Compositions and methods for increasing tetrahydrobiopterin plasma exposure

Abstract

To provide compositions including sepiapterin, or a pharmaceutically acceptable salt thereof, and methods for the treatment of BH4-related disorders.SOLUTION: The present invention provides a method of treating a BH4-related disorder in a subject in need thereof, the method comprising the step for administering to the subject an effective amount of sepiapterin or a pharmaceutically acceptable salt thereof, together with food. In some embodiments, these compositions and methods result in an increase in plasma exposure of BH4.SELECTED DRAWING: None

Description

[Background technology]

[0001] Sepiapterin is a naturally occurring precursor of tetrahydrobiopterin (BH4), an essential cofactor for key intracellular enzymes, including but not limited to phenylalanine hydroxylase (PAH) (Kaufman, 1958), tyrosine hydroxylase (TH) (Nagatsu et al., 1964), tryptophan hydroxylase (TPH) (Ichiyama et al., 1970), nitric oxide synthase (NOS) (Kwon et al., 1989), (Mayer et al., 1991), and alkylglycerol monooxygenase (AGMO) (Tietz et al., 1964). Rapid conversion of sepiapterin to BH4 occurs via a two-step reduction in the salvage pathway for BH4 synthesis (Sawabe, 2008). Synthetic forms of BH4 (e.g., sapropterin dihydrochloride) are used as therapy for disorders associated with elevated plasma phenylalanine, such as phenylketonuria (PKU). PKU is an inborn error of metabolism primarily caused by mutations in the PAH gene. BH4 has also been tested as a treatment for various central nervous system symptoms and other disorders associated with PKU, but efficacy has been limited, likely due to BH4's inability to effectively cross the blood-brain barrier (Klaiman et al., 2013; Grant et al., 2015).

[0002] Recent studies suggest that, compared with BH4, peripherally administered sepiapterin has higher membrane permeability and, as a result, more readily accesses liver, kidney, and brain cells. Sepiapterin is rapidly converted to BH4 intracellularly, thereby increasing BH4 levels in the liver, kidney, and brain (Sawabe, 2008). As a result, sepiapterin may serve as a useful therapeutic agent for diseases associated with low intracellular BH4 levels or dysfunction of various BH4-dependent metabolic pathways. Summary of the Invention

[0003] The present invention is directed to the discovery that administering sepiapterin with food to a subject unexpectedly increases BH4 production and further results in plasma, CSF, and / or brain exposure of BH4 in the subject. Without being bound by theory, increased BH4 plasma exposure may be due to delayed absorption of sepiapterin by increasing gastric residence time, or prolonged absorption rate of sepiapterin by increasing foregut residence time, or increased maximum rate of enzymatic activity of sepiapterin reductase or dihydrofolate reductase (V max This may result in prolonged intracellular concentrations of sepiapterin below, at, or slightly above BH4, or a combination of the above, resulting in a greater proportion of the administered sepiapterin being converted to BH4 before passive or active transport into the circulation for excretion and / or elimination. The present invention features compositions comprising sepiapterin or a salt thereof, and methods for treating BH4-related disorders. In some embodiments, the compositions and methods result in increased plasma exposure of BH4.

[0004] As is known in the art, food can affect the absorption of a compound. Absorption may be delayed but not decreased, or the total amount of drug absorbed may be reduced. The effect of food may be due to slowing gastric residence time, slowing foregut residence time, reducing compound access to the absorption site, changing the dissolution rate of the compound, or changing gastric pH. Because of this effect, it is important to establish a specific administration schedule for drugs that should be administered separately from or with food.

[0005] In one aspect, the invention features a method of treating a BH4-related disorder in a subject in need thereof by administering an effective amount of sepiapteprin or a pharmaceutically acceptable salt thereof with food.

[0006] In another aspect, the invention features a method of increasing BH4 plasma exposure in a subject undergoing sepiapterin therapy by administering to the subject an effective amount of sepiapterin or a pharmaceutically acceptable salt thereof with food.

