symptoms, or clinical sequelae of overdose of the study intervention or concomitant medication.

[0264] Lack of efficacy or failure of the intended pharmacological effect itself was reported as an AE or SAE but was captured in the efficacy assessment.

[0265] Events that do not meet the definition of AE: - Any clinically significant abnormal laboratory result or other abnormal safety assessment related to the underlying disease, unless the investigator believes the participant is more ill than expected - The disease / disorder being studied or the anticipated progression, signs, or symptoms of the disease / disorder being studied, unless the participant's condition is more severe than anticipated. - Medical or surgical procedure (eg, endoscopy, appendectomy): The condition leading to the procedure is an AE. - No unfortunate medical incidents (social and / or convenience hospitalizations). - Expected day-to-day fluctuations in one or more pre-existing diseases or conditions that were present or detected at study entry and not worsened

[0266] If an event is not an AE according to the above definition, it cannot be an SAE even if the serious criteria are met (eg, hospitalization for signs / symptoms of the disease under study, death due to disease progression).

[0267] Serious Adverse Event (SAE): An SAE is any unfortunate medical incident that, at any dose: a) resulting in death; b) life-threatening (the term “life-threatening” refers to an event / reaction in which the participant is at risk of death at the time of the event / reaction; it does not refer to an event / reaction that, if hypothesized to be more severe, could result in death); c) Requires hospitalization of the patient or results in a prolongation of an existing hospitalization (generally, a hospitalization means the participant has been admitted (usually involving at least an overnight stay) to a hospital or emergency department for observation or treatment that would not be appropriate in a physician's office or outpatient setting. Complications that occur during a hospitalization are AEs. An event is serious if the complication prolongs the hospitalization or meets any other seriousness criteria. When there is doubt as to whether a hospitalization occurred or was necessary, an AE should be considered serious. Hospitalizations for elective treatment of a pre-existing condition that did not worsen from baseline are not considered AEs); d) results in persistent disability / incapacity (the term disability means a substantial impairment of a person's ability to carry out normal life functions. This definition is not intended to include experiences of relatively minor medical significance, such as uncomplicated headaches, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g., a sprained ankle) that may interfere with or hinder daily life functions but do not constitute a substantial impairment); e) congenital anomaly / birth defect; f) Other circumstances, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but could harm the participant or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definitions. These events should generally be considered serious. Examples of such events include invasive or malignant cancer, intensive treatment for allergic bronchospasm in the emergency department or at home, blood disorders or seizures that do not result in hospitalization, or the emergence of drug dependence or drug abuse.

[0268] Recording and follow-up of AEs and / or SAEs

[0269] AE and SAE Recording: When an AE / SAE occurs, review all documentation related to the event (e.g., hospital progress notes, laboratory reports, and diagnostic reports) and record all relevant AE / SAE information in the eCRF. It is unacceptable for the investigator to send a copy of the participant's medical record to the sponsor representative without completing the AE / SAE eCRF page. Medical records may need to be submitted as additional data with SAE and AESI reports. In such cases, anonymize the participant's name and initials by replacing them with the study participant number. There may be instances where the sponsor requests a copy of the medical record for certain cases. In such cases, all participant identifiers except the participant number are redacted from the copy of the medical record before submission to the sponsor. The investigator attempts to establish a diagnosis for the event based on signs, symptoms, and / or other clinical information. Whenever possible, a diagnosis (not individual signs / symptoms) is documented as an AE / SAE.

[0270] Intensity Assessment: The intensity of AEs / SAEs reported during the study was assessed and assigned to one of the following categories: - Mild: Events that are easily tolerated by the participant, cause minimal discomfort, and do not interfere with daily activities. -Moderate: Events that cause enough discomfort to interfere with normal daily activities. - Severe: An event that interferes with normal daily activities. AEs assessed as severe should not be confused with SAEs. Severity is a category used to rate the intensity of an event; both AEs and SAEs can be assessed as severe.

[0271] An event was defined as “serious” when it met at least one of the predefined outcomes as described in the SAE definition, rather than when it was rated as severe.

[0272] Assessment of Causality: The investigator is obligated to evaluate the relationship between the study intervention and each occurrence of each AE / SAE. A "reasonable possibility" of a relationship indicates that facts, evidence, and / or arguments exist to suggest a causal relationship, but not that a relationship cannot be ruled out. The investigator uses clinical judgment to determine this relationship. Alternative causes, such as one or more underlying diseases, concomitant therapies, and other risk factors, as well as the temporal relationship of the event to the administration of the study intervention, are considered and investigated. The investigator also consults the Investigator's Brochure (IB) and / or product information for the marketed product in their assessment.

[0273] For each AE / SAE, the investigator documents in the medical note that they have reviewed the AE / SAE and provided an assessment of causality. There may be instances where an SAE has occurred and the investigator includes minimal information in the initial report to the sponsor. However, it is very important that the investigator always assesses the causality of each event before the initial transmission of SAE data to the sponsor. The investigator may change their opinion on causality based on follow-up information and will send a follow-up SAE report with an updated assessment of causality. The assessment of causality is one of the criteria used when determining regulatory reporting requirements.

[0274] Follow-up of AEs and SAEs: As medically indicated or requested by the monitoring team representative, the investigator is obligated to perform or arrange for additional measurements and / or evaluations to elucidate the nature and / or causality of the AE or SAE as fully as possible. This may include additional laboratory tests or studies, histopathology, or consultation with other healthcare professionals. Record any new or updated information in the initially completed eCRF. If a participant dies while participating in the study or during the recognized follow-up period, the investigator will provide the sponsor representative with a copy of any autopsy results, including histopathology. Record any new or updated information in the initially completed eCRF. The investigator will submit any updated SAE data to the sponsor within 24 hours of receipt.

[0275] Reporting of SAEs: SAEs are reported to the sponsor via the electronic data collection tool. The primary mechanism for reporting SAEs to the sponsor is the electronic data collection tool. If the electronic system is unavailable for more than 24 hours, the site uses a paper SAE data collection tool (see this application). Once the electronic system is available, the site immediately enters the SAE data into the electronic system. After the study is completed at a given site, the electronic data collection tool is taken offline to prevent the entry of new data or the modification of existing data. If a site receives a new SAE report from a study participant or receives updated data for a previously reported SAE after the electronic data collection tool has been taken offline, the site can report the information on a paper SAE form (see Example 1.8C) or report the information to the sponsor by telephone.

[0276] Reporting SAEs to the Sponsor via Case Report Form (CRF): Fax transmission of the SAE paper CRF is the preferred method of transmitting this information to the Sponsor. In rare circumstances and where fax equipment is not available, notification by telephone is acceptable with a copy of the SAE data collection tool sent by overnight mail or courier service. Initial notification by telephone does not replace the need for the Investigator to complete and sign the SAE CRF pages within the specified reporting timeframe. Example 1.8C - Time period and frequency of collecting AE and SAE information

[0277] All AEs (including SAEs) were collected from the signing of the ICF until EOT at the time points specified in the SOA (Table 1). As indicated in Example 1.8B, all SAEs and AESI were recorded and reported to the sponsor or designee within 24 hours. The investigator submitted any updated SAE data to the sponsor within 24 hours of the data being available. The investigator was not obligated to actively seek out AEs or SAEs after the conclusion of study participation. However, if the investigator learned of any SAE (including death) at any time after the participant officially left the study and he / she believed that the event was reasonably related to the study intervention or study participation, the investigator was to notify the sponsor immediately. Methods for recording, evaluating, and assessing the causal relationship of AEs and SAEs and procedures for completing and transmitting SAE reports are provided in Example 1.8B. Example 1.8D - Method for Detecting AE and SAE

[0278] When detecting AEs and / or SAEs, care should be taken not to introduce bias. Open-ended, unguided verbal questioning of participants is the preferred method for inquiring about the occurrence of AEs. Example 1.8 Follow-up of E-AEs and SAEs

[0279] After the initial AE / SAE report, the investigator will be required to actively follow up with each participant at subsequent visits / contacts. All SAEs and non-serious AESIs (as defined in Example 1.8B) will be followed up until resolution, stabilization, or an explanation is required for the event, or the participant is lost to follow-up (as defined in Example 1.4E3) at the scheduled study end date. Example 1.8F-Pregnancy

[0280] Details of all pregnancies were collected from female participants and female partners of male participants after the start of the study intervention and until the last visit of the study. If a pregnancy was reported, the investigator notified the sponsor within 24 hours of learning of the pregnancy and the procedures outlined in Example 1.17 were followed. Abnormal pregnancy outcomes (e.g., spontaneous abortion, fetal death, stillbirth, congenital anomaly, ectopic pregnancy) were considered SAEs. Example 1.8G - Cardiovascular Events and Deaths

[0281] Atrial fibrillation, atrial flutter, observation of a QTc ≥ 500 ms, or other clinically significant arrhythmias were considered AESIs in this study and were reported to the sponsor as soon as possible. All other cardiovascular events were reported according to standard safety reporting and safety surveillance practices, including data review by the IDMC. Central ECG review was performed to ensure consistency in ECG evaluation. Deaths were reported according to standard SAE reporting rules to clarify the cause of death and report the diagnosis of the fatal event as an SAE. Example 1.8H-Multiple Sclerosis Relapse Report

[0282] Multiple sclerosis relapses, as determined by the evaluations described in Example 1.6B, were exempt from reporting as AEs, as were all efficacy endpoints, unless they met the definition of an SAE. Hospitalization for an MS relapse was not considered a severity criterion for this study if routinely completed on-site (e.g., high-dose IV methylprednisolone). Other worsening of neurological symptoms that did not meet the definition of an MS relapse were reported as AEs according to general safety reporting rules. Example 1.8I - Reporting of Safety Screening Results from Magnetic Resonance Imaging

[0283] Magnetic resonance imaging scans were reviewed locally for any non-MS pathology. If such findings were present, the MRI report was provided to the investigator for appropriate safety reporting. When available, the pathological diagnosis underlying such MRI findings, or the findings themselves, were reported as AEs until the diagnosis was clear. Multiple sclerosis findings on MRI were not required to be reported unless they were considered unusual and therefore unique safety findings. Example 1.9 - Treatment of drug overdose

[0284] The sponsor does not recommend specific treatment for overdose. In the event of overdose, the investigator should: -Contact the Medical Monitor immediately. - Closely monitor participants for any AEs / SAEs and laboratory abnormalities until study intervention is no longer systemically detectable and activity is concluded (at least 9 days). - Obtain plasma samples for PK analysis within 1 day of the last dose of the study intervention, if possible, or later if requested by the Medical Monitor (determined on a case-by-case basis). - Record the amount of the overdose and the duration of the overdose in the eCRF.

