Method of protecting organ of patient susceptible to postoperative complications including photosensitivity prior to surgical procedure

Abstract

Methods of treating a patient by administering a combination of tin protoporphyrin and iron sucrose prior to a planned attack, such as a surgical procedure, are provided. The method provides protection for photosensitive patients and patients susceptible to postoperative complications.

Description

[0001] This application claims the benefit of U.S. Provisional Application No. 63 / 478,975, filed on January 8, 2023; U.S. Provisional Application No. 63 / 449,974, filed on May 3, 2023; U.S. Provisional Application No. 63 / 595,699, filed on November 2, 2023; U.S. Provisional Application No. 63 / 601,700, filed on November 21, 2023; and U.S. Provisional Application No. 63 / 602,216, filed on November 22, 2023, each of which is hereby incorporated by reference in its entirety. Background Art

[0002] The damage of body organs can cause the protective response of organs, so that if the injury event (that is, attack) continues or reoccurs, the body organs just can better protect themselves.For example, a renal injury can cause a protective response, and the protective response protects the kidney from subsequent more serious renal injury after a lag time of 18 hours.This protection can last for a long period of time (several days to several weeks).This protective phenomenon is referred to as "ischemic preconditioning" or "acquired cell tolerance" in the art.

[0003] A kind of thought is to use the phenomenon of acquired cell tolerance to protect organs preemptively, especially when a known attack is about to occur. Various pharmacological preconditioning strategies, such as volatile anesthetics, inert gases, dexmedetomidine (dexmedetomidine) and levosimendan (levosimendan) have been evaluated in randomized controlled trials of cardiac surgery, and the results are mostly neutral. The inventors have previously found that acquired cell tolerance can be induced to protect organs before an attack (such as exposure to surgery, cardiopulmonary bypass or radiocontrast agent toxicity administration). The inventors have previously disclosed that the combination of an iron compound and protoporphyrin, particularly tin protoporphyrin (e.g., stannsoporfin (stannsoporfin) or SnPP) can be used to protect organs from attack, such as surgery. See U.S. Patent No. 9,844,563, filed December 19, 2017, entitled “COMPOSITIONS, KITS, AND METHODS TO INDUCE ACQUIRED CYTORESISTANCE USING STRESS PROTEIN INDUCERS.”

[0004] The problem of photosensitivity after administration of SnPP is well documented. See Land et al., "Photophysical studies of tin(IV)-protoporphyrin: Potential phototoxicity of a chemotherapeutic agent proposed for the prevention of neonatal jaundice," Proc. Natl. Acad. Sci. USA, Vol. 85, pp. 5249–5253 (1988). Photosensitivity appears to have been a factor that previously led others to abandon the use of SnPP for the treatment of neonatal jaundice with tin mesoporphyrin (SnMP). Furthermore, the inventors cited photosensitivity as an exclusion criterion in the original study design for the Phase II clinical trial NCT04564833, titled "Effect of RBT-1 on Preconditioning Response Biomarkers in Subjects Undergoing CABG and / or Cardiac Valve Surgery." Specifically, the study excluded patients with "a history of photosensitivity or active skin conditions that the investigators believed might be exacerbated by RBT-1."

[0005] There remains a need to develop methods to protect organs prior to surgery in photosensitive patients and to improve postoperative outcomes in patients undergoing surgery. Summary of the Invention

[0006] One aspect of the present invention relates to a method for reducing postoperative complications in a human patient caused by injury based on a planned or anticipated surgical procedure, the method comprising administering to the human patient prior to the surgical procedure a composition comprising a therapeutically effective amount of (i) an iron compound; and (ii) a tin protoporphyrin in an amount of 20-80 mg, wherein the human patient is susceptible to photodermatosis.

[0007] In aspects where the patient is photosensitive, the method can involve applying a sunscreen to the patient's skin within six days of the planned or anticipated surgical procedure. Sunscreen can be applied to the patient's skin within six days of the planned or anticipated surgical procedure, prior to any anticipated sun exposure. In one aspect, the human patient can be instructed or may need to reduce or eliminate sun exposure between the administration of the therapeutically effective composition and the planned or anticipated surgical procedure. After the planned or anticipated surgical procedure, the human patient can apply a sunscreen when sun exposure is expected for at least six days. In one aspect, a sunscreen is applied when sun exposure is expected after the administration of the therapeutically effective composition. The sunscreen can have a sun protection factor (SPF) of 50+.

[0008] In another aspect, the present invention relates to a method for reducing postoperative complications in a human patient caused by injury based on a planned or anticipated attack on an organ of the human patient, the method comprising: (a) administering to the patient a therapeutically effective composition comprising (i) an iron compound; and (ii) a tin protoporphyrin, and (b) applying a sunscreen to the skin of the human patient around the time of administering the therapeutically effective composition to the human patient or within six days after the planned or anticipated surgical procedure. The sunscreen can be applied to the skin of the human patient before any anticipated sun exposure within six days after the planned or anticipated surgical procedure. In one aspect, the human patient can be instructed or may be required to reduce or eliminate sun exposure between administration of the therapeutically effective composition and the planned or anticipated surgical procedure. After the planned or anticipated surgical procedure, the human patient can apply a sunscreen when sun exposure is anticipated for at least six days. In one aspect, the sunscreen is applied when sun exposure is anticipated after administration of the therapeutically effective composition. The sunscreen can have a sun protection factor (SPF) of 50+.

[0009] In another aspect, the present invention relates to a method for reducing cardiopulmonary resuscitation readmissions in human patients after surgery by at least 60%, the method comprising administering to the patient prior to the surgery a therapeutically effective composition comprising an amount of (i) an iron compound; and (ii) a tin protoporphyrin. The method can result in a reduction in cardiopulmonary resuscitation readmission rate of at least 70%, or more specifically, 72%. The human patient can be selected from patients at high risk for cardiopulmonary resuscitation readmissions after CABG and / or heart valve surgery.

[0010] In another aspect, the present invention relates to a method for reducing postoperative complications in a human patient caused by an injury based on a planned or anticipated surgical procedure, the method comprising administering to the patient prior to the surgical procedure a therapeutically effective composition comprising an amount of (i) an iron compound; and (ii) a tin protoporphyrin, wherein the postoperative complications comprise: (a) an intensive care unit stay exceeding three days, (b) mechanical ventilation use exceeding 24 hours, (c) hospital readmission for cardiopulmonary surgery, (d) the need for a blood transfusion, (e) new onset postoperative atrial fibrillation (POAF) during hospitalization, or a combination of two or more of (a) to (e). The human patient can be selected from patients who have undergone CABG and / or heart valve surgery and are at high risk for postoperative complications, including one or more of the complications listed above.

[0011] In any of the above embodiments, the tin protoporphyrin can be administered at a dose of 20-80 mg, more preferably at a dose of 30-70 mg or at a dose of 45 mg. The iron sucrose can be administered at a dose of 190-290 mg or preferably at a dose of 240 mg. In one embodiment, the tin protoporphyrin is administered at a dose of 45 mg, and the iron compound is iron sucrose, administered at a dose of 240 mg.

[0012] In any of the above embodiments, the iron compound can be present in an aqueous pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier. The tin protoporphyrin can be present in an aqueous pharmaceutical composition comprising: a total impurity level of 1.5% or less, as measured by gas chromatography. In one aspect, preparation of the therapeutically effective composition for administration can comprise combining the following in an intravenous bag: (a) an aqueous iron pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier; and (b) a tin protoporphyrin composition, wherein the total impurity level of the tin protoporphyrin composition is 1.5% or less, as measured by gas chromatography.

[0013] In one aspect, the therapeutically effective amount of tin protoporphyrin can be administered at a dosage of 0.5-0.8 mg / kg, more preferably 0.6-0.7 mg / kg, and particularly 0.63 mg / kg. In another aspect, the therapeutically effective amount of iron sucrose can be 2-6 times the weight of tin protoporphyrin, or more preferably 3-4 times the amount of tin protoporphyrin.

[0014] In one aspect, the planned or anticipated surgical procedure is a surgical procedure on an organ. The organ can be the heart, kidney, liver, or lung. In one aspect, the iron compound and the tin protoporphyrin are administered at least 24 hours before the planned or anticipated surgical procedure on the organ. In one aspect, it is desirable to administer the iron compound and the tin protoporphyrin no more than 48 hours before the planned or anticipated surgical procedure on the organ.