[0007] In a further aspect, the invention features a method for reducing the absorption rate of an oral formulation of sepiapterin, as measured by the BH4 concentration achieved in plasma over time, in a subject in need of its therapeutic effect, comprising administering to the subject an effective amount of sepiapterin or a pharmaceutically acceptable salt thereof with food.

[0008] In some embodiments of any of the above-described methods, the effective amount is a dosage (e.g., 2.5 mg / kg to 100 mg / kg per administration) sufficient to produce a BH4 concentration of at least 50 ng / ml (e.g., at least 60 ng / mL, at least 100 ng / mL, at least 200 ng / mL, at least 400 ng / mL, at least 600 ng / mL, at least 1000 ng / mL, or at least 2000 ng / mL) in the subject's plasma within 10 hours after administration with food. An effective amount may include a dose that is at least 5% (at least 10%, at least 20%, at least 50%, at least 70%, at least 90%, at least 100%, at least 110%, at least 120%, at least 130%, at least 140%, or at least 150%) less than a dose sufficient to produce a maximum BH4 plasma concentration (Cmax) of at least 50 ng / ml (e.g., at least 60 ng / mL, at least 100 ng / mL, at least 200 ng / mL, at least 400 ng / mL, at least 600 ng / mL, at least 1000 ng / mL, or at least 2000 ng / mL) in the subject's plasma within 10 hours after administration of sepiapterin without food.

[0009] In some embodiments of any of the above-described methods, administration to the subject occurs less than 30 minutes before or after ingestion of the food, e.g., immediately before ingestion but up to 1 hour after ingestion of the food. In some embodiments, administration to the subject occurs substantially simultaneously with the food. In some embodiments of any of the above-described methods, the food is a high-protein food. In some embodiments of any of the above-described methods, the food is a high-fat food (e.g., at least 25, 30, 40, or 50% of the calories are from fat). In some embodiments of any of the above-described methods, the food is a high-protein and high-fat food. In some embodiments, the food is a high-calorie food (e.g., the food contains at least 100 calories, e.g., at least 200 calories, at least 300 calories, at least 400 calories, at least 500 calories, e.g., 500-1500 or 800-1000 calories). In some embodiments of any of the above-described methods, the food is a meal, e.g., breakfast, lunch, or dinner.

[0010] In some embodiments, administration with food (e.g., less than 30 minutes before or after food ingestion, e.g., immediately before food ingestion up to 1 hour after food ingestion) results in an increase in the Cmax of BH4 (e.g., at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, at least 100%, at least 110%, at least 120%, at least 130%, at least 140%, or at least 150%) compared to administration without food (e.g., more than 2 hours after food ingestion up to 30 minutes before further food ingestion).

[0011] In some embodiments, administration with food (e.g., less than 30 minutes before or after food ingestion, e.g., immediately before food ingestion up to 1 hour after food ingestion) reduces the extent of BH4 production and resulting plasma exposure (AUC 0-last) increase (e.g., at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, at least 100%, at least 110%, at least 120%, at least 130%, at least 140%, or at least 150%).

[0012] In some embodiments of any of the above aspects, the sepiapterin is provided in a composition separate from the food to be ingested (e.g., the sepiapterin is not incorporated into a food product). In some embodiments of any of the above aspects, the food is ingested before the administration of the sepiapterin (e.g., the food is ingested within one hour immediately prior to the administration of the sepiapterin). In some embodiments, the food is ingested after the administration of the sepiapterin (e.g., the food is ingested immediately after administration but up to 30 minutes after administration).

[0013] In a further aspect, the invention features a pharmaceutical composition of sepiapterin, or a pharmaceutically acceptable salt thereof, formulated to mimic the effect of administration with food, e.g., to increase gastric residence time (e.g., the formulation described in Radhakrishnan et al. Drug Delivery Letters, 2017, 7, 190-200, which is incorporated by reference).