[0285] Decisions regarding dose interruptions or modifications were made by the investigator in consultation with the medical monitor based on the participant's clinical evaluation. Example 1.10 - Pharmacokinetics Example 1.10A - Sampling Time

[0286] For all participants in both cohorts, samples for BTK inhibitor PK analysis were collected 1 hour (± 0.5 hours) post-dose at visits during weeks 1, 4, 8, 12, and 16. For all participants in both cohorts, additional PK samples were collected 3 hours (± 0.5 hours) post-dose at visits during weeks 4 and 12. Data on the most recent meal prior to PK sampling were specifically recorded in the eCRF. Example 1.10B - Pharmacokinetic Processing Procedure

[0287] A total of 2 mL of blood was collected for each PK sample. The total amount of blood used for PK and the total number of samples collected during the study are presented in Table 6 for each participant. Table 6 - Blood volume and total number of samples per participant Example 1.10C - Bioanalytical Methods

[0288] BTK inhibitors were measured by a validated LC / MS method. Example 1.10D-PK parameters

[0289] Descriptive statistics were used to report BTK inhibitor concentrations at selected time points after IMP ingestion. Additional PK parameters (such as C max , t max and AUC at steady state) were estimated using a population PK approach. Example 1.11 - Pharmacodynamics Example 1.11A - Sampling Time

[0290] Venous blood samples for PBMCs will be collected for measurement of BTK occupancy at baseline (before dosing) and 1 hour (± 0.5 hours) after BTK inhibitor dosing for lymphocyte subset analysis at visits during Weeks 12 and 16 (as part of a biomarker adjunct study). Example 1.11B - Bioanalytical Methods for Pharmacodynamic Parameters

[0291] Peripheral blood mononuclear cells were prepared from whole blood to determine BTK occupancy. Descriptive statistics were used to report the percentage of BTK occupancy at selected time points. Example 1.12 - Pharmacogenetics

[0292] 6 mL blood samples were collected for DNA isolation from participants who agreed to participate in the genetic analysis portion of the study. Participants who did not wish to participate in the genetic study were still able to participate in the study. Samples were collected to investigate allelic variants of drug metabolizing enzymes and / or drug transporters as intrinsic factors associated with PK or PD variability of BTK inhibitors (Example 1.18).

[0293] In the event of DNA extraction failure, a replacement genetic blood sample can be requested from the participant. Example 1.13 - Biomarkers

[0294] Plasma and serum samples for biomarker studies were collected from all participants in this study as specified in the SoA (Table 1). Samples from all participants were tested for neurofilament light chain and chitinase 3-like protein 1 protein and immunoglobulin levels to evaluate their correlation with observed clinical responses. Blood samples for PBMC isolation were collected from all participants from sites that were selected based on their ability to rapidly send blood samples to a central laboratory for processing. Peripheral blood mononuclear cell samples were used to evaluate BTK receptor occupancy (Example 1.11B), for analysis of selected lymphocyte subsets during the study period, and for other possible biomarkers. For all of these samples, approximately 50 mL of blood was drawn. Example 1.14 - Statistical Considerations Example 1.14A - Statistical Assumptions

[0295] The primary objective of the study was to assess the dose-response relationship based on the primary endpoint (number of new Gd-enhancing T1-hyperintense lesions detected by brain MRI) at the end of 12 weeks of BTK inhibitor treatment. The null hypothesis was a flat, no dose-response curve for the primary endpoint, and the alternative was the presence of a dose-response signal. Example 1.14B - Sample Size Determination

[0296] The study included 120 participants who were randomly assigned equally to one of four BTK inhibitor doses in two cohorts (60 participants in each of Cohorts 1 and 2). Cohorts 1 and 2 represented different treatment sequences, and participants in each cohort crossed over to the BTK inhibitor or placebo group in a blinded manner.

[0297] Based on the assumption of a constant average number of new Gd-enhancing T1-hyperintense lesions per month during the 12-week placebo treatment period, 60 participants in cohort 2 began with a 4-week placebo run-in and were used as placebo data in the analysis of the primary endpoint. Assuming that 15% of participants did not have the primary endpoint at the end of 12 weeks of BTK inhibitor treatment, 105 participants (26 per BTK inhibitor dose) had a power of at least 83% to enroll patients using a randomized controlled trial with 6 predefined dose-response curves (2 E max A 2-step MCP-Mod of 100 models (including 100 models, 2 ... Example 1.14C - Populations used for analysis

[0298] For analysis purposes, the following groups were defined as shown in Table 7: Table 7 - Populations used for analysis Example 1.14D - Statistical Analysis

[0299] Efficacy analysis

[0300] Primary Analysis: The primary objective of the dose-response relationship of BTK inhibitors with the primary endpoint (number of new Gd-enhancing T1-hyperintense lesions as detected by brain MRI at the end of 12 weeks of BTK inhibitor treatment) was evaluated in a modified intention-to-treat (mITT) population by a 2-step multiple comparison procedure with modeling techniques (MCP-Mod). The first step of the procedure was to test the efficacy signal (compared to the null hypothesis of a flat no dose-response curve) in a procedure that controlled for type 1 error. To account for uncertainty in the shape of the dose-response, six candidate models were considered to cover diverse and potential dose-response curves: 2 E max Model (ED 50 =10mg, ED 50=30 mg), linear model, quadratic model, logistic model and exponential model. The second step is dose estimation of the dose-response curve, provided that the efficacy signal is established in the first step.

[0301] A negative binomial regression model with baseline Gd-enhanced T1 hyperintense lesion counts, treatment, and covariates of group (group 1 or group 2) was used to estimate the average count of new Gd-enhanced T1 hyperintense lesions in each of the 4 dose groups at the end of 12 weeks of BTK inhibitor treatment and at the end of 4 weeks of placebo. Under the assumption that the rate of formation of Gd-enhanced T1 hyperintense lesions is constant, if the participant receives placebo over 12 weeks, the 4-week post-randomization placebo data from group 2 (i.e., the 4th week data from group 2) is used as the placebo data for week 12 in the analysis. The participants in group 2 contributed placebo data (at week 4) and data from 4 BTK inhibitor doses (at week 16). Therefore, in order to illustrate the potential correlation between the measurements of the 4-week placebo phase and the subsequent 12-week BTK inhibitor treatment phase in group 2, a generalized estimating equation (GEE) method was used to fit a negative binomial model, which explained the intra-participant correlation via the repeated statement in SAS PROC GENMOD. The negative logarithmic transformation of the mean lesion count was input into the MCP-Mod program. Each of the 6 candidate dose-response models was subjected to a joint evaluation of the null hypothesis (i.e., no dose-response relationship) of a flat dose-response curve at the end of 12 weeks of BTK inhibitor treatment for the primary endpoint using a comparative test, wherein the family wise error rate was controlled at a bilateral α=0.05. If step 1 produces a significant result, the best fitting model from the 6 predefined candidate models was selected using the generalized Akaike information criterion (AIC).

[0302] The primary analysis was based on combined data from Cohorts 1 and 2 for each BTK inhibitor dose (i.e., for the number of new Gd-enhancing T1-hyperintense lesions, data from Cohort 1 at Week 12 and data from Cohort 2 at Week 16). Data from Cohorts 1 and 2 were also explored separately as needed.

[0303] Secondary endpoints of analysis: For the secondary endpoint of the number of Gd-enhancing T1-hyperintense lesions at the end of 12 weeks of BTK inhibitor treatment, a similar negative binomial model and MCP-Mod procedure were used. For the total number of Gd-enhancing T1-hyperintense lesions, because it was reasonable to assume a constant rate of lesion formation over 12 weeks with placebo, the same approach as used for the primary endpoint was used by using the week 4 data from cohort 2 as the placebo data for week 12, while accounting for within-participant correlation. Descriptive summary statistics over time are provided for each of the four BTK inhibitor doses.

[0304] Descriptive summary statistics for the number of new or enlarging T2 lesions over time (weeks 4, 8, 12, and 16) are provided for each of the four BTK inhibitor doses. In addition, if it is considered reasonable to extrapolate the week 4 data from cohort 2 to the placebo data at week 12, a similar MCP-Mod approach will be explored.

[0305] The primary efficacy analysis was based on the mITT population.For endpoints assessed by change from baseline, the baseline value was defined as the last measurement collected on or before the randomization visit (Day 1) prior to the start of the first dose of the study intervention.

[0306] Data from cohorts 1 and 2 were combined for the primary analysis (i.e., for the number of new Gd-enhancing T1 hyperintense lesions, data for cohort 1 at week 12 and data for cohort 2 at week 16). For each cohort, descriptive statistics were summarized over time (weeks 4, 8, 12, and 16) as appropriate. The summary from cohort 1 included descriptive statistics for the 4-week placebo period following 12 weeks of BTK inhibitor treatment. Additional efficacy analyses are described in the SAP. Table 8 - Efficacy Analysis

[0307] Security Analysis

[0308] All safety analyses were performed on the safety population. All safety summaries are descriptive. No statistical significance tests were performed on the safety data. The safety endpoints are described in Table 9.