[0015] In one aspect, the planned or anticipated surgical procedure can be a surgical procedure comprising: coronary artery bypass grafting (CABG) to cardiopulmonary bypass (CPB), heart valve surgery, or combined CABG / valve surgery. In another aspect, the planned or anticipated surgical procedure is an organ transplant surgery. In the case of an organ transplant, the method can reduce or eliminate the need to administer blood products after the planned or anticipated surgical procedure. This can include whole blood products from a donor. BRIEF DESCRIPTION OF THE DRAWINGS

[0016] Figure 1 A flow chart illustrating the study design for evaluating RBT-1 to reduce postoperative complications in patients undergoing cardiothoracic surgery is shown;

[0017] Figure 2 Statistically significant increases in cytoprotective response biomarkers HO-1, ferritin, and IL-10 were shown using RBT-1;

[0018] Figure 3 The left graph shows the percentage of individuals in each group who were on a ventilator for more than 24 hours after cardiac surgery, and the right graph shows the percentage of individuals who were admitted to the ICU for more than 3 days;

[0019] Figure 4 The mean duration of ventilator use, ICU stay, and hospital stay for each group after cardiac surgery is shown;

[0020] Figure 5 Improvements in the average hospitalization component were shown for patients treated with RBT-1;

[0021] Figure 6 The median troponin I level within the first postoperative day is shown; and

[0022] Figure 7 Improved postoperative outcomes in patients undergoing cardiac surgery treated with RBT-1 were shown;

[0023] Figure 8 Improved postoperative outcomes in patients undergoing cardiac surgery treated with RBT-1 were shown;

[0024] Figure 9 A flow chart of the patient population according to Example 2 is shown.

[0025] Figure 10 Shown are the mean composite values ​​of the maximum preoperative changes from baseline for HO-1, IL-10, and ferritin in Example 2.

[0026] Figure 11 Evaluation of hospital course by ventilator time and length of stay (LOS) in the ICU and hospital according to Example 2 is shown.

[0027] Figure 12 The main result - the preconditioning response according to Example 3 - is shown.

[0028] Figure 13 The ventilator, ICU and hospitalization processes according to Example 3 are shown.

[0029] Figure 14 Postoperative troponin I according to Example 3 is shown.

[0030] Figure 15 is a table showing the main results of the temporary population according to Example 3.

[0031] Figure 16 is a table showing baseline characteristics of the safety population according to Example 3.

[0032] Figure 17 is a table showing the baseline characteristics of the modified intention-to-treat population according to Example 3.

[0033] Figure 18 is a table showing additional pre-specified results for the modified intention-to-treat population according to Example 3.

[0034] Figure 19 is a table showing the stratified composite results (win rates) according to Example 3.

[0035] Figure 20 Shown is a comparison of ventilator, ICU time, and cardiopulmonary readmissions for stage 2 patients undergoing CABG and / or valve surgery for cardiopulmonary bypass.

[0036] Figure 21 The design of the Phase III study of RBT-1 is shown. DETAILED DESCRIPTION

[0037] Throughout this disclosure, various patents, patent applications, and publications are cited. The disclosures of these patents, patent applications, and publications are incorporated herein by reference in their entireties for all purposes in order to more fully describe the state of the art as known to those skilled in the art as of the date of this disclosure. This disclosure will govern in the event of any inconsistency between the cited patents, patent applications, and publications and the present disclosure.

[0038] For convenience, certain terms used in the specification, examples and appended claims are collected here. Unless otherwise defined, all technical and scientific terms used in this disclosure have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs.

[0039] "RBT-1" is a synonym for the combination of tin protoporphyrin and iron sucrose that was used to generate the data disclosed in this application.

[0040] The sucrose iron used in RBT-1 is a sucrose iron composition that can be easily combined with tin protoporphyrin (SnPP) to form a stable solution that can be administered to a patient, as described in US Pat. No. 11,292,813, filed on April 5, 2022, entitled “NOVEL IRON COMPOSITIONS AND METHODS OF MAKING AND USING THE SAME,” the subject matter of which is incorporated herein by reference. The composition, also known as RBT-3, is an aqueous iron pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier, wherein the iron sucrose is present in a pharmaceutically effective amount to provide organ protection to the patient, the iron is present in both iron (II) and iron (III) forms, the pH of the pharmaceutical composition is greater than 9, the concentration of iron (II) is between 0.05% w / v and 0.41% w / v, and the MW of the iron sucrose based on GPC is between 33,000 Daltons and 38,000 Daltons. RBT-3 (iron sucrose) is a low molecular weight iron nanoparticle with the potential to rapidly restore iron levels and improve blood product utilization in cardiac surgery and / or ER patients. RBT-3 has also demonstrated the potential to mitigate cisplatin-induced nephrotoxicity in preclinical models. Opportunities to advance the clinical development of RBT-3 in these potential indications are currently being explored.

[0041] The sucrose iron composition can be, for example, prepared by dissolving enough sucrose iron complex in water (about 3.5 L) to produce a 12 mg / mL (expressed as iron) solution when diluted to 6.0 L. The amount of sucrose iron required is calculated for the final volume 6100 mL (6.1 L) of the liquid so that the final concentration is 12 mg / mL. This requires 73.2 g of iron. The use efficacy of sucrose iron is 0.0550. Therefore, 73.2 g / 0.0550 or 1331 g ± 1 g of sucrose iron is required. 1331 g ± 1 g of sucrose iron is directly weighed into a 6.0 L conical flask. About 3-3.5 L of water is added to the conical flask, and the contents of the flask are stirred.

[0042] Sodium bicarbonate is added in an amount such that the final sodium bicarbonate concentration is 10 mg / mL when diluted to 6.0 L. 109.8 ± 0.1 g sodium bicarbonate is weighed and added to a 6.0 L flask. Sodium chloride is added in an amount such that the final sodium chloride concentration after dilution is 9.0 mg / mL. 54.9 ± 0.1 g sodium chloride is weighed and added to a 6.0 L flask. The suspension is stirred for 30-120 minutes to produce a black, opaque solution. The pH of the solution is monitored with a pH meter while adding 1 M sodium hydroxide in small portions until a pH of 10.30 is reached and remains stable. 40.0 ± 0.1 g sodium hydroxide is added to a 1.0 L Erlenmeyer flask. 1.0 ± 0.1 L water is added to the 1.0 L Erlenmeyer flask and stirred until all the sodium hydroxide is dissolved. A pH probe was attached to monitor the pH of the 6.0 L Erlenmeyer flask, and sodium hydroxide was added in portions <100 mL until the pH was 10.3 ± 0.1. The solution was then stirred for 10 minutes. After 10 minutes, the pH was checked again and adjusted, if necessary, to within 10.3 ± 0.1.

[0043] The solution was then transferred to a precise volumetric flask and diluted to 6.1 L with water. A 2 L volumetric flask was used twice to accurately transfer 4 L of the 10.3 pH solution to a 6 L Erlenmeyer flask. The remaining 10.3 pH solution was diluted to 2 L in a volumetric flask and added to the 6 L Erlenmeyer flask. 100 ± 0.1 mL was added to the 6.0 L Erlenmeyer flask using a 100 mL graduated cylinder and the resulting solution was stirred for 10 minutes.

[0044] The resulting product solution exhibited a dark red to brown color. Two iron isotopes were present in the sample preparation, with ratios consistent with those of the standard preparation. The pH of the resulting material was 10.3, which is within the preferred range of 10.1-10.4. The resulting material had an iron content of 11.5 / 11.6 parts per thousand (mg / mL) according to SOP 174472, which determines iron by inductively coupled plasma mass spectrometry.

[0045] The tin protoporphyrin used in RBT-1 is a high-purity composition as described in U.S. Provisional Application No. 63 / 394,146, filed on August 1, 2022, entitled “NOVEL SN-PROTOPORPHYRIN COMPOSITIONS, METHODS OF MAKING, AND USES THEREOF,” the subject matter of which is incorporated herein by reference. The Sn-protoporphyrin composition comprises a compound of formula (I)

[0046]

[0047] wherein the composition comprises a total impurity level of 1.5% or less as measured by gas chromatography. Sn-protoporphyrin (IX) is prepared using the following two-step process:

[0048] Hemin was dissolved in hot formic acid and iron powder was then added in aliquots over 20 minutes. The resulting mixture was heated and stirred for 30 minutes, then filtered through diatomaceous earth. The filtrate was added to the stirred NH4OAc aqueous solution to precipitate the desired product, which was then filtered and dried. This crude material was dissolved in hot pyridine, and the hot solution was filtered through diatomaceous earth. After cooling, the purified product was precipitated from the filtrate and recovered by filtration.

[0049] Under inert atmosphere, stannous chloride is dissolved in pyridine, add glacial acetic acid, and mixture is heated at 50 ℃.Then add protoporphyrin IX, and stir and heat at least 24 hours, and monitor completion by HPLC. Make reaction solution cool to room temperature and filter.Then product is first wet-milled with water, then uses 2M HCl (aqueous solution) wet-milling, and then again wet-milled with water. Carry out IPC to determine whether to carry out pyridine / AcOH recrystallization, carry out other water wet-milling subsequently.Then product is dried to remove residual solvent.

[0050] The inventors were surprised to find through human trials that clinical outcomes can be improved by reducing the amount of tin protoporphyrin used. The efficacy showed a U-shaped curve, and it was unexpectedly found that reducing the amount of SnPP could improve efficacy. Specifically, the data analysis in the human clinical trials disclosed herein showed that the effect of 90 mg of tin protoporphyrin, which is considered to be effective and desirable, was less than that of the lower dose of 45 mg. In addition, the high purity SnPP used may also have a role in improving the effectiveness of the composition. In addition, the inventors found that by using a lower dose of SnPP, complications related to photosensitivity can be avoided and / or reduced without reducing the effectiveness of preventing postoperative complications associated with surgical procedures. This prompted the inventors to develop a method for treating patients susceptible to photosensitivity using RBT-1.