[0014] In some embodiments, the compositions are formulated as bioadhesive formulations, dense formulations, expandable formulations, superporous hydrogel formulations, or floating formulations (e.g., compositions comprising ion exchange resins, raft systems, inflatable chambers, effervescent mixtures, swellable hydrocolloids, or multiparticulate systems).

[0015] In another aspect, the invention features a method for treating a BH4-related disorder in a subject in need thereof by administering to the subject an effective amount of any of the pharmaceutical compositions described above.

[0016] In yet another aspect, the invention features a method of increasing BH4 plasma exposure in a subject undergoing sepiapterin therapy by administering to the subject an effective amount of any of the pharmaceutical compositions described above.

[0017] In a further aspect, the invention features a method for delaying or reducing (e.g., by at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50%) the rate of absorption of an oral formulation of sepiapterin as measured by the BH4 concentration achieved in the plasma over time in a subject in need of its therapeutic effect by administering to the subject an effective amount of any of the pharmaceutical compositions described above.

[0018] In one aspect, the invention features a method for increasing homovanillic acid and / or 5-hydroxyindoleacetic acid levels in a subject, the method comprising administering an effective amount of sepiapterin or a pharmaceutically acceptable salt thereof with food. In some embodiments, the level of homovanillic acid and / or 5-hydroxyindoleacetic acid in the subject's cerebrospinal fluid (CSF) is increased. In some embodiments, the level of homovanillic acid and / or 5-hydroxyindoleacetic acid in the subject (e.g., in the subject's CSF) is increased by at least 5% compared to the level before administration (e.g., increased by at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, at least 100%, at least 150%, at least 200%, at least 250%, or at least 300% compared to the level before administration).

[0019] In some embodiments, prior to administration of sepiapterin or a pharmaceutically acceptable salt thereof, the subject has homovanillic acid and / or 5-hydroxyindoleacetic acid levels that are less than 50% (e.g., less than 40%, less than 30%) of the levels in an average subject (e.g., the subject has a CSF level of homovanillic acid less than 15 ng / ml and / or a CSF level of 5-hydroxyindoleacetic acid less than 5 ng / ml). In some embodiments, the subject has not been diagnosed with a BH4-related disease. In some embodiments, the subject does not have symptoms of a BH4-related disease. In some embodiments, after administration of sepiapterin or a pharmaceutically acceptable salt thereof, the homovanillic acid and / or 5-hydroxyindoleacetic acid levels in the subject are greater than 50% of the levels in an average subject (e.g., the subject has a CSF level of homovanillic acid greater than 15 ng / ml and / or a CSF level of 5-hydroxyindoleacetic acid greater than 5 ng / ml).

[0020] In some embodiments of any of the above aspects, the subject has and / or has been diagnosed with a BH4-related disorder.

[0021] In some embodiments of any of the aforementioned aspects, the BH4-related disorder is primary BH4 deficiency, GTPCH deficiency, 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency, DHPR deficiency, sepiapterin reductase deficiency, dopamine-responsive dystonia, Segawa syndrome, tyrosine hydroxylase deficiency, phenylketonuria, DNAJC12 deficiency, Parkinson's disease, Parkinson's depression, or depression in Parkinson's disease patients. impulsivity, major depression, autism spectrum disorder, ADHD, schizophrenia, bipolar disorder, cerebral ischemia, restless legs syndrome, obsessive-compulsive disorder, anxiety disorder, aggression in Alzheimer's disease, cerebrovascular accident, convulsions after subarachnoid hemorrhage, myocarditis, coronary vasospasm, cardiac hypertrophy, arteriosclerosis, hypertension, thrombosis, infection, endotoxic shock, liver cirrhosis, hypertrophic pyloric stenosis, gastric mucosal injury, pulmonary hypertension, renal dysfunction, impotence, or hypoglycemia. In some embodiments of any of the above aspects, the BH4-related disease is phenylketonuria, BH4 deficiency (e.g., primary BH4 deficiency), CNS disorder (e.g., Segawa syndrome, depression, schizophrenia, autism