[0309] Baseline values are generally defined as the last available value before the first administration of the randomized study intervention. The safety data for the first 4 weeks after randomization (wherein the participants in group 2 receive placebo) are summarized by BTK inhibitor and placebo. The safety data during the 4-week placebo period (i.e., 4 weeks) in group 1 are summarized separately and displayed by BTK inhibitor dose group and overall. For BTK inhibitor treatment safety data, a summary by dose group, by time on BTK inhibitor, and overall is provided.

[0310] For safety variables, the following observation periods were defined and used for the classification of AEs, determination of on-treatment PCSA values, and the final on-treatment values of laboratory and vital sign parameters. The pre-treatment period was defined as the time from signing the ICF to the first administration of the randomized study intervention. For the purpose of defining "treatment-emergent," the on-treatment period was defined as the time from the first administration of the randomized study intervention until the last study visit. The treatment period was further defined as: - The "Week 1 to 4 period" is defined as the time from the first administration of randomized study treatment to the administration of Week 4 study treatment. For Cohort 1, this is BTK inhibitor treatment for 4 weeks and for Cohort 2, placebo treatment for 4 weeks. - Define the "BTK inhibitor treatment period" as weeks 1 to 12 for Cohort 1 and weeks 4 to 16 for Cohort 2. Note: Participants from the Cohort 1 weeks 1 to 4 period were also included in the 12 weeks of the BTK inhibitor treatment period. - The "post-placebo / BTK inhibitor period" was defined as Week 12 to Week 16 for Cohort 1. This was 4 weeks of placebo treatment following 12 weeks of BTK inhibitor treatment.

[0311] The analysis of AEs focused on adverse events (TEAEs) that occurred during treatment. AEs before treatment were defined as AEs that occurred, worsened, or became severe during the pre-treatment time period. AEs that occurred during treatment (TEAEs) were defined as AEs that occurred, worsened, or became severe during the treatment period.

[0312] The following definitions apply to laboratory parameters, ECG, and vital sign results: - Potentially clinically significant abnormal (PCSA) values were defined as abnormal values that the sponsor considered medically important based on predefined criteria / thresholds based on a literature review and defined by the sponsor for clinical laboratory tests and vital signs. - Potentially clinically significant abnormalities criteria identified which participants had at least 1 PCSA during the on-treatment period, taking into account all evaluations performed during the on-treatment period (including unplanned or repeat evaluations). The number of all such participants was the numerator of the percentage of on-treatment PCSA. Table 9-Safety Analysis

[0313] Individual PK concentrations are summarized descriptively by visit. Additional PK parameters as well as population PK and PD analyses as described in Example 1.10D are presented in separate files. Example 1.15 - Interim Analysis

[0314] If deemed necessary due to slower-than-expected recruitment, an interim analysis will be conducted when at least 44 participants have completed the 16-week study (12 weeks of BTK inhibitor treatment and 4 weeks of placebo). If the trial recruits rapidly, an interim analysis will not be conducted because it would be too close in time to the final analysis (i.e., less than 3 to 4 months) to be worthwhile. The purpose of the interim analysis is to explore the efficacy signal and optimize the plan for the Phase 3 study. The operating documents predefine the conditions for conducting the interim analysis (e.g., recruitment rate), and the decision to conduct the interim analysis is made before the SAP is finalized. If an interim analysis is conducted, the reduction in the number of new Gd-enhancing T1-hyperintense lesions (only in the 60 mg group or in the combined 60 mg and 30 mg groups) compared to the placebo group (using the 4-week post-randomization placebo data from Cohort 2) and the potential dose-response curve will be explored. The interim analysis will be conducted by an unblinded independent statistician. Since the study will not be stopped early due to efficacy claims based on this potential exploratory interim analysis, no alpha adjustment will be performed at the final analysis if the interim analysis is conducted. SAP describes in more detail the plan for an interim analysis (if one is to be performed).

[0315] The IDMC will be used to monitor the safety of the study. Example 1.16 - Clinical Laboratory Testing

[0316] Details of the clinical laboratory tests are provided in Table 10. Additional testing determined necessary by the Investigator or required by local regulations was performed at any time during the study. Table 10 - Safety laboratory assessments required by the protocol Example 1.17 - Contraceptive guidance and pregnancy information collection

[0317] Women of childbearing potential (WOCBP): Women are considered fertile after menarche and until postmenopause unless permanently infertile.

[0318] Women in the following categories are not considered WOCBP: 1) Before menarche 2) Premenopausal women with one of the following: documented hysterectomy, documented bilateral salpingectomy, documented bilateral oophorectomy. 3) Postmenopausal women Postmenopausal status is defined as 12 months of amenorrhea with no alternative medical reason. In women not using hormonal contraception or hormone replacement therapy (HRT), a high FSH level in the postmenopausal range can be used to confirm postmenopausal status. However, a single FSH measurement is inadequate in the absence of 12 months of amenorrhea. - Women taking HRT and whose menopausal status is in question need to use a non-estrogen hormonal highly effective contraceptive method if they wish to continue their HRT during the study. Otherwise, they must discontinue HRT to allow confirmation of postmenopausal status before study enrollment.

[0319] Contraception guidance Male participants ○ Male participants with female partners of reproductive potential are eligible if they agree to one of the following from enrollment until 3 months after the last dose of the study intervention: ■Not engaging in penile-vaginal intercourse (long-term and sustained abstinence) as per usual and preferred lifestyle and agreeing to remain abstinent ■ Agree to use male condoms during penile-vaginal intercourse with a woman of reproductive potential who is not currently pregnant, plus a contraceptive method with a failure rate of < 1% per year as described in Table 11 ○ In addition, male participants must refrain from donating sperm for the duration of the study and for 6 months after the last dose of the study intervention vMale participants with pregnant or breastfeeding partners must agree to abstain from penile-vaginal intercourse for 3 months after the last dose or to use a male condom during each penile penetration. Female participants Because established reproductive toxicity studies have not been conducted with BTK inhibitors, investigators should take appropriate precautions during WOCBP exposure in this clinical trial. Female participants of childbearing potential are eligible to participate if they agree to use dual contraception (including a highly effective method of contraception that is continuous and correct as described in Table 9) from enrollment and until 2 months after the last study dose. In addition, WOCBP must refrain from donating eggs for the duration of the study and for 2 months after the last dose of the study intervention. Table 11. Highly effective contraceptive methods

[0320] Pregnancy Testing: WOCBP were included only after a confirmed menstrual period and a negative high-sensitivity serum pregnancy test. Pregnancy testing was performed monthly during the intervention period and 1 month after the last dose of the study intervention and as needed locally. Pregnancy testing was performed whenever a menstrual period was missed or pregnancy was otherwise suspected.

[0321] Pregnancy Information Collection:

[0322] Male Participants with Pregnant Partners - While male participants are in this study, the investigator will attempt to collect pregnancy information from the pregnant female partner of any male participant. This applies only to male participants receiving BTK inhibitors. After obtaining the necessary signed informed consent directly from the pregnant female partner, the investigator will record the pregnancy information on the appropriate form and submit it to the sponsor within 24 hours of learning of the partner's pregnancy. The female partner should also be followed up to determine the outcome of the pregnancy. Information about the status of the mother and child will be forwarded to the sponsor. Generally, follow-up will not exceed 6 to 8 weeks after the expected date of delivery. Any termination of pregnancy will be reported regardless of the fetal status (presence or absence of abnormalities) or surgical indications.

[0323] Pregnant Female Participants - The investigator collected pregnancy information from any female participant who became pregnant during participation in this study. This information was recorded on the appropriate form and submitted to the sponsor within 24 hours of learning of the participant's pregnancy. Participants were followed to determine the outcome of the pregnancy. The investigator collected follow-up information on the participant and the newborn and forwarded this information to the sponsor. Generally, follow-up was not required for more than 6 to 8 weeks after the due date. Any termination of pregnancy was reported regardless of fetal status (presence or absence of abnormalities) or surgical indication. Any pregnancy complication or elective termination of pregnancy was reported as an AE or SAE. Spontaneous miscarriage was always considered an SAE and reported as an SAE. Any post-study pregnancy-related SAE that the investigator believed was reasonably related to the study intervention was reported to the sponsor. Although the investigator was not obligated to actively seek this information from former study participants, he or she could learn of an SAE through spontaneous reporting. Any female participant who became pregnant during participation in the study discontinued the study intervention and withdrew from the study. Example 1.18 - Genetics

[0324] DNA use / analysis

[0325] Genetic variation can influence a participant's response to a study intervention, disease susceptibility, and disease severity and progression. Variable responses to a study intervention can be due to genetic determinants that influence drug absorption, distribution, metabolism, and excretion; the drug's mechanism of action; disease etiology; and / or the molecular subtype of the disease being treated. Therefore, blood samples for DNA analysis were collected from consenting participants, as permitted by local regulations and the IRB / IEC.