[0051] In one aspect, the inventors discovered that lower doses of SnPP can be used, and in doing so, unexpectedly, allows for the inclusion of photosensitivity patients. Previous literature suggests that photosensitivity patients should not be administered SnPP. The inventors discovered that the claimed methods allow for the use of lower doses of SnPP in photosensitivity patients while maintaining the efficacy of RBT-1 in protecting organs from planned attacks (e.g., CABG surgery). The inventors discovered that the use of sunscreen and a lower dose of 45 mg SnPP by photosensitivity patients can enable their participation in the study.

[0052] On the other hand, the present inventors have found that patients at risk of readmission after CABG surgery can benefit from the administration of lower doses of SnPP. Re-hospitalization rates were reduced by at least 60% relative to placebo, and in some cases, readmission rates were reduced by at least 70%, or more specifically 72%. Other postoperative complications were found to be improved by administering SnPP at lower doses. These complications include: (a) stay in the intensive care unit for more than three days, (b) use of a ventilator for more than 24 hours, (c) readmission for cardiopulmonary surgery, (d) need for a blood transfusion, (e) new onset of postoperative atrial fibrillation (POAF) during hospitalization, or a combination of two or more of (a)-(e). The human patient can be selected from patients who are at high risk of postoperative complications after undergoing CABG and / or heart valve surgery, including one or more of the complications listed above.

[0053] In certain embodiments, the tin protoporphyrin may be administered at a dose of 20-80 mg, more preferably at a dose of 30-70 mg or at a dose of 45 mg. Iron sucrose may be administered at a dose of 190-290 mg or preferably at a dose of 240 mg. In one embodiment, the tin protoporphyrin is administered at a dose of 45 mg, and the iron compound is iron sucrose, administered at a dose of 240 mg.

[0054] In certain embodiments, the iron compound can be present in an aqueous pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier. The tin protoporphyrin can be present in an aqueous pharmaceutical composition comprising: a total impurity level of 1.5% or less, as measured by gas chromatography. In one aspect, the preparation of the therapeutically effective composition for administration can comprise combining the following in an intravenous bag: (a) an aqueous iron pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier; and (b) a tin protoporphyrin composition, the total impurity level of the tin protoporphyrin composition being 1.5% or less, as measured by gas chromatography.

[0055] In certain embodiments, the therapeutically effective amount of tin protoporphyrin can be administered at a dose of 0.5-0.8 mg / kg, more preferably 0.6-0.7 mg / kg, and particularly 0.63 mg / kg. On the other hand, the therapeutically effective amount of iron sucrose can be 2-6 times the weight of tin protoporphyrin, or more preferably 3-4 times the amount of tin protoporphyrin.

[0056] In one aspect, the planned or anticipated surgical procedure is a surgical procedure on an organ. The organ can be the heart, kidney, liver, or lung. In one aspect, the iron compound and the tin protoporphyrin are administered at least 24 hours before the planned or anticipated surgical procedure on the organ. In one aspect, it is desirable to administer the iron compound and the tin protoporphyrin no more than 48 hours before the planned or anticipated surgical procedure on the organ.

[0057] In one aspect, the planned or anticipated surgical procedure can be a surgical procedure comprising: coronary artery bypass grafting (CABG) to cardiopulmonary bypass (CPB), heart valve or combined CABG / valve surgery. In another aspect, the planned or anticipated surgical procedure is an organ transplant surgery. In the case of an organ transplant, the method can reduce or eliminate the need for administering blood products after the planned or anticipated surgical procedure. This can include whole blood products from a donor.

[0058] Example 1

[0059] Figure 1The study design of administering RBT-1 (FeS+SnPP) to 42 individuals at a low dose of 45 mg tin protoporphyrin (SnPP) / 240 mg ferric sucrose (FeS) and to 42 individuals at a high dose of 90 mg SnPP / 240 mg FeS was shown, while an additional 42 individuals using placebo (a total of 126 individuals) were observed. The study was a multicenter, double-blind, placebo-controlled Phase 2 study in individuals undergoing coronary artery bypass grafting (CABG) and / or heart valve surgery for cardiopulmonary bypass. Individuals were administered these doses prior to undergoing cardiac surgery. The primary objective of the study was to determine the role of RBT-1 in generating a preconditioning response, as measured by a comprehensive measurement of plasma biomarkers on day 1 before surgery. These biomarkers included heme oxygenase-1 (HO-1), ferritin, and interleukin-10 (IL-10). Key secondary and exploratory objectives of the study include the impact of RBT-1 on individual recovery as measured by number of ventilator-days, intensive care unit (ICU) stay, hospital length of stay, incidence of acute kidney events (AKI), incidence of major adverse kidney events (MAKE), hospital readmission rate, and safety.

[0060] Subjects were enrolled at 19 sites in the United States, Canada, and Australia. The overall study population was not enriched for events. Subjects were randomized at the site level to account for differences in standard of care. The safety population consisted of all subjects who received study drug. The ITT population consisted of subjects who received study drug and underwent biomarker assessments according to the protocol for the primary assessment. The MITT population consisted of ITT subjects who underwent surgery within the protocol-defined timeframe (all clinical outcome endpoints were based on this group).

[0061] The total number of individuals included in this study was 152 individuals, of which 12 failed screening and 7 withdrew (5 withdrew before infusion). The safety population included 135 individuals, 44 in the placebo group, 45 in the low-dose group, and 46 in the high-dose group. The ITT population included 132 individuals, 44 in the placebo group, 42 in the low-dose group, and 46 in the high-dose group. The MITT population included a total of 121 individuals, 41 in the placebo group, 39 in the low-dose group, and 41 in the high-dose group. The demographic data, baseline characteristics, AKI risk factors, and EuroSCORE of the individuals in the MITT population are shown in Tables 1-4.

[0062]

[0063]

[0064]

[0065]

[0066]

[0067]

[0068] Figure 2 A graph is shown demonstrating that for the MITT population, there was a statistically significant increase (p<0.0001) in anti-inflammatory and antioxidant biomarkers with cytoprotective preconditioning using RBT-1. The biomarkers assessed were interleukin-10 (IL-10), heme oxygenase-1 (HO-1), and ferritin. Table 5 shows Figure 2 Composite biomarker responses of the data shown.

[0069]

[0070] All subsequent analyses were performed on the MITT population as predefined.

[0071] Figure 3 The extended time individuals in each group spent on a ventilator and in the ICU is shown. The graph demonstrates the reduction in the percentage of individuals requiring a ventilator after surgery between the placebo group and the low-dose and high-dose groups, with the high-dose group having the lowest percentage. Figure 3 Also shown was a reduction in the percentage of individuals requiring ICU stay for more than 3 days following surgery, with the lowest percentage in the low-dose group. Figure 4 The graph shows the average time individuals in each group spent on a ventilator, in the ICU, and in the hospital. The graph shows the reduction in ventilator, ICU, and hospital stays for patients treated with RBT-1. Figure 5 An overall improvement in the mean hospitalization composition was seen in patients treated with RBT-1.

[0072] The low-dose RBT-1 group exhibited the lowest median troponin I levels, while the high-dose group additionally exhibited levels lower than those in the placebo group. The combined RBT-1 group had a clinically meaningful reduction (47%) in troponin I levels compared to the placebo group. Figure 6 Shown are increases in plasma troponin I from preoperative baseline to 12 hours (left series) and 1 day (right series) after cardiac surgery. The analysis population was derived from a modified intention-to-treat population that excluded patients who underwent mitral valve repair or replacement, ablation, or septal myectomy because of the anticipated significant increase in troponin I levels after these major surgical procedures.

[0073] exist Figure 7 and Figure 8In the figure, the combined RBT-1 group showed improvements in postoperative outcomes relative to the placebo group on measures such as ventilator days, ICU days, hospital stay, AKI, major adverse renal events at 30 days (MAKE30), readmissions, readmissions (cardiopulmonary), and atrial fibrillation (AFib). Compared to placebo, individuals treated with RBT-1 had clinically meaningful improvements in ventilator days (-1 day), hospital stay (-1.3 days), AKI rate (-10%), and AFib rate (-37%).

[0074] The number of days in the ICU was statistically significantly reduced (-2.7 days, p < 0.03). 30-day readmissions due to cardiopulmonary causes were statistically significantly reduced (-71%, p < 0.05), and all-cause readmissions were reduced by 60%. The data also indicated an overall well-tolerated safety profile.

[0075] The win ratio for the combination of high-dose and low-dose RBT-1 was calculated based on the data collected in the trial. The win ratio is a method for examining composite endpoints and has since been widely adopted in cardiovascular (CV) trials. Improving the conventional method for analyzing composite endpoints, the win ratio takes into account the relative priority of the components and allows the components to be different types of outcomes. Redfors B. et al. The win ratio approach for composite endpoints: practical guidance based on previous experience. Eur Heart J. Dec 7, 2020; 41(46): 4391-4399. doi: 10.1093 / eurheartj / ehaa665. PMID: 32901285 further describes the win ratio.

[0076] Tables 6-9 illustrate the win rate calculations for the trial. In an analysis of the composite endpoint of death, ICU days, ventilator days, atrial fibrillation rate, hospital days, and hospitalization rate using a win rate approach, a highly statistically significant benefit was observed in the treatment group (win rate 1.63, p < 0.02). These positive top-line data provide strong support for the potential of RBT-1 to reduce the risk of multi-organ injury and thereby improve postoperative outcomes in patients undergoing cardiothoracic surgery. These data suggest that RBT-1 may provide extensive protection against organ injury and has the potential to reduce postoperative complications, length of stay, and costs of care.

[0077]

[0078]

[0079]

[0080]

[0081] Several treatment comparisons were performed according to individual weight category classification to determine the benefit of each kg dose (mg / kg) and to explore the minimum feasible dose. Unexpectedly, the drug benefit increased at lower doses. Typically, based on a 70 kg patient, the ideal range is 20-70 mg, preferably 28-63 mg or 35-63 mg.

[0082] In order to define the categories, a ternary test (tertial, i.e., about 1 / 3 of the patients in each category) was used. "Low weight" was less than about 81 kg (average 72 kg), "medium weight" was between about 81 kg and 99 kg (average 90 kg), and "high weight" was greater than about 99 kg (average 115 kg). Table 10 below shows the win rate results classified by weight category. Using the average weight within the category, the results displayed in the order of per kg dose show more U-shaped relationships. Once a certain dose threshold is exceeded, the effectiveness of the dose will decline, and the benefit of the dose will also decline.

[0083]

[0084] The 95% confidence interval (CI) results are rough estimates, indicating that the sample sizes for these subgroup analyses were small and the win rates are not very precise. However, these results generally suggest that the peak effect is about 0.6 mg / kg or 0.7 mg / kg. For example, a 100 kg person would correspond to a suggested dose of 63 mg, although the data also suggest that 63 mg may be a bit too high for lighter patients. In one embodiment, the dose administered to the patient is a function of the patient's weight to improve the benefit of the dose.

[0085] Adverse events of interest in the trial were recorded. Table 11 shows a summary of treatment-emergent adverse events (TAEs), and Table 12 shows TAEs of interest for the safety population.

[0086]

[0087]

[0088]

[0089] The occurrence of photosensitivity is recorded and shown in Table 13. Three surgical procedures were postponed due to individual photosensitivity. Each surgical procedure postponed due to photosensitivity occurred in a high-dose individual and was otherwise exposed to sunlight for a long period of time after infusion.

[0090]

[0091] Example 2

[0092] 152 patients were enrolled at 19 sites in the United States, Canada, and Australia, and 135 patients were randomized. The safety population consisted of all patients receiving study drug. Of these, 132 (98%) patients had biomarker measurements collected (ITT population). In the ITT population, 121 patients underwent surgery on time (24 to 48 hours after infusion) and constituted the MITT population, for which secondary endpoints and clinical outcomes were assessed. Figure 9 The inclusion and patient populations are shown. The total number of patients included and randomly assigned is shown. The distribution of patients by dose group is provided for each patient population. Reasons for screening failure included high serum ferritin (N=5), receiving IV iron before the planned infusion (N=1), acute organ injury / organ instability (n=4), hypersensitivity to tin-based products (n=1), and change of surgical site (n=1). Five patients withdrew from the study before treatment; two patients withdrew from the study after treatment (one due to delayed surgery and one due to difficulty in drawing blood).

[0093] In the MITT population, 41 patients received placebo (normal saline), 39 patients received low-dose RBT-1 (45 mg SnPP / 240 mg FeS), and 41 patients received high-dose RBT-1 (90 mg SnPP / 240 mg FeS). Baseline characteristics of the randomly assigned patients were similar between the groups (Table 14). The time between infusion and start of surgery and the duration of CPB were also similar among the three groups.

[0094]

[0095]

[0096] Key results

[0097] The mean composite value of the maximum preoperative change from baseline in HO-1, IL-10, and ferritin was 1.00 (95% CI: 0.86, 1.17) in the placebo group, 2.63 (95% CI: 2.25, 3.07) in the low-dose RBT-1 group, and 3.60 (95% CI: 3.10, 4.18) in the high-dose RBT-1 group. Figure 10 , p < 0.0001 for both comparisons. Figure 10 The primary endpoint, preconditioning response, is shown. The preconditioning response is shown as the geometric least squares mean of the ratio of the maximum preoperative change to baseline in the complex of heme oxygenase-1 (HO-1), interleukin-10 (IL-10), and ferritin; ***p<0.001 (vs. placebo).

[0098] Secondary End Points

[0099] The incidence of AKI and sustained reductions in urine output were numerically lower with both doses of RBT-1 but not significantly different from placebo (Table 15). Composite values ​​of renal tubular injury biomarkers did not change significantly (Table 15), and these biomarkers were not associated with the maximum change in serum creatinine.

[0100]

[0101] *GLSM, geometric least squares mean of the ratio of the maximum postoperative value to the baseline.

[0102] **AKI is defined as a ≥1.5-fold increase in serum creatinine relative to baseline, a persistent decrease in urine output, or the initiation of dialysis up to day 5 after cardiac surgery.

[0103] ***Persistently decreased urine volume was defined as an adverse event (AE) of oliguria, anuria, or “persistently” decreased urine volume reported up to day 5 after cardiac surgery.

[0104] Other pre-specified endpoints

[0105] The hospital course was assessed by ventilator duration and length of stay (LOS) in the ICU and hospital. Figure 11The ventilator, ICU and hospitalization processes are shown. The average time (days) on ventilator, ICU and hospitalization for each treatment group is shown; *p=0.02 (relative to placebo). The average ventilator use time in the placebo, low-dose RBT-1 and high-dose RBT-1 groups was 2.4 days, 1.7 days and 1.2 days (p=0.428 and p=0.060 (relative to placebo, respectively)). The average LOS in the ICU was 6 days in the placebo group and 3.3 days in the low-dose and high-dose RBT-1 groups (p=0.019 and p=0.128 (relative to placebo, respectively)). The average LOS in the hospital for the placebo, low-dose RBT-1 and high-dose RBT-1 groups were 10.0 days, 8.3 days and 9.1 days, respectively (p=0.744 and p=0.918 (relative to placebo, respectively)).

[0106] Postoperative complications included three deaths (7.3%) in the placebo group, one death (2.6%) in the low-dose RBT-1 group, and two deaths (4.9%) in the high-dose RBT-1 group (Table 16). One patient (2.4%) in the placebo group required dialysis for AKI, but none in the RBT-1 group. Postoperative atrial fibrillation occurred in 17 (42%), 12 (31%), and 10 (24%) patients in the placebo, low-dose RBT-1, and high-dose RBT-1 groups, respectively (Table 16). Hypervolemia was diagnosed in 10 (24%), 3 (8%), and 4 (10%) patients in the placebo, low-dose RBT-1, and high-dose RBT-1 groups (Table 16). Of note, one day after surgery, the change in postoperative troponin I levels from baseline was reduced by 63% in the low-dose RBT-1 group and by 30% in the high-dose RBT-1 group (p = 0.016 (low-dose RBT-1 vs. placebo)). Patients were assessed for MAKE at 30, 60, and 90 days. In this non-increased population, the number of patients with MAKE was low, as expected, and no statistical differences were observed between the groups (Table 16).

[0107] Finally, seven patients (17%) in the placebo group were readmitted for a cardiopulmonary diagnosis 30 days after discharge, compared with two patients (5%) in each of the low-dose and high-dose RBT-1 groups (Table 16). Eight patients (21%) in the placebo group required a cardiopulmonary readmission 60 and 90 days after discharge, compared with two patients (5%) in each of the low-dose and high-dose RBT-1 groups. All-cause readmissions showed similar results (Table 16).

[0108]

[0109] MAKE 60 and 90 give the same result.

[0110] *Individuals who died during their index hospitalization were excluded from the readmission analysis; the total sample sizes were 38, 38, and 39 patients for placebo, LD, and HD, respectively.

[0111] Cardiopulmonary readmission and all readmission outcomes were similar at 60 and 90 days.

[0112] Post-mortem analysis

[0113] Given the demonstrated multi-organ benefits of RBT-1, the effect of RBT-1 was explored in a post hoc composite analysis (win rate), in which clinical outcomes were evaluated in rank order of severity (death, AKI requiring dialysis, ICU days, 30-day cardiopulmonary re-admission, atrial fibrillation, and hospital days). The win rate in the low-dose RBT-1 group was 2.02 (p = 0.004), and the win rate in the high-dose RBT-1 group was 1.34 (p = 0.131) (Table 17A-B), indicating that patients treated with RBT-1 had improved outcomes compared to patients treated with placebo.