[0326] The DNA samples are used for research related to the research intervention or MS and related diseases. They can also be used to develop tests / assays, including diagnostic tests related to the research intervention and indications. Genetic studies can consist of analyzing one or more candidate genes or analyzing genetic markers of the entire genome (as appropriate). DNA samples are analyzed to study allelic variants of drug metabolizing enzymes and / or drug transporters as intrinsic factors associated with the PK or PD variability of BTK inhibitors. Additional analysis can be performed if it is hypothesized that this can help to further understand the clinical data. The samples can be analyzed as part of a multi-study assessment involving genetic factors that respond to BTK inhibitors or such research interventions to understand the research disease or related conditions. Example 1.19 - List of Example Prohibited Drugs

[0327] The following drugs that are strong inducers or inhibitors of CYP3A or CYP2C8 hepatic enzymes should not be taken during the study because they have the potential to alter BTK inhibitor kinetics due to interactions with P450-mediated metabolism (according to the list in the University of Washington Drug Interaction Database Project (www.druginteractioninfo.org)). Please note that the list provided is not exhaustive and product information for concomitant medications should be consulted. Table 12 - List of example drugs that may be metabolized by BTK inhibitors Table 13 - List of exemplary drugs with the potential to affect plasma exposure of BTK inhibitors via reduction of gastric acid Table 14 - Abbreviations Example 2: Results of a dose-finding and safety study of a BTK inhibitor in relapsing multiple sclerosis

[0328] We present here the results of the dose-finding and safety studies described in Example 1. We determined the dose-response relationship of BTK inhibitors in reducing the number of new active brain lesions, including the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions. We also evaluated the efficacy of BTK inhibitors on disease activity, as measured by imaging, by measuring the number of new or enlarging T2 lesions and the total number of Gd-enhancing T1 hyperintense lesions. We also evaluated the safety and tolerability of the BTK inhibitor dose response.

[0329] This study was a multicenter study with a total of 40 active sites in Europe and North America, as described in Example 1. All participants were centrally assigned in equal ratios to 1 of 8 groups (4 dose groups in each of 2 cohorts) using an interactive voice / web response system to start the BTK inhibitor (in Cohort 1) or placebo (in Cohort 2) period and then cross over.

[0330] Within each cohort, participants were randomly assigned equally in a blinded fashion to 1 of 4 BTK inhibitor doses (5 mg, 15 mg, 30 mg, or 60 mg once daily).

[0331] Cohort 1: Participants received a BTK inhibitor dose for the first 12 weeks and then crossed over to the placebo group for 4 weeks.

[0332] Cohort 2: Participants received placebo for the first 4 weeks and then crossed over to a BTK inhibitor dose for 12 weeks.

[0333] All brain scans were reviewed and interpreted by one or more effectively blinded radiologists at an independent, treatment-blinded central facility, thus avoiding bias and ensuring standardized end-point assessments.

[0334] Diagnostic and inclusion criteria: Participants were aged 18 to 55 years, diagnosed with RMS according to the 2017 revised McDonald diagnostic criteria, and had at least 1 documented relapse in the past year, or ≥2 documented relapses in the past 2 years, or ≥1 active Gd-enhancing brain lesion on MRI scans taken 6 months before screening.

[0335] Primary key endpoints and main secondary key endpoints

[0336] effect: ● Primary: The number of new gadolinium (Gd)-enhancing T1-hyperintense lesions as detected by brain MRI at the end of 12 weeks of BTK inhibitor treatment.

[0337] secondary: The number of new or enlarging T2 lesions at the end of 12 weeks of BTK inhibitor treatment; Number of Gd-enhancing T1-hyperintense lesions at the end of 12 weeks of BTK inhibitor treatment

[0338] Security: Adverse events (AEs), serious adverse events (SAEs), potentially clinically significant abnormalities in laboratory tests, electrocardiograms (ECGs), or vital signs during the study period

[0339] Statistical methods:

[0340] Analysis of the primary endpoint:

[0341] The primary analysis was based on the combined data from cohorts 1 and 2 for each BTK inhibitor dose (ie, for the number of new Gd-enhancing T1-hyperintense lesions, data at week 12 for cohort 1 and data at week 16 for cohort 2).

[0342] The primary objective of the dose-response relationship of BTK inhibitors with the primary endpoint (number of new Gd-enhancing T1-hyperintense lesions as detected by brain MRI at the end of 12 weeks of BTK inhibitor treatment) was evaluated in a modified intention-to-treat (mITT) population by a 2-step multiple comparison procedure with modeling techniques (MCP-Mod). The first step of the procedure was to test the efficacy signal (compared to the null hypothesis of a flat no dose-response curve) in a procedure that controlled for type 1 error. To account for uncertainty in the dose-response shape, six candidate models were considered to cover diverse and potential dose-response curves: 2 E max Model (ED 50 =10mg, ED 50 =30 mg), linear model, quadratic model, logistic model and exponential model. In the second step, since the efficacy signal was established in the first step, the dose-response curve was estimated.

[0343] In MCP-Mod step 1, a negative binomial regression model with baseline Gd-enhanced T1 high signal lesion activity (presence / absence) and treatment covariates was used to assess the average count of new Gd-enhanced T1 high signal lesions in each of the 4 dose groups at the end of 12 weeks of BTK inhibitor treatment and at the end of 4 weeks of placebo. If the participant received systemic corticosteroids within 30 days before the MRI assessment date, MRI assessment was excluded from the analysis. Under the assumption that Gd-enhanced T1 high signal lesion formation rate is constant, if the participant receives placebo through 12 weeks, the 4-week post-randomization placebo data from group 2 (i.e., the 4th week data from group 2) is used as the placebo data for the 12th week in the analysis. The participant in group 2 contributed placebo data (at the 4th week) and the data of 4 kinds of BTK inhibitor dosages (at the 16th week). The 4-week placebo exhaustion data from group 1 were not included in the analysis. Therefore, to illustrate the potential correlation between the measurements of the 4-week placebo period and the subsequent 12-week BTK inhibitor treatment period in Group 2, the generalized estimating equation (GEE) method was used to fit a negative binomial model that accounted for intra-participant correlation using the "REPEATED" statement in SAS PROC GENMOD. The negative logarithmic transformation of the mean lesion count was input into the MCP-Mod program. A joint evaluation of the null hypothesis of a flat dose-response curve (i.e., no dose-response relationship) for the primary endpoint at the end of 12 weeks of BTK inhibitor treatment was performed for each of the 6 candidate dose-response models using a comparative test that controlled the family error rate at a two-sided α of 0.05. Test statistics and adjusted p-values were provided for all 6 candidate models.

[0344] In MCP-Mod step 2, all candidate models with adjusted p-values < 0.05 from step 1 were fitted. The generalized Akaike information criterion (AIC) and model parameters were provided. The best-fitting model was selected as the model with the smallest generalized AIC. Doses for the phase 3 program were then estimated based on the final selected model.

[0345] In addition, the relative reduction in the mean count of new Gd-enhancing T1-hyperintense lesions and the corresponding 95% confidence intervals (CIs) are provided for each of the four BTK inhibitor dose groups relative to the placebo group based on the negative binomial regression model described above.

[0346] Descriptive statistics are also provided for the number of new Gd-enhancing T1-hyperintense lesions observed over time for the four BTK inhibitor dose groups (Week 4 / Week 8, Week 8 / Week 12, and Week 12 / Week 16 for Cohort 1 / Cohort 2) and the placebo group (Week 4 for Cohort 2).

[0347] Analysis of secondary endpoints:

[0348] For each secondary endpoint, a similar negative binomial model and MCP-Mod procedure were used. Because it was reasonable to assume a constant rate of lesion formation over 12 weeks under placebo treatment, the same approach as used for the primary endpoint was used, i.e., using the week 4 data from cohort 2 as the placebo data at week 12, while accounting for within-participant correlation. Descriptive summary statistics are provided for each of the four BTK inhibitor dose groups over time.

[0349] All safety summaries are descriptive and performed for the safety population. Safety data for the first 4 weeks after randomization (when participants in Cohort 2 received placebo) were summarized by BTK inhibitor treatment and placebo treatment. Safety data during the BTK inhibitor treatment period (from the first BTK inhibitor administration) were summarized by BTK inhibitor dose group and overall.

[0350] Group characteristics:

[0351] 130 patients were randomized.

[0352] Participant demographics and characteristics at baseline were generally well balanced across the eight treatment groups (two cohorts, four treatment arms each). The median age of participants was 36.3 years (range: 19 to 55 years). The majority of participants were female (91; 70.0%). Notably, 119 of the 130 participants (91.5%) were white.

[0353] All 130 participants were diagnosed with RMS (128 with relapsing RMS and 2 with secondary progressive MS) and had a mean EDSS score of 2.50, a median time since first diagnosis of 3.5 years, and a median time since first symptom of MS of 4.9 years. One hundred and twenty-seven (97.7%) participants had at least one relapse in the year before screening, and 61 (46.9%) had highly active disease (HAD), defined as one relapse in the year before screening and ≥1 Gd-enhancing lesion on MRI performed within 6 months before screening, or nine or more T2 lesions at baseline, or two or more relapses in the year before screening.

[0354] A total of 129 of the 130 patients completed the treatment period. One participant permanently discontinued treatment after week 12 due to refusal to comply with contraceptive requirements.

[0355] Table 15 provides details of patient disposition. Tables 16A-16B summarize the demographic and baseline characteristics of the patients. Table 17 shows details of the duration of exposure in each group, and Table 18 shows details of exposure by dose in each group.

[0356] Efficacy results:

[0357] Primary Efficacy Endpoint: The study achieved its primary objective, demonstrating a dose-response relationship for the BTK inhibitor as evidenced by a reduction in the number of new active Gd-enhancing T1-hyperintense brain lesions detected by brain MRI after 12 weeks of treatment.

[0358] Table 19 provides a summary of the relative reduction in new Gd-enhancing T1-hyperintense brain lesions compared to placebo after 12 weeks of treatment. Table 20 shows the MCP-Mod of new Gd-enhancing T1-hyperintense brain lesions after 12 weeks of treatment. MCP-Mod evaluation was performed as described above in the Statistical Methods section.

[0359] MCP-Mod step 2 was obtained to assess the estimated dose-response curve for new Gd-enhancing T1-hyperintense brain lesions. To account for potential correlations between measurements in cohort 2 during the run-in period and the treatment period, a generalized estimating equation method (GEE) was used to fit a model that accounted for within-subject correlations. The mean lesion counts at week 12 for BTK inhibitor treatment and the mean lesion counts for placebo at week 4 were estimated and explained by a negative binomial regression model for potential correlations between measurements during the 4-week placebo period and the subsequent 12-week BTK inhibitor treatment period in cohort 2. MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days prior to the MRI assessment date.