[0114]

[0115]

[0116] The Finkelstein-Schoenfeld method-based win rates were derived from a rank-order analysis of death, AKI requiring dialysis, ICU days, 30-day cardiopulmonary rehospitalization, atrial fibrillation, and hospital length of stay, and were compared for each patient who received placebo versus each patient who received low-dose RBT-1 and high-dose RBT-1. The cells in the upper table indicate the total number of wins and losses for all endpoints, and the cells in the lower table indicate the number of wins and losses observed for each endpoint in the hierarchy.

[0117] Safety results

[0118] RBT-1 was well tolerated, with the main adverse event (AE) associated with RBT-1 being considered photosensitivity, a known reaction to the SnPP component of RBT-1. Photosensitivity was dose-dependent, occurring in 6 of 45 patients (13%) treated with low-dose RBT-1 and in 12 of 46 patients (26%) treated with high-dose RBT-1. Photosensitivity reactions were generally transient and mild to moderate in intensity. The median duration of photosensitivity onset was 2.5 days in the low-dose RBT-1 group and 2.0 days in the high-dose RBT-1 group; the median duration of remission was 3.5 days in the low-dose RBT-1 group and 7.0 days in the high-dose RBT-1 group. All photosensitivity reactions resolved within 28 days in the LD group and within 93 days in the HD group. Three photosensitivity reactions in the high-dose RBT-1 group caused surgical delays.

[0119] discuss

[0120] This RBT-1 study met its primary endpoint, demonstrating statistically significant increases in the levels of cytoprotective proteins (plasma HO-1, IL-10, and ferritin), which are surrogate measures of RBT-1-mediated activation of the preconditioning response. The overall incidence of AKI was low, and in this non-elevated population, AKI-related outcomes did not show statistical significance.

[0121] Cardiac surgery, particularly cardiopulmonary bypass, induces systemic inflammation that can lead to multi-organ dysfunction, thereby compromising clinical outcomes. Importantly, inflammation and oxidative stress exist in a feed-forward loop, amplifying the responses of each pathway. The deleterious effects of these cell-damaging mediators can be seen in the phenomenon of "organ crosstalk," where damage to one organ can lead to damage in another. Just as these harmful mediators can adversely affect distant organs, cell-protective mediators can also be carried from one organ to another.

[0122] The benefits observed with RBT-1 may be related to mitigating these adverse effects before surgery by activating anti-inflammatory and antioxidant pathways, resulting in direct and indirect beneficial effects in various organs. These broad organ-protective benefits may lead to improved clinical outcomes, as evidenced by reduced short-term ventilator use, reduced need for vasopressors, reduced new-onset atrial fibrillation and fluid overload, and reduced long-term cardiopulmonary readmissions. To further evaluate this hypothesis, the effect of RBT-1 was explored in a post hoc analysis using a composite endpoint based on the win rate, in which clinical outcomes were assessed in rank order of severity. Cardiopulmonary readmissions, atrial fibrillation, and length of stay on this assessment day demonstrated clinical improvement in response to RBT-1, which will be confirmed in a larger, upcoming study.

[0123] The safety profile of RBT-1 showed that it was well tolerated, with the main drug-related adverse reaction being photosensitivity, which was dose-related and time-limited. The SnPP component of RBT-1, a metalloporphyrin, may be responsible for the photosensitivity, as metalloporphyrins are photoresponsive and may cause sunburn in patients exposed to sunlight, especially when exposure is prolonged or when sunscreen is not used.

[0124] Given the better safety profile of low-dose RBT-1 (45 mg SnPP / 240 mg FeS) with respect to photosensitivity, this dose was selected for a phase 3 study in which the planned primary endpoint would be a stratified composite of clinical outcomes in rank order of severity.

[0125] Example 3

[0126] 152 patients were enrolled at 19 sites in the United States, Canada, and Australia (Table 18).

[0127]

[0128]

[0129] Unless otherwise indicated, data are n (%). Percentages are rounded. CABG = coronary artery bypass grafting. EuroSCORE = European System for Cardiac Surgical Risk Evaluation. NYHA = New York Heart Association. Of the enrolled patients, 135 were randomly assigned to high-dose RBT-1 (n = 46), low-dose RBT-1 (n = 45), or placebo (n = 44). Figure 12Preconditioning responses are shown as the geometric least squares mean of the ratio of the maximum preoperative change to baseline in the complex of heme oxygenase-1 (HO-1), interleukin-10 (IL-10), and ferritin in the intention-to-treat population. HO = heme oxygenase, IL = interleukin.

[0130] The planned interim analysis was conducted from May 9 to June 6, 2022, and included the first 62 randomly assigned patients (n = 20 high dose, n = 19 low dose, and n = 23 placebo). Interim results indicated that the primary outcome was significantly different in both the high-dose RBT-1 (p < 0.0001) and low-dose RBT-1 (p < 0.0001) groups compared with the placebo group (Table 19).

[0131]

[0132] Unless otherwise stated, data are GLSM (95% CI). GLSM = geometric least squares mean. * GLSM is the ratio of the maximum value after surgery to the baseline value. The GLSM ratio represents the ratio of the GLSM in the active treatment group to the GLSM in the placebo group.

[0133] The unblinded statistician recommended that the study continue without accrual to provide additional evidence to support the secondary outcomes, and the study sponsor representative agreed. Therefore, an additional 73 patients (approximately 24 per group) were enrolled without accrual. The safety population consisted of all randomly assigned patients (n=135) who all received study treatment. Of these, 132 (98%) patients had biomarker measurements collected (ITT population) and were evaluated for their primary outcomes (n=46 high dose, n=42 low dose, n=44 placebo). In the ITT population, 121 patients underwent surgery on time (24 to 48 hours after infusion) and constituted the MITT population, which was evaluated for its secondary and clinical outcomes (n=41 high dose, n=39 low dose, n=41 placebo).

[0134] At the time of randomization, baseline characteristics were generally similar between the intervention groups in the safety population (Supplementary Table S3), the ITT population (Table 18), and the MITT population (Supplementary Table S4). In the ITT population, EuroSCORE and AKI risk factors were generally numerically lower in the placebo group relative to both RBT-1 groups. However, the opposite incidence was observed for combined surgery (CABG + valve). The time between infusion and start of surgery and the duration of cardiopulmonary bypass were similar among the three treatment groups.

[0135] The primary composite outcome in the ITT population was 3.60 in the high-dose RBT-1 group, 2.63 in the low-dose RBT-1 group, and 1.00 in the placebo group (Table 20, Figure 12 Both high and low doses of RBT-1 were associated with increases in preconditioning biomarker responses compared with placebo (high dose vs. placebo; GLSM ratio 3.58; 95% CI 2.91-4.41; p<0.0001; and low dose vs. placebo; GLSM ratio 2.62; 95% CI 2.11-3.24; p<0.0001).

[0136] The secondary outcomes of AKI incidence and sustained reduction in urine output were numerically lower with both doses of RBT-1 compared with placebo, but the differences were not significant (Table 20).

[0137]

[0138] Unless otherwise stated, data are n (%). Percentages are rounded. GLSM = geometric least squares mean. * GLSM is the ratio of the maximum value after surgery to the baseline value. The GLSM ratio represents the ratio of the GLSM in the active treatment group to the GLSM in the placebo group.

[0139] Composite values ​​of tubular injury biomarkers occurred with similar frequencies in the RBT-1 and placebo groups, and these biomarkers were not associated with maximum changes in serum creatinine (data not shown).The primary composite results for the MITT population were consistent with those for the ITT population.

[0140] RBT-1 was generally well tolerated by patients. The major drug-related AE was photosensitivity, a known reaction to the SnPP component of RBT-1 (Table 21).

[0141]

[0142]

[0143] Photosensitivity was dose-dependent and occurred in 12 of 46 patients (26%) treated with high-dose RBT-1 and 6 of 45 patients (13%) treated with low-dose RBT-1 in the safety population. Generally, in terms of intensity. The median time to photosensitivity onset was 2.0 days in the high-dose RBT-1 group and 2.5 days in the low-dose RBT-1 group; the median time to remission was 7.0 days in the high-dose RBT-1 group and 3.5 days in the low-dose RBT-1 group. All photosensitivity reactions in the high-dose RBT-1 group resolved within 93 days, and all photosensitivity reactions in the low-dose RBT-1 group resolved within 28 days. Three photosensitivity reactions in the high-dose RBT-1 group resulted in surgical delays. Other AEs of general interest are also provided in Table 21.