[0360] As shown in Table 19, the observed mean (SD) of new Gd-enhancing T1 hyperintense lesion counts at 12 weeks after treatment was 1.03 (2.50) in the placebo group, 1.39 (3.20) in the BTK inhibitor 5 mg group, 0.77 (1.48) in the BTK inhibitor 15 mg group, 0.76 (3.31) in the BTK inhibitor 30 mg group, and 0.13 (0.43) in the BTK inhibitor 60 mg group. Based on the negative binomial regression model adjusted for baseline Gd-enhancing T1 hyperintense lesion activity, the relative reduction in lesions at 12 weeks compared to placebo was statistically significant in the 60 mg dose group (85.02%; 95% CI [28.02%, 96.88%]; nominal p value = 0.0178), but not in the lower dose groups. Notably, 90.30% of participants (28 of 31) in the BTK inhibitor 60 mg dose group with evaluable MRI data had no new Gd-enhancing T1 hyperintense lesions at the end of 12 weeks of treatment. An exponential model was selected as the best-fit dose-response curve.

[0361] Key secondary efficacy endpoints: Table 21 provides a summary of the relative reduction in new or enlarged T2 lesion counts compared to placebo after 12 weeks of treatment. Table 22 shows the MCP-Mod for new and enlarged T2 lesion counts after 12 weeks of treatment. Table 23 provides a summary of the relative reduction in total T2 Gd-enhancing T1 hyperintense lesion counts compared to placebo after 12 weeks of treatment. Table 24 shows the MCP-Mod for the total count of Gd-enhancing T1 hyperintense lesions after 12 weeks of treatment. The 12 weeks after treatment represent week 12 for BTK inhibitor-treated cohort 1, week 16 for BTK inhibitor-treated cohort 2, and week 4 for placebo-treated cohort 2. MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days prior to the MRI assessment date. MCP-Mod 1 failed to declare significance.

[0362] As shown in Table 21, for the secondary endpoint of counts of new or enlarged T2 lesions at the end of 12 weeks of BTK inhibitor treatment, the observed mean (SD) was 2.12 (5.16) in the placebo group, 1.90 (3.97) in the BTK inhibitor 5 mg group, 1.32 (1.83) in the BTK inhibitor 15 mg group, 1.30 (4.90) in the BTK inhibitor 30 mg group, and 0.23 (0.62) in the BTK inhibitor 60 mg group. Unlike the other dose groups, the 60 mg group showed a statistically significant relative reduction in the adjusted counts of new and enlarged T2 lesions relative to the placebo group (89.34%; 95% CI: [68.39%, 96.41%]; nominal p value = 0.0001). 87.1% of participants (27 of 31) in the BTK inhibitor 60 mg group with evaluable MRI data were free of new and enlarging T2 lesions at the end of 12 weeks of treatment.A linear model was selected as the best fit for the dose-response curve.

[0363] As shown in Table 23, for the secondary endpoint count of Gd-enhancing T1 hyperintense lesions at 12 weeks of BTK inhibitor treatment, the observed mean (SD) was 1.36 (3.52) in the placebo group, 1.77 (4.10) in the BTK inhibitor 5 mg group, 0.87 (1.59) in the BTK inhibitor 15 mg group, 1.18 (4.87) in the BTK inhibitor 30 mg group, and 0.29 (0.86) in the BTK inhibitor 60 mg group. No statistically significant relative reduction in lesion counts was observed at any of the BTK inhibitor test doses relative to placebo. However, a higher percentage of participants in the BTK inhibitor 60 mg group with evaluable MRI data (87.1%, 27 of 31) were observed to have no Gd-enhancing T1 hyperintense lesions at the end of 12 weeks of treatment compared to the placebo group (74.6%, 44 of 59).

[0364] Safety results: BTK inhibitors were well tolerated over 12 weeks of treatment. Table 25A provides an overview of adverse events that occurred during the treatment period in weeks 1-4. Table 25B provides an overview of adverse events during the 4-week period. Table 25C provides an overview of adverse events during the 12-week period. Table 26 provides an overview of adverse events that occurred during treatment in the BTK inhibitor treatment period. Table 27 provides an overview of serious treatment-emergent adverse events in the BTK inhibitor treatment period. Table 28 provides an overview of treatment-emergent adverse events of particular concern in the 1-4 weeks period. Table 29 provides an overview of treatment-emergent adverse events of particular concern in the BTK inhibitor treatment period. Table 30 provides an overview of adverse events that occurred in more than two patients across the dose range during the 12-week treatment period.

[0365] As shown in Table 17, the mean duration of BTK inhibitor exposure during the first 16 weeks was 82.1 days, 81.5 days, 83.6 days, and 82.1 days for the 5 mg, 15 mg, 30 mg, and 60 mg BTK inhibitor groups, respectively, and 28.0 days for the placebo group. The mean duration of exposure to the BTK inhibitor across all dose groups was 82 days.

[0366] No deaths were reported in the study. One treatment-emergent SAE was reported in a participant in Cohort 1 treated with 60 mg of the BTK inhibitor. The event (an MS relapse in a 32-year-old female participant) occurred approximately 8 weeks after starting treatment with the BTK inhibitor. The participant had difficulty talking and was unable to drink water without drooling. Dysphagia was not reported in the hospitalization record. She was hospitalized 2 days after experiencing symptoms to rule out a possible stroke. The investigators assessed the event as severe. An MS relapse was confirmed, treatment continued without interruption, and the participant completed the study and was successfully enrolled in the long-term extension study.

[0367] With the exception of one severe TEAE reported in the 60 mg BTK inhibitor group (the SAE of severe MS relapse described above), all TEAEs reported were mild or moderate in intensity.

[0368] There were no TEAEs that led to permanent treatment discontinuation. The proportion of participants experiencing TEAEs at Weeks 1 to 4 was 34.8%, 31.3%, 18.8%, 12.5%, and 31.3% in the placebo group and the 5 mg, 15 mg, 30 mg, and 60 mg groups, respectively. The proportion of participants with TEAEs during the treatment period was similar in the four BTK inhibitor groups (57.6%, 53.1%, 54.5%, and 50.0% in the 5 mg, 15 mg, 30 mg, and 60 mg BTK inhibitor groups, respectively).

[0369] The most frequently reported TEAEs (>3 events total) by primary SOC during the Weeks 1 to 4 (placebo-controlled) period were headache (4 patients in the placebo group, 3 patients in the BTK inhibitor 5 mg group, 2 patients in the BTK inhibitor 15 mg group, and 1 patient in the BTK inhibitor 60 mg group), upper respiratory tract infection (1 patient in each treatment group including the placebo group), and nausea (1 patient in the placebo group, 2 patients in the BTK inhibitor 5 mg group, and 1 patient in the BTK inhibitor 30 mg group).

[0370] As shown in Table 30, the most frequently reported TEAEs by primary SOC during the 12-week BTK inhibitor treatment period were: headache (1 in the BTK inhibitor 5 mg group, 3 in the BTK inhibitor 15 mg group, 1 in the BTK inhibitor 30 mg group, and 4 in the BTK inhibitor 60 mg group), upper respiratory tract infection (2 in the BTK inhibitor 5 mg group, 2 in the BTK inhibitor 15 mg group, 1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group), nasopharyngitis (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 30 mg group, and 3 in the BTK inhibitor 60 mg group), back pain (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 15 mg group, and 2 in the BTK inhibitor 30 mg group), peripheral edema (2 in the BTK inhibitor 5 mg group and 2 in the BTK inhibitor 60 mg group), dizziness (2 in the BTK inhibitor 5 mg group and 2 in the BTK inhibitor 60 mg group), vomiting (2 in the BTK inhibitor 5 mg group and 2 in the BTK inhibitor 60 mg group), vomiting (2 in the BTK inhibitor 5 mg group and 2 in the BTK inhibitor 60 mg group), dizziness (2 in the BTK inhibitor 15 mg group and 2 in the BTK inhibitor 60 mg group), vomiting ... rheumatoid arthritis (2 in the BTK inhibitor 15 mg group and 2 in the BTK inhibitor 60 mg group), nasopharyngitis (2 in the BT The incidence of cataract (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group) was higher in the BTK inhibitor group than in the BTK inhibitor 60 mg group, with a decrease in the incidence of cataract (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group), gastroenteritis (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group), respiratory tract infection (1 in the BTK inhibitor 15 mg group, 1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group), muscle spasm (1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group), oropharyngeal pain (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group), alopecia (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 15 mg group, and 1 in the BTK inhibitor 60 mg group), increased alanine aminotransferase (1 in the BTK inhibitor 5 mg group, 1 in the BTK inhibitor 30 mg group, and 1 in the BTK inhibitor 60 mg group), and accidental overdose (3 in the BTK inhibitor 60 mg group). Each of the three participants who experienced hair loss had a medical history of conditions that could potentially explain the event.

[0371] As shown in Table 29, two AESI (alanine aminotransferase increase> 3x ULN) were reported in this study, 1 during the 30mg BTK inhibitor treatment period and 1 during the 60mg BTK inhibitor treatment period. In both cases, the liver enzyme elevation was transient, IMP was not discontinued, liver enzymes returned to normal levels, and the participants completed the study. The event in the participant receiving 60mg was assessed by the investigator as mild and accompanied by reported pruritus, while the other was assessed as moderate and without accompanying symptoms. One participant (60mg group) had an ALT level above ULN (34U / L) at screening and randomization (48 and 50U / L, respectively) and reached> 3x ULN levels (107U / L) at the 4th week visit. ALT levels gradually decreased, reaching normal levels (28U / L) at week 12. Another participant (30 mg group) had an ALT level >3x ULN (105 U / L) at the Week 8 visit, and the level returned to normal (32 U / L) within 4 days. Both participants were female.

[0372] PCSA were reported in multiple treatment groups with no dose relationship in relation to the following: vital signs (systolic blood pressure, weight), lab (hemoglobin ≤115 g / L [males], ≤95 g / L [females]; hematocrit ≤0.37 v / v [males], ≤0.32 v / v [females]; ALT >3 x ULN, bilirubin >1.5 x ULN), and ECG (e.g., heart rate <50 beats / min, heart rate >90 beats / min, heart rate >100 beats / min, PR >200 msec, QRS >110 msec, QTc Bazett >450 msec, QTc Fridericia >450 msec).

[0373] in conclusion

[0374] The study met its primary objective, demonstrating a dose-response relationship for the BTK inhibitor, as demonstrated by a reduction in the number of new active Gd-enhancing T1-hyperintense brain lesions detected by brain MRI after 12 weeks of treatment, with a statistically significant difference in the 60 mg BTK inhibitor group compared to placebo; the differences in the other BTK inhibitor treatment groups compared to placebo were not statistically significant. Consistently, efficacy for disease activity was also demonstrated by a reduction in the number of new and enlarging T2 lesions detected by brain MRI after 12 weeks of 60 mg BTK inhibitor treatment, but not for the 5 mg, 15 mg, and 30 mg BTK inhibitor doses. However, the data did not show a statistically significant reduction in the total count of Gd-enhancing T1-hyperintense lesions after 12 weeks of BTK inhibitor treatment, regardless of the dose tested.

[0375] There was no direct correlation between the dose of BTK inhibitor administered and the number of TEAEs. The most common events (preferably duration) observed in participants in the BTK inhibitor treatment group were headache, upper respiratory tract infection, and nasopharyngitis. Low numbers of AESI and PCSA were observed across multiple dose groups. No new risks were identified in this trial.

[0376] These findings suggest that BTK inhibitor treatment across a range of doses is well tolerated and effective in reducing MRI lesions in patients with relapsing MS. Table 15 - Patient Disposition n: number of participants in category, N: number of participants randomized, BTKi: BTK inhibitor Note: Percentages were calculated using the number of participants randomized as the denominator. Table 16A - Demographics and Baseline Characteristics Demographics and Participant Characteristics at Baseline - Randomized Group BMI: body mass index, n: number of participants in the category, N: number of participants randomized, placebo: 4-week placebo period in cohort 2, BTKi: BTK inhibitor Table 16B - Baseline Characteristics of Patients EDSS = Expanded Disability Status Scale; Gd = gadolinium; RRMS = relapsing-remitting multiple sclerosis. Highly active disease was defined as one relapse in the year before screening and ≥1 Gd-enhancing lesion on MRI performed within 6 months before screening, or ≥9 T2 lesions at baseline, or ≥2 relapses in the year before screening. Values are mean (SD) unless otherwise stated; a Only cohort 2 placebo group, which started BTKi treatment at week 4, was included; b N = 127; c N = 32; d N=31. Table 17 - Duration of Exposure: Safety Population Exposure to Investigational Drug - Safety Population n: number of participants in the category, N: number of participants in the safety population, Placebo: 4-week placebo period in Cohort 2, BTKi: BTK inhibitor. Duration of IMP exposure was defined as the last dose date minus the first dose date + 1 day, not accounting for unplanned intermittent discontinuations. Table 18 - Duration of Exposure: Safety Population Table 19 - Descriptive Summary of New Gd-Enhancing T1 Hyperintense Lesions After 12 Weeks of Treatment and Relative Reduction Compared to Placebo BTKi: BTK inhibitor mg per day. *After 12 weeks of BTK inhibitor treatment stands for: Week 12 for BTK inhibitor-treated Cohort 1, Week 16 for BTK inhibitor-treated Cohort 2, and Week 4 for placebo for Cohort 2. **MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days before the date of MRI assessment. #Negative binomial model adjusted for baseline Gd-enhancing T1-hyperintense lesion activity (presence / absence). ***P-values not adjusted for multiplicity. Table 20 - MCP-Mod of new Gd-enhancing T1-hyperintense lesions after 12 weeks of treatment BTKi: BTK inhibitor mg per day. *After 12 weeks of BTK inhibitor treatment stands for: Week 12 for BTK inhibitor-treated Cohort 1, Week 16 for BTK inhibitor-treated Cohort 2, and Week 4 for placebo for Cohort 2. Note 1: MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days before the date of the MRI assessment. Note 2: Select the exponential model with the smallest AIC. Table 21 - Descriptive Summary of New or Enlarging T2 Lesion Counts and Relative Reduction Compared to Placebo After 12 Weeks of Treatment BTKi: BTK inhibitor mg per day. *After 12 weeks of BTK inhibitor treatment stands for: Week 12 for BTK inhibitor-treated Cohort 1, Week 16 for BTK inhibitor-treated Cohort 2, and Week 4 for placebo for Cohort 2. **MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days before the date of MRI assessment. #Negative binomial model adjusted for baseline T2 hyperintense lesion activity (presence / absence). ***P-values not adjusted for multiplicity. Table 22 - MCP-Mod of new or enlarging T2 lesion counts after 12 weeks of treatment BTKi: BTK inhibitor mg per day. *After 12 weeks of BTK inhibitor treatment stands for: Week 12 for BTK inhibitor-treated Cohort 1, Week 16 for BTK inhibitor-treated Cohort 2, and Week 4 for placebo for Cohort 2. Note 1: MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days before the date of the MRI assessment. Note 2: Select the linear model with the smallest AIC. Table 23 - Descriptive Summary of Total Gd-Enhancing T1 Hyperintense Lesions and Relative Reduction Compared to Placebo after 12 Weeks of Treatment* BTKi: BTK inhibitor mg per day. *Represents after 12 weeks of BTK inhibitor treatment: Week 12 for BTK inhibitor-treated Cohort 1, Week 16 for BTK inhibitor-treated Cohort 2, and Week 4 for placebo for Cohort 2. **MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days before the date of MRI assessment. #Negative binomial model adjusted for baseline Gd-enhancing T1-hyperintense lesion activity (presence / absence). ***P-values not adjusted for multiplicity. Table 24 - MCP-Mod of the total count of Gd-enhancing T1 hyperintense lesions after 12 weeks of treatment Table 25A - Summary of Treatment-Emergent Adverse Events - Weeks 1 to 4 TEAE: treatment-emergent adverse event, SAE: serious adverse event n(%) = number and percentage of participants with at least one TEAE Note: Placebo is the 4-week placebo period for Cohort 2. Table 25B - Overview of Adverse Events - Weeks 1 to 4 Table 25C - Overview of Adverse Events - Weeks 1 to 12 Table 26 - Summary of Treatment-Emergent Adverse Events - BTK Inhibitor Treatment Period, Safety Population TEAE: treatment-emergent adverse event, SAE: serious adverse event n(%) = number and percentage of participants with at least one TEAE Table 27 - Serious Treatment-Emergent Adverse Events - BTK Inhibitor Treatment Period, Safety Population Number (%) of Participants with One or More Treatment-Emergent SAEs by Primary SOC and PT during the BTK Inhibitor Treatment Period SAE: Serious Adverse Event, SOC: System Organ Class, PT: Preferred Term MedDRA 22.1 n(%) = number and percentage of participants with at least one treatment-emergent SAE Note: Table presented based on a summary of all TEAEs, sorted by internationally agreed order of SOC and PTs in descending frequency Table 28 - Treatment-emergent adverse events of special interest - Weeks 1 to 4 Table 29 - Treatment-Emergent Adverse Events of Special Interest - BTK Inhibitor Treatment Period, Safety Population Table 30 - Adverse Events Emerging in >2 Patients Across the Dose Range During the 12-Week Treatment Period Example 3 - MRI Outcomes from a Long-Term Extension Study of a BTK Inhibitor in Patients with Relapsing Multiple Sclerosis: 2-Year Results

[0377] The long-term safety of BTK inhibitors was also measured.

[0378] Objective: To report MRI outcomes at week (W) 96 (year 2) in the long-term safety (LTS) extension of a phase 2b BTK inhibitor trial in patients with relapsing multiple sclerosis.

[0379] Background: BTK inhibitors are brain-penetrant inhibitors of Bruton's tyrosine kinase currently being evaluated for the treatment of multiple sclerosis. In the double-blind phase (DBP) of a Phase 2b trial (NCT03889639), BTK inhibitors were well tolerated over 12 weeks, with a dose-dependent reduction in new gadolinium (Gd)-enhancing T1 and new / enlarged T2 lesions. LTS16004 (NCT03996291) is an ongoing LTS extension study of a BTK inhibitor in patients who have completed the Phase 2b study.

[0380] Design / Methods: After the last DBP BTK inhibitor dose and a variable treatment interval thereafter (mean ± SD, 7 ± 7.3 weeks; range, 0-21 weeks), patients began LTS extension part A, in which they continued to receive their DBP dose (5 mg / day, 15 mg / day, 30 mg / day, or 60 mg / day) in a double-blind fashion until a phase 3 dose was selected. In the current open-label extension part B, all patients received 60 mg / day. MRI outcomes included the number of new Gd-enhancing and new / enlarging T2 lesions, change from baseline in T2 lesion volume, slowly evolving lesions (SEL), and paramagnetic rim lesions (PRL).