[0144] Postoperative complications included 2 deaths (5%) in the high-dose RBT-1 group, 1 death (3%) in the low-dose RBT-1 group, and 3 deaths (7%) in the placebo group. Figure 18 (Table S5). One patient (2%) in the placebo group required dialysis for AKI, but none in the RBT-1 group. The number of patients with MAKE was relatively low, and no statistical differences were observed between the groups. Postoperative atrial fibrillation and hypervolemia were numerically lower in both RBT-1 groups compared with the placebo group, but the differences were not significant. The mean duration of ventilator use was 1·2 days in the high-dose RBT-1, 1·7 days in the low-dose RBT-1, and 2·4 days in the placebo group. Figure 13 and Figure 18 (Table S5). The mean length of ICU stay was 3·3 days in the two RBT-1 groups and 6·0 days in the placebo group. The mean length of hospital stay was 9·1 days in the high-dose RBT-1, 8·3 days in the low-dose RBT-1, and 10·0 days in the placebo group. Finally, 2 patients (5%) in each of the two RBT-1 groups were readmitted for a cardiopulmonary diagnosis 30 days after discharge, compared with 7 patients (18%) in the placebo group. At 60 and 90 days after discharge, the rate of cardiopulmonary readmission remained the same in the two RBT-1 groups, with 2 patients (5%) in each group readmitted, compared with 8 patients (21%) in the placebo group. Similar results were seen for all-cause readmissions.

[0145] Given the demonstrated multi-organ benefits of RBT-1, the role of RBT-1 was explored in a post hoc composite analysis (win rate), in which clinical outcomes were evaluated in rank order of severity (death > AKI requiring dialysis > ICU days > 30-day cardiopulmonary rehospitalization) in the MITT population. Compared with placebo, the win rate for patients treated with high-dose RBT-1 was 1.39 (95% CI, 0.80-2.42), and the win rate for patients treated with low-dose RBT-1 was 2.26 (95% CI, 1.23-4.15). Figure 19 (Table S6).

[0146] In an analysis of myocardial injury using troponin I, the elevation in troponin I after cardiac surgery (GLSM ratio of the value one day after surgery to the preoperative baseline value) was numerically lower in the high-dose RBT-1 group compared with placebo, but the difference was not significant (GLSM ratio, 0.71; 95% CI, 0.32-1.58). However, the elevation in troponin I after surgery was reduced in the low-dose RBT-1 group compared with the placebo group (GLSM ratio, 0.37; 95% CI, 0.17-0.82). Figure 14 Shown are increases in plasma troponin I from preoperative baseline to 12 hours (left series) and 1 day (right series) after cardiac surgery. The analysis population was derived from the modified intention-to-treat population, excluding patients who underwent mitral valve repair or replacement, ablation, or septal myectomy because of the anticipated significant increase in troponin I levels after these major surgical procedures. The analysis population was derived from the MITT population, excluding patients who underwent mitral valve repair or replacement, ablation, or septal myectomy because of the anticipated significant increase in troponin I levels after these major surgical procedures.

[0147] discuss

[0148] This RBT-1 study met its primary endpoint, demonstrating statistically significant increases in the levels of cytoprotective proteins (plasma HO-1, IL-10, and ferritin), which are surrogate measures of RBT-1-mediated activation of the preconditioning response. RBT-1 biomarker responses were consistent with the Phase 1b study. In this population, the overall incidence of AKI was low, and differences in AKI-related outcomes were not significant. 430 Despite the relatively small sample size of this study, the reduction in adverse postoperative outcomes was observed, suggesting that RBT-1 may improve recovery after cardiac surgery.

[0149] Cardiac surgery, particularly cardiopulmonary bypass, induces systemic inflammation, which can lead to multi-organ dysfunction and compromise clinical outcomes. Importantly, inflammation and oxidative stress exist in a feed-forward loop, amplifying the responses of each pathway. The deleterious effects of these cell-damaging mediators can be seen in the phenomenon of "organ crosstalk," where damage to one organ can lead to damage to another.

[0150] The benefits observed with RBT-1 may be related to mitigating these adverse effects before surgery by activating anti-inflammatory and antioxidant pathways, thereby producing direct and indirect beneficial effects in various organs. For example, the RBT-1-mediated anti-inflammatory response may prevent fluid extravasation into tissues due to capillary leak, thereby reducing the need for fluid (volume) replacement and ultimately reducing fluid overload, as observed with the reduction in hypervolemia in patients treated with RBT-1. The broad organ-protective benefits of RBT-1 may lead to improved clinical outcomes as manifested by short-term reductions in ventilator use, ICU stays, vasopressor requirements, new-onset atrial fibrillation and fluid overload, and long-term reductions in cardiopulmonary readmissions. To further evaluate this hypothesis, the effect of RBT-1 was explored in a post hoc analysis using the odds ratio based on a composite value of clinical outcomes assessed on a rank order of severity. This assessment, comprised of death, AKI requiring dialysis, ICU days, and 30-day cardiopulmonary readmission, demonstrated clinical improvement in response to RBT-1, which will be confirmed in an upcoming Phase 3 study.

[0151] The safety profile of RBT-1 showed that it was well tolerated, with the main drug-related AE being photosensitivity, which was dose-related and time-limited. The SnPP component of RBT-1, a metalloporphyrin, may be responsible for the photosensitivity, as metalloporphyrins are photoresponsive and may cause sunburn in patients exposed to sunlight, especially if exposure is prolonged or sunscreen is not used. Due to comparable efficacy and fewer photosensitivity reactions compared to the high-dose RBT-1, a low-dose RBT-1 (45 mg SnPP / 240 mg FeS) is planned for the final Phase 3 trial.

[0152] As a Phase 2 trial, the goal was to investigate whether RBT-1 administered preoperatively would elicit a preconditioning response in patients undergoing CABG and / or heart valve surgery and was not powered (i.e., relatively small sample size) to demonstrate a statistically significant reduction in clinical outcomes; a larger Phase 3 trial is needed to demonstrate such an effect. This study was conducted during the COVID-19 pandemic, which may have impacted LOS in the ICU; however, to minimize variability in standard of care, patients were randomized at the site level. Although post hoc assessment of the composite outcome showed statistically significant improvement, a consistent trend toward improvement with RBT-1 treatment was observed. One (0.7%) patient had incomplete serum creatinine values ​​required for the MAKE results at Days 60 and 90 due to COVID-19 preventing the patient from returning to the hospital for laboratory collection. However, laboratory values ​​were estimated for this patient. Given the exploratory nature of the trial, type I error rates were not controlled using bias adjustment methods.

[0153] This RBT-1 study met its primary outcome, demonstrating statistically significant increases in the levels of cytoprotective proteins (plasma HO-1, IL-10, and ferritin), which are surrogate measures of RBT-1-mediated activation of the preconditioning response. Given the positive trends in clinical outcomes and the adequate safety profile, a Phase 3 study of RBT-1 is planned, in which the primary outcome will be a stratified composite of clinical outcomes.

[0154] like Figure 20 As shown, patients undergoing CABG / heart valve surgery showed improvements in clinical outcomes including (a) ventilator time, (b) ICU time, and (c) cardiopulmonary readmission. Specifically, ventilator time decreased from 3.29 in the placebo group to 1.57 in the RBT-1 treatment group. ICU time decreased from 7.57 in the placebo group to 3.71 in the RBT-1 treatment group. 30-day, 60-day, and 90-day cardiopulmonary readmissions decreased from 30.8% in the placebo group to 7.7% in the RBT-1 treatment group. Figure 20 These results were further supported by the fact that RBT-1 had an outperformance ratio of 2.1 over placebo, as shown in Figure 2 .

[0155] Additional observations from the study include the following:

[0156] As the researchers report, a significant 49% reduction in the incidence of postoperative anemia was observed in response to RBT-1 treatment compared to placebo (p=0.0447).

[0157] A 33% reduction in transfusion requirements was observed in the RBT-1 group compared with placebo.

[0158] Similarly, a 42% reduction in iron supplementation requirements was observed in the RBT-1 group compared with placebo.

[0159] When all patients requiring both blood and iron transfusions were compared, a statistically significant reduction was observed in the RBT-1 group compared to placebo (RBT-1: 0.0% vs. placebo: 12.2%; p=0.0046).

[0160] Importantly, despite lower rates of blood transfusion and iron supplementation, patients who received RBT-1 had hemoglobin levels at discharge that were comparable to those who received placebo (RBT-1: 9.8 g / dL vs. placebo: 9.8 g / dL).

[0161] Example 4

[0162] A patient who was found to be photosensitized (skin that burns easily) was treated with an intravenous infusion of RBT-1 between 24 and 48 hours before planned CABG surgery. The RBT-1 dose was 45 mg of tin protoporphyrin and 240 mg of iron sucrose. Following the infusion of RBT-1 and prior to sun exposure, the patient's exposed skin was treated with an SPF 50 sunscreen. The patient underwent CABG surgery. Following surgery, an SPF 50 sunscreen was applied prior to any sun exposure for six days from surgery.

[0163] Example 5

[0164] A patient who was found to be photosensitized (skin that burns easily) was treated with RBT-1 by intravenous infusion between 24 and 48 hours before planned CABG surgery. The RBT-1 dose was 45 mg of tin protoporphyrin and 240 mg of iron sucrose. Sun exposure was avoided from the time of RBT-1 administration and surgery. The patient underwent CABG surgery. After surgery, SPF 50 sunscreen was applied before any sun exposure for six days from surgery.