[0381] Results: Of the 125 patients treated in the LTS extension, 124 completed Part A and transitioned to Part B; as of February 18, 2022 (cutoff W96), 114 (90.5%) remained on study. At baseline DBP, the mean ± SD age of enrolled patients was 37.7 ± 9.6 years (range, 19-56); 69% were women. The number of new Gd-enhancing lesions remained low in the 60 / 60 mg group until W96, while decreasing from W48 to W96 in the other groups (W96 mean ± SD for the 5 / 60 mg group, 0.41 ± 0.91 for the 15 / 60 mg group, 0.90 ± 2.16 for the 30 / 60 mg group, and 0.31 ± 0.66 for the 60 / 60 mg group). New / enlarging T2 lesion counts remained low in the 60 / 60 mg group. T2 lesion volume changes remained low for the 60 / 60 mg group (W96 compared to baseline [mean ± SD]: +0.38 ± 2.11 cm 3The median (IQR) W96 SEL volumes for the 5 / 60 mg, 15 / 60 mg, 30 / 60 mg, and 60 / 60 mg groups were 247.5 (84-420) mm3, 258 (66-906) mm3, 570 (133.5-1011) mm3, and 244.5 (87-939) mm3, respectively. PRL counts remained unchanged in 18 patients; 2 patients had 1 PRL at baseline but not at W96; and 3 patients had 1-3 additional PRLs at W96 compared to baseline (none in the 60 / 60 mg group).

[0382] Conclusions: When all participants switched to 60 mg, new Gd-enhancing lesion counts remained low for the BTK inhibitor 60 / 60 mg group and decreased in the lower-dose groups from Weeks 48 to 96 of the LTS. As of March 7, 2022, 90.5% of participants with MS enrolled in the BTK inhibitor LTS extension remained in the study. New Gd-enhancing lesion counts remained low for the BTK inhibitor 60 / 60 mg group through Week 96 and decreased in the lower-dose groups from Weeks 48 to 96 of the LTS. Changes in T2 lesion volume remained low in the 60 / 60 mg group. Longer follow-up in the ongoing extension and data from the Phase 3 trial will continue to build on the safety and efficacy of BTK inhibitors for people with MS.

[0383] Table 31 summarizes the data on the number of new Gd-enhancing T1-hyperintense lesions. Table 31 - Data on the number of new Gd-enhancing T1 hyperintense lesions

[0384] Note: MRI assessments were excluded from the analysis if participants received systemic corticosteroids within 30 days prior to the MRI assessment date.

[0385] Table 32 summarizes the data on the number of new or enlarging T2 lesions. Table 32 - Data on the number of new or enlarging T2 lesions

[0386] Table 33 summarizes the data on the volume of new or enlarging T2 lesions. Table 33 - Data on the volume of new or enlarging T2 lesions

[0387] Table 34 summarizes the data on the number of new T1 non-enhancing (hyponteneous) lesions. Table 34 - Data on the number of new T1 non-enhancing (hyponymotic) lesions

[0388] In Tables 15-18, Week 12 represents 12 weeks of BTK inhibitor treatment during the dose-finding study (not the visit). The Week 0 value is from the last MRI obtained in the dose-finding study (if performed within 6 weeks before Day 1 of the long-term safety study). For some patients, the Week 0 value starts after an interval time period ranging from 0 to 21 weeks. For patients whose interval time period is 0 weeks, the Week 0 value starts immediately after completing the dose-finding study at Week 16. For patients whose interval time period is more than 6 weeks, a new MRI is obtained before Day 1 of the long-term safety study.

[0389] If from Week 16 of the dose-finding study (Cohort 2), it is also included in Week 12. If from Week 16 of the dose-finding study (Cohort 1), it is after the 4-week placebo run-out.

[0390] Example 4 - No disease activity rebound after placebo exhaustion in patients with relapsing multiple sclerosis in a phase 2b trial of tobrutinib

[0391] The absence or presence of disease rebound was also studied.

[0392] Background: After discontinuation of some disease-modifying therapies for multiple sclerosis (MS), disease activity rebound, characterized by recurrence of neurologic symptoms and brain lesions, has been reported. (Barry B et al. Neurol Ther 2019;8(2):241-50; González-Suarez I et al. Brain Behav 2017;7:e00671). A 16-week phase 2b trial (NCT03889639) of tobutinib, a brain-penetrant Bruton's tyrosine kinase (BTK) inhibitor, in patients with relapsing forms of MS (RMS) showed a dose-dependent reduction in new gadolinium-enhancing (Gd+) T1 lesions and new / enlarged T2 lesions. The unique crossover trial design, which included a 4-week placebo run-in and run-out period to minimize placebo exposure, enabled the assessment of potential disease rebound after tobutinib discontinuation. This assessment could inform treatment sequencing.

[0393] Objective: To evaluate potential disease rebound in patients with RMS after the placebo run-out period in a phase 2b trial of tobrutinib.

[0394] Methods: As described in Examples 1 and 2, a 16-week, double-blind, crossover trial randomized 130 patients with RMS (1:1:1:1) to tobutinib 5 mg / day, 15 mg / day, 30 mg / day, or 60 mg / day. Magnetic resonance imaging (MRI) scans were obtained at screening and every 4 weeks for 16 weeks. Cohort 1 (n=64) received tobutinib for 12 weeks, followed by a 4-week placebo run-in; Cohort 2 (n=66) received a 4-week placebo run-in, followed by 12 weeks of tobutinib. The study design is shown in Figure 1 .

[0395] Outcomes: Outcomes evaluated in this example included: the incidence of relapse measured during the 4-week placebo run-in and run-out period; the number of new Gd-enhancing T1 lesions detected by magnetic resonance imaging (MRI) at weeks 4, 8, and 16; the number of new or enlarging T2 lesions measured at weeks 4, 8, and 16; and plasma CD19+ B cell counts (P < 0.05) measured at baseline, 1 hour after the first dose, and then at weeks 12 and 16 in the placebo run-out cohort. Figure 3 ).

[0396] Results: Table 35 summarizes the baseline characteristics of patients in Cohorts 1 and 2. Table 35 - Baseline Characteristics a The higher mean number of Gd-enhancing lesions in cohort 2 was due to 3 participants with 25-30 lesions at baseline. Values are mean (SD) unless otherwise stated. EDSS = Expanded Disability Status Scale; Gd = gadolinium; RRMS = relapsing-remitting MS; SD = standard deviation.

[0397] Table 36 summarizes the disposition of patients in Cohorts 1 and 2. Table 36 - Patient Disposition n: number of participants in category, N: number of participants randomized, SAR: BTK inhibitor

[0398] Table 37 summarizes the data on the number of new Gd-enhancing T1-hyperintense lesions in Cohort 1. Table 37 - Data on the number of new Gd-enhancing T1 hyperintense lesions - Cohort 1 Gd: gadolinium; SAR: mg of BTK inhibitor per day; SD: standard deviation. Note 1: Cohort 1 participants received one of the BTK inhibitor doses for the first 12 weeks and then crossed over to placebo for 4 weeks. Note 2: MRI assessments were excluded from the analysis if the participant received systemic corticosteroids within 30 days before the date of the MRI assessment.

[0399] Table 38 summarizes the data on the number of new / enlarging T2 lesions in Cohort 1. Table 38 - Data on the number of new / enlarging T2 lesions - Cohort 1 Gd: gadolinium; SAR: mg of BTK inhibitor per day; SD: standard deviation. Note 1: Cohort 1 participants received one of the BTK inhibitor doses for the first 12 weeks and then crossed over to placebo for 4 weeks. Note 2: MRI assessments were excluded from the analysis if the participant received systemic corticosteroids within 30 days before the date of the MRI assessment.

[0400] Table 39 summarizes the data on the number of Gd-enhancing T1-hyperintense lesions in Cohort 1. Table 39 - Data on the number of Gd-enhanced T1 hyperintense lesions - Group 1 Gd: gadolinium; SAR: mg of BTK inhibitor per day; SD: standard deviation. CHI3L1: chitinase 3-like protein 1 gene, IgG: immunoglobulin G, IgM: immunoglobulin M. Note 1: Cohort 1 participants received one of the BTK inhibitor doses for the first 12 weeks and then crossed over to placebo for 4 weeks. Note 2: MRI assessments were excluded from the analysis if the participant received systemic corticosteroids within 30 days before the date of the MRI assessment.

[0401] There was one relapse during the placebo run-in period in Cohort 1 (98.4% of patients remained relapse-free), compared to four relapses during the placebo run-in period in Cohort 2 (93.9% remained relapse-free). After 12 weeks of tobutinib treatment (Cohort 1), 83.3% of patients had no new Gd-enhancing T1 lesions; 4 weeks after discontinuing tobutinib (placebo run-in), 85.2% of patients had no new Gd-enhancing T1 lesions. In Cohort 1, the mean (SD) Gd-enhancing T1 lesion counts were 0.37 (0.99) after 12 weeks of tobutinib and 0.44 (1.70) after 4 weeks of placebo run-in. For patients in Cohort 1 who received tobutinib 60 mg / day (the dose used in the Phase 3 study), the mean (SD) Gd+ lesion counts were 0.20 (0.56) after 12 weeks of tobutinib and 0.31 (0.70) after 4 weeks of placebo run-in. The mean (SD) Gd+ lesion count after 4 weeks of placebo run-in (Cohort 2) was 1.03 (2.50). At Week 12 in Cohort 1, the mean (SD) number of new / enlarging T2 lesions was 0.58 (1.27), compared to 0.95 (2.72) after 4 weeks of placebo run-in and 2.12 (5.16) after 4 weeks of placebo run-in (Cohort 2).

[0402] All 130 enrolled participants completed their assigned placebo period. As shown in Table 35, baseline characteristics of Cohort 1 (placebo run-in) and Cohort 2 (placebo run-in) were largely similar. The mean ± SD age of participants enrolled was 37 ± 10 years; 70% were female. One relapse occurred during the placebo run-in period and four relapsed during the placebo run-in period.

[0403] The number of new Gd-enhancing T1 lesions and the number of new / enlarging T2 lesions decreased after 12 weeks of tobutinib treatment (particularly in the 60 mg group) and showed only minimal increases after placebo exhaustion. In Cohort 1 (placebo exhaustion), the percentage of participants without new Gd-enhancing T1 lesions after 12 weeks of tobutinib treatment (83.3%) was similar to the percentage without new Gd-enhancing T1 lesions 4 weeks after stopping treatment (85.2%).

[0404] Conclusions: These preliminary findings suggest that discontinuation of tobutinib in patients with RMS does not result in a rebound in disease activity. Longer observation periods will be needed to validate this finding. Crossover to placebo after 12 weeks of tobutinib treatment was not associated with an increased risk of relapse during the 4-week run-out period. Focal inflammation, as evidenced by new lesion formation, decreased after 12 weeks of tobutinib treatment (particularly in the 60 mg dose group) and remained low during the 4-week placebo run-out period. The number of B cells in the peripheral circulation increased within 1 hour after the first dose of tobutinib and returned to baseline levels after the 4-week placebo run-out period.

[0405] Therefore, treatment with tobutinib does not result in disease rebound in RMS. Therefore, embodiments of the present application provide methods for preventing rebound of MS flare-ups (sometimes referred to as "relapses" or attacks). This occurs by administering tobutinib to a patient for at least 12 weeks followed by at least 4 weeks of placebo. It has been found that if it is administered, there is no additional risk of relapse during the 4-week placebo treatment period. Therefore, a treatment method can be designed in which a patient is administered tobutinib for, for example, 12 weeks, 1 year, 96 weeks, two years (or any other time period), followed by 4 weeks of placebo, and then tobutinib is reintroduced to the patient.

Claims

1. A method of reducing the incidence of a relapse of multiple sclerosis (MS) in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof for at least 12 weeks; and b) stopping administration of the BTK inhibitor, wherein the incidence of MS relapses in the subject after discontinuation of administration of the BTK inhibitor is equal to or less than the incidence of MS relapses in the subject during the 1 year prior to administration of the BTK inhibitor.

2. The method of claim 1, wherein the subject remains relapse-free for at least 4 weeks after discontinuation of administration of the BTK inhibitor.

3. The method of claim 1 or 2, wherein the subject remains relapse-free for at least 6 weeks after discontinuation of administration of the BTK inhibitor.

4. The method of any one of claims 1-3, wherein the subject remains relapse-free for at least 21 weeks after discontinuation of administration of the BTK inhibitor.

5. A method of reducing the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof for at least 12 weeks; and b) stopping administration of the BTK inhibitor, wherein the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject after discontinuation of administration of the BTK inhibitor is equal to or less than the baseline number of new gadolinium (Gd)-enhancing T1 hyperintense lesions or new or enlarging T2 hyperintense lesions measured in the subject during the 4 weeks prior to administration of the BTK inhibitor.

6. The method of claim 5, wherein the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 2.

7. The method of claim 6, wherein the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 1.

8. The method of any one of claims 5-7, wherein the total number of new gadolinium (Gd) enhancing T1 hyperintense lesions or the number of new or enlarging T2 hyperintense lesions measured in the subject up to 4 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 1.

9. The method of claim 5, wherein the total number of new or enlarging T2 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 3.

10. The method of claim 5, wherein the total number of new or enlarging T2 hyperintense lesions measured in the subject up to 6 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 1.

11. A method of reducing the total number of gadolinium (Gd) enhancing T1 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS) in need thereof, the method comprising the steps of: a) administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof for at least 12 weeks; and b) stopping administration of the BTK inhibitor, wherein the total number of gadolinium (Gd)-enhancing T1 hyperintense lesions measured in the subject after discontinuation of administration of the BTK inhibitor is equal to or less than the baseline number of gadolinium (Gd)-enhancing T1 hyperintense lesions measured in the subject before administration of the BTK inhibitor.

12. The method of claim 11, wherein the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 4.

13. The method of claim 11 or 12, wherein the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject up to 21 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 2.

14. The method of any one of claims 11-13, wherein the total number of gadolinium (Gd) enhancing T1 hyperintense lesions measured in the subject from baseline up to 4 weeks after discontinuation of administration of the BTK inhibitor is equal to or less than 1.

15. The method of any one of claims 1-14, wherein the dose of the BTK inhibitor is 60 mg daily.

16. The method of any one of claims 5-15, wherein the lesion is measured by MRI.

17. The method of any one of claims 1-16, wherein the BTK inhibitor is administered to the subject for at least 16 weeks.

18. The method of any one of claims 1-17, wherein the BTK inhibitor is administered to the subject for at least 24 weeks.

19. The method of any one of claims 1-18, wherein the BTK inhibitor is administered to the subject for at least 48 weeks.

20. The method of any one of claims 1-19, wherein the BTK inhibitor is administered to the subject for at least 72 weeks.

21. The method of any one of claims 1-20, wherein the BTK inhibitor is administered to the subject for at least 96 weeks.

22. A method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof, the method comprising determining whether the patient has elevated transferrin levels or elevated ferritin levels, and when the patient is found not to have elevated transferrin levels or elevated ferritin levels, administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

23. A method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof, the method comprising determining the patient's iron status and, when the patient is found to have suitable iron status, administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

24. A method of treating relapsing multiple sclerosis (RMS), comprising administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the patient does not have elevated transferrin levels or elevated ferritin levels.

25. A method for treating relapsing multiple sclerosis (RMS), comprising the steps of: (a) performing an iron status test in the patient's blood or serum; (b) detecting a level of said iron status test within a normal range; and (c) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the iron status test measures any one or more of the iron level, ferritin level, transferrin saturation level, and total iron binding capacity (TIBC) level in the patient's blood or serum, and wherein the normal range for the iron status test includes one or more of the following: (i) an iron level of 60 to 170 μg / dL, (ii) a ferritin level of ≤500 μg / L, (iii) a transferrin saturation level of ≤50% in male patients or a transferrin saturation level of ≤40% in female patients, and (iv) a TIBC of 240 to 450 μg / dL.

26. A method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: (a) detecting a transferrin saturation level in the patient's blood or serum that is within a normal range; and (b) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, The transferrin saturation level in the blood or serum of a male patient within a normal range is a transferrin saturation of ≤50%, and the transferrin saturation level in the blood or serum of a female patient within a normal range is a transferrin saturation of ≤40%.

27. A method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: (a) detecting a ferritin level in the patient's blood or serum within a normal range; as well as (b) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, The ferritin level in the patient's blood or serum is within the normal range and is ≤500 μg / L.

28. A method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: (a) Perform liver function tests in patients; (b) testing the patient for adequate liver function; as well as (c) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the liver function test measures one or more of the following levels in the patient's blood: aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, alkaline phosphatase, total and direct bilirubin, and total protein, and Patients with adequate liver function had one or more of the following: ALT ≤ 1.5 x upper limit of normal (ULN), AST level ≤ 1.5 x ULN, alkaline phosphatase ≤ 2 x ULN (unless caused by a non-liver-related disorder or explained by a stable chronic liver disorder), and total bilirubin ≤ 1.5 x ULN (unless due to Gilbert's syndrome or a non-liver-related disorder).

29. A method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: (a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); (b) measuring alanine aminotransferase (ALT) levels in the patient; (c) ALT levels >8x the upper limit of normal (ULN) were detected; (d) ceasing administration of the compound to the patient; and optionally (e) monitoring ALT levels in the patient; as well as (f) when the patient's ALT level is determined to be <1.5 x ULN, resuming administration of the therapeutically effective amount of the compound to the patient.

30. A method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: (a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); (b) measuring alanine aminotransferase (ALT) levels in the patient; (c) ALT levels >5x the upper limit of normal (ULN) detected during a period of at least two weeks; (d) ceasing administration of the compound to the patient; and optionally (e) monitoring ALT levels in the patient; as well as (f) when the patient's ALT level is determined to be <1.5 x ULN, resuming administration of the therapeutically effective amount of the compound to the patient.

31. A method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: (a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); (b) measuring alanine aminotransferase (ALT) levels in the patient; (c) ALT levels >3x the upper limit of normal (ULN) were detected; (d) measuring one or more of total bilirubin and international normalized ratio (INR) in the patient; (e) one or more of total bilirubin >2x ULN and INR >1.5 was detected; (f) ceasing administration of the compound to the patient; and optionally (g) monitoring ALT levels in the patient; and (h) when the patient's ALT level is determined to be <1.5 x ULN, resuming administration of the therapeutically effective amount of the compound to the patient.

32. A method for treating relapsing multiple sclerosis (RMS), the method comprising the steps of: (a) administering to a patient in need thereof a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (compound); (b) measuring alanine aminotransferase (ALT) levels in the patient; (c) ALT levels >3x the upper limit of normal (ULN) were detected; (d) discontinuing administration of the compound to the patient if the patient experiences one or more of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, and eosinophilia >5%; and optionally (e) monitoring ALT levels in the patient; as well as (f) when the patient's ALT level is determined to be <1.5 x ULN, resuming administration of the therapeutically effective amount of the compound to the patient.

33. The method according to any one of claims 29 to 32, wherein the ALT level in step (b) is determined at least once a month.

34. The method of any one of claims 29 to 32, wherein the ALT level in step (d) is monitored at least once a week.

35. The method of any one of claims 29 to 32, wherein the ALT level in step (d) is monitored once every 2 to 3 days.

36. A method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof, the method comprising administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the patient is not currently receiving strong and moderate inducers of cytochrome P450 3A (CYP3A) or strong inhibitors of the CYP2C8 liver enzyme.

37. A method of treating relapsing multiple sclerosis (RMS) in a patient in need thereof, the method comprising the steps of: (a) advising the patient to limit alcohol consumption during treatment; as well as (b) administering to the patient a therapeutically effective amount of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the patient is female and is advised to limit alcohol intake to 14 grams per day or less, or wherein the patient is male and is advised to limit alcohol intake to 28 grams per day or less.

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