[0165] Example 6

[0166] A patient prone to post-CABG readmission for cardiopulmonary reasons was treated with RBT-1 via intravenous infusion between 24 and 48 hours before planned CABG surgery. The RBT-1 dose consisted of 45 mg of tin protoporphyrin and 240 mg of iron sucrose. The patient underwent CABG surgery. After surgery, the patient's likelihood of needing a cardiopulmonary readmission was reduced by at least 60%.

[0167] Example 7

[0168] A patient at high risk for postoperative complications after CABG surgery was treated with RBT-1 via intravenous infusion between 24 and 48 hours before planned CABG surgery. The RBT-1 dose consisted of 45 mg of tin protoporphyrin and 240 mg of iron sucrose. The patient underwent CABG surgery. After surgery, the patient was less likely to experience the following complications: (a) intensive care unit stay for more than three days, (b) mechanical ventilation for more than 24 hours, (c) hospital readmission for cardiopulmonary surgery, (d) need for a blood transfusion, (e) new onset of postoperative atrial fibrillation (POAF) during hospitalization, or a combination of two or more of (a)–(e).

[0169] Example 8

[0170] A phase III study was conducted to evaluate the reduction in the risk of postoperative complications in patients undergoing cardiothoracic surgery. Figure 21 The design of this study is shown. The primary objective of this study is to evaluate the efficacy of RBT-1 on a stratified composite (win rate) of the following: death, incidence of acute kidney injury (AKI) requiring dialysis, number of days in the intensive care unit (ICU), and 30-day cardiopulmonary readmission rate compared to placebo. The secondary objectives of the study will focus on postoperative complications, number of days in the ICU, 30-day cardiopulmonary readmission rate, and safety. Postoperative complications to be studied include death, AKI requiring dialysis, ICU stay>3 days, use of a ventilator>24 hours, 30-day cardiopulmonary readmission, need for a blood transfusion during the first hospitalization, and new-onset postoperative atrial fibrillation (POAF) during the first hospitalization.

[0171] Other embodiments and uses of the present invention will be apparent to those skilled in the art by consideration of the specification and practice of the invention disclosed herein. All references cited herein, including all U.S. and foreign patents and patent applications, are specifically and entirely incorporated herein by reference. The description and examples are intended to be considered exemplary only, with the true scope and spirit of the invention being indicated by the appended claims.

Claims

1. A method of reducing postoperative complications in a human patient caused by injury based on a planned or anticipated surgical procedure, the method comprising administering to the human patient prior to the surgical procedure a composition comprising a therapeutically effective amount of (i) an iron compound; and (ii) a tin protoporphyrin in an amount of 20-80 mg, wherein the human patient is susceptible to photodermatosis.

2. The method of claim 1, wherein the tin protoporphyrin is administered at a dose of 30-70 mg.

3. The method of any one of claims 1 or 2, wherein the tin protoporphyrin is administered at a dose of 45 mg.

4. The method of any one of claims 1 to 3, wherein the iron compound is iron sucrose, administered at a dose of 190-290 mg.

5. The method of any one of claims 1 to 4, wherein the iron compound is iron sucrose, administered at a dose of 240 mg.

6. The method of any one of claims 1 to 5, wherein the tin protoporphyrin is administered at a dose of 45 mg and the iron compound is iron sucrose, administered at a dose of 240 mg.

7. The method of any one of claims 1 to 6, wherein sunscreen is applied to the patient's skin within six days of the planned or anticipated surgical procedure.

8. The method of claim 7, wherein sunscreen is applied to the patient's skin prior to any anticipated sun exposure within six days of the planned or anticipated surgical procedure.

9. The method of any one of claims 1 to 8, wherein the human patient avoids sun exposure between administration of the therapeutically effective composition and the planned or anticipated surgical procedure, and wherein the human patient applies sunscreen when sun exposure is expected for at least 6 days after the planned or anticipated surgical procedure.

10. The method of any one of claims 1 to 9, wherein the human patient applies sunscreen in anticipation of sun exposure after administration of the therapeutically effective composition.

11. The method of any one of claims 1 to 10, wherein the sunscreen has a sun protection factor (SPF) of 50+.

12. The method of any one of claims 1 to 11, wherein the iron compound is present in an aqueous pharmaceutical composition comprising: iron sucrose; a bicarbonate salt; and a pharmaceutically acceptable aqueous carrier.

13. The method of any one of claims 1 to 12, wherein the tin protoporphyrin is present in an aqueous pharmaceutical composition comprising: a total impurity level of 1.5% or less as measured by gas chromatography.

14. The method of any one of claims 1 to 13, wherein preparing the therapeutically effective composition comprises combining in an intravenous bag: a. An aqueous iron pharmaceutical composition, the aqueous iron pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier; and b. A tin protoporphyrin composition having a total impurity level of 1.5% or less as measured by gas chromatography.

15. The method of any one of claims 1 to 14, wherein the therapeutically effective amount of tin protoporphyrin is 0.5-0.8 mg / kg.

16. The method of any one of claims 1 to 15, wherein the therapeutically effective amount of tin protoporphyrin is 0.6-0.7 mg / kg.

17. The method of any one of claims 1 to 16, wherein the therapeutically effective amount of tin protoporphyrin is 0.63 mg / kg.

18. The method of any one of claims 1 to 17, wherein the therapeutically effective amount of iron sucrose is 2-6 times the amount of tin protoporphyrin.

19. The method of any one of claims 1 to 18, wherein the therapeutically effective amount of iron sucrose is 3-4 times the amount of tin protoporphyrin.

20. The method of any one of claims 1 to 19, wherein the planned or anticipated surgical procedure is surgery on an organ.

21. The method of claim 20, wherein the organ is the heart.

22. The method of claim 20, wherein the organ is a kidney.

23. The method of claim 20, wherein the organ is the liver.

24. The method of claim 20, wherein the organ is a lung.

25. The method of any one of claims 1 to 24, wherein the iron compound and the tin protoporphyrin are administered at least 24 hours before the planned or anticipated surgical procedure on the organ occurs.

26. The method of any one of claims 1 to 25, wherein the iron compound and the tin protoporphyrin are administered no more than 48 hours before the planned or anticipated surgical procedure on the organ.

27. The method of any one of claims 1 to 26, wherein the planned or anticipated surgical procedure is a surgical procedure comprising coronary artery bypass graft (CABG) to cardiopulmonary bypass (CPB), a heart valve, or combined CABG / valve surgery.

28. The method of any one of claims 1 to 27, wherein the planned or anticipated surgical procedure is organ transplant surgery.

29. The method of any one of claims 1 to 28, wherein the method reduces or eliminates the need to administer blood products following the planned or anticipated surgical procedure.

30. The method of any one of claims 1 to 29, wherein the blood product comprises whole blood from a donor.

31. The method of any one of claims 1 to 30, wherein the method reduces the need for hospital readmission for cardiopulmonary reasons.

32. The method of any one of claims 1 to 31, wherein the method reduces post-operative complications of the planned or anticipated surgical procedure.

33. The method of claim 32, wherein the postoperative complications comprise intensive care unit stay for more than three days, ventilator use for more than 24 hours, readmission for cardiopulmonary surgery, need for blood transfusion, new onset of postoperative atrial fibrillation (POAF) during hospitalization, or a combination of two or more thereof.

34. A method of reducing postoperative complications in a human patient caused by injury based on a planned or anticipated attack on an organ of the human patient, the method comprising: (a) administering to the patient a therapeutically effective composition comprising (i) an iron compound; and (ii) a tin protoporphyrin, and (b) applying a sunscreen to the skin of said human patient around the time of administering said therapeutically effective composition to said human patient or within six days of said planned or anticipated surgical procedure, wherein said therapeutically effective composition is administered before said planned or anticipated attack on said organ occurs.

35. The method of claim 34, wherein step (a) comprises administering the tin protoporphyrin at a dose of 20-80 mg.

36. The method of any one of claims 34 to 35, wherein the tin protoporphyrin is administered at a dose of 30-70 mg.

37. The method of any one of claims 34 to 36, wherein the tin protoporphyrin is administered at a dose of 45 mg.

38. The method of any one of claims 34 to 37, wherein the iron sucrose is administered at a dose of 190-290 mg.

39. The method of any one of claims 34 to 38, wherein the iron sucrose is administered at a dose of 240 mg.

40. The method of any one of claims 34 to 39, wherein the tin protoporphyrin is administered at a dose of 45 mg and the iron sucrose is administered at a dose of 240 mg.

41. The method of any one of claims 34 to 40, further comprising applying a sunscreen to the patient's skin, wherein the sunscreen protects the patient when the patient is exposed to the therapeutically effective composition.

42. The method of any one of claims 34 to 41, wherein the step of administering the therapeutically effective composition to the patient is performed before applying a sunscreen to the patient's skin.

43. The method of any one of claims 34 to 42, wherein the patient avoids sun exposure between administration of the therapeutically effective composition and the challenge, and wherein the patient applies sunscreen for at least 6 days after surgery.

44. The method of any one of claims 34 to 43, wherein the patient applies sunscreen in anticipation of sun exposure after administration of the therapeutically effective composition.

45. The method of any one of claims 34 to 44, wherein the sunscreen has a sun protection factor (SPF) of 50+.

46. ​​The method of any one of claims 34 to 45, wherein the iron compound is present in an aqueous pharmaceutical composition comprising: iron sucrose; a bicarbonate salt; and a pharmaceutically acceptable aqueous carrier, wherein the iron sucrose is present in a pharmaceutically effective amount, the iron is present in both iron (II) and iron (III) forms, the pH of the pharmaceutical composition is greater than 9, the concentration of iron (II) is between 0.05% w / v and 0.41% w / v, and the iron sucrose has a MW by GPC of between 33,000 and 38,000 Daltons.

47. The method of any one of claims 34 to 46, wherein the tin protoporphyrin is present in an aqueous pharmaceutical composition comprising: a total impurity level of 1.5% or less as measured by gas chromatography.

48. The method of any one of claims 34 to 47, wherein preparing the therapeutically effective composition comprises combining in an intravenous bag: a. An aqueous iron pharmaceutical composition, the aqueous iron pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier, wherein the iron sucrose is present in a pharmaceutically effective amount to provide kidney protection to the patient, the iron is present in both iron (II) and iron (III) forms, the pH of the pharmaceutical composition is greater than 9, the concentration of iron (II) is 0.05% w / v to 0.41% w / v, and the iron sucrose has a MW according to GPC of between 33,000 and 38,000 Daltons; and b. A tin protoporphyrin composition having a total impurity level of 1.5% or less as measured by gas chromatography.

49. The method of any one of claims 34 to 48, wherein the therapeutically effective amount of tin protoporphyrin is 0.5-0.8 mg / kg.

50. The method of any one of claims 34 to 49, wherein the therapeutically effective amount of tin protoporphyrin is 0.6-0.7 mg / kg.

51. The method of any one of claims 34 to 50, wherein the therapeutically effective amount of tin protoporphyrin is 0.63 mg / kg.

52. The method of any one of claims 34 to 51, wherein the therapeutically effective amount of iron sucrose is 2-6 times the amount of tin protoporphyrin.

53. The method of any one of claims 34 to 52, wherein the therapeutically effective amount of iron sucrose is 3-4 times the amount of tin protoporphyrin.

54. The method of any one of claims 34 to 53, wherein the challenge is surgery.

55. The method of any one of claims 34 to 54, wherein the organ is the heart.

56. The method of any one of claims 34 to 55, wherein the organ is a kidney.

57. The method of any one of claims 34 to 56, wherein the organ is the liver.

58. The method of any one of claims 34 to 57, wherein the organ is a lung.

59. The method of any one of claims 34 to 58, wherein the iron sucrose and the tin protoporphyrin are administered at least 24 hours before the planned or anticipated attack on the organ occurs.

60. The method of any one of claims 34 to 59, wherein the iron sucrose and the tin protoporphyrin are administered no more than 48 hours before the planned or anticipated attack on the organ occurs.

61. The method of any one of claims 34 to 60, wherein the challenge is a surgical procedure comprising coronary artery bypass graft (CABG) to cardiopulmonary bypass (CPB), a heart valve, or combined CABG / valve surgery.

62. The method of any one of claims 34 to 61, wherein the challenge is organ transplant surgery.

63. The method of any one of claims 34 to 62, wherein the method reduces or eliminates the need to administer blood products following surgery.

64. The method of any one of claims 34 to 63, wherein the blood product comprises whole blood from a donor.

65. The method of any one of claims 34-64, wherein the method reduces the need for hospital readmission for cardiopulmonary reasons.

66. The method of any one of claims 34 to 65, wherein the method reduces post-operative complications of the surgical procedure.

67. The method of claim 66, wherein the postoperative complications include: Admission to the intensive care unit for more than three days, use of a ventilator for more than 24 hours, readmission for cardiopulmonary surgery, need for a blood transfusion, and / or new onset of postoperative atrial fibrillation (POAF) during hospitalization.

68. A method of reducing hospital readmissions for cardiopulmonary reasons in a human patient following surgery by at least 60%, said method comprising administering to said patient prior to said surgery a therapeutically effective composition comprising an amount of (i) an iron compound; and (ii) a tin protoporphyrin.

69. The method of claim 66, wherein the cardiopulmonary readmissions are reduced by at least 70%.

70. The method of claim 66, wherein the cardiopulmonary readmissions are reduced by at least about 72%.

71. A method of reducing postoperative complications in a human patient resulting from injury based on a planned or anticipated surgical procedure, said method comprising administering to said patient prior to said surgical procedure a therapeutically effective composition comprising an amount of (i) an iron compound; and (ii) a tin protoporphyrin, wherein said postoperative complications include: (a) intensive care unit admission for more than three days, (b) ventilator use for more than 24 hours, (c) readmission for cardiopulmonary surgery, (d) need for blood transfusion, (e) new onset of postoperative atrial fibrillation (POAF) during hospitalization, or a combination of two or more of (a)–(e).

72. The method of any one of claims 68 to 71, wherein the tin protoporphyrin is administered at a dose of 30-70 mg.

73. The method of any one of claims 68-71, wherein the tin protoporphyrin is administered at a dose of 45 mg.

74. The method of any one of claims 68 to 73, wherein the iron compound is iron sucrose, administered at a dose of 190-290 mg.

75. The method of any one of claims 68 to 74, wherein the iron compound is iron sucrose, administered at a dose of 240 mg.

76. The method of any one of claims 68 to 75, wherein the tin protoporphyrin is administered at a dose of 45 mg and the iron compound is iron sucrose, administered at a dose of 240 mg.

77. The method of any one of claims 68 to 76, wherein the iron compound is present in an aqueous pharmaceutical composition comprising: iron sucrose; a bicarbonate salt; and a pharmaceutically acceptable aqueous carrier.

78. The method of any one of claims 68 to 77, wherein the tin protoporphyrin is present in an aqueous pharmaceutical composition comprising: a total impurity level of 1.5% or less as measured by gas chromatography.

79. The method of any one of claims 68 to 78, wherein preparing the therapeutically effective composition comprises combining in an intravenous bag: a. An aqueous iron pharmaceutical composition, the aqueous iron pharmaceutical composition comprising: iron sucrose; bicarbonate; and a pharmaceutically acceptable aqueous carrier; and b. A tin protoporphyrin composition having a total impurity level of 1.5% or less as measured by gas chromatography.

80. The method of any one of claims 68 to 79, wherein the therapeutically effective amount of tin protoporphyrin is 0.5-0.8 mg / kg.

81. The method of any one of claims 68 to 80, wherein the therapeutically effective amount of tin protoporphyrin is 0.6-0.7 mg / kg.

82. The method of any one of claims 68-81, wherein the therapeutically effective amount of tin protoporphyrin is 0.63 mg / kg.

83. The method of any one of claims 68-82, wherein the therapeutically effective amount of iron sucrose is 2-6 times the amount of tin protoporphyrin.

84. The method of any one of claims 68-83, wherein the therapeutically effective amount of iron sucrose is 3-4 times the amount of tin protoporphyrin.

85. The method of any one of claims 68 to 84, wherein the planned or anticipated surgical procedure is surgery on an organ.

86. The method of claim 85, wherein the organ is the heart.

87. The method of claim 85, wherein the organ is a kidney.

88. The method of claim 85, wherein the organ is the liver.

89. The method of claim 85, wherein the organ is a lung.

90. The method of any one of claims 68 to 89, wherein the iron compound and the tin protoporphyrin are administered at least 24 hours before the planned or anticipated surgical procedure on the organ occurs.

91. The method of any one of claims 68 to 90, wherein the iron compound and the tin protoporphyrin are administered no more than 48 hours before the planned or anticipated surgical procedure on the organ.

92. The method of any one of claims 68 to 91, wherein the planned or anticipated surgical procedure is a surgical procedure comprising coronary artery bypass graft (CABG) to cardiopulmonary bypass (CPB), a heart valve, or combined CABG / valve surgery.

93. The method of any one of claims 68 to 92, wherein the planned or anticipated surgical procedure is organ transplant surgery.

94. The method of any one of claims 68 to 93, wherein the method reduces or eliminates the need to administer blood products following the planned or anticipated surgical procedure.

95. The method of any one of claims 68 to 94, wherein the blood product comprises whole blood from a donor.

96. The method of any one of claims 68-95, wherein the method reduces the need for hospital readmission for cardiopulmonary reasons.

97. The method of any one of claims 68 to 96, wherein the method reduces post-operative complications of the planned or anticipated surgical procedure.

98. The method of claim 97, wherein the postoperative complications comprise intensive care unit stay for more than three days, ventilator use for more than 24 hours, readmission for cardiopulmonary surgery, need for blood transfusion, new onset of postoperative atrial fibrillation (POAF) during hospitalization, or a combination of two or more thereof.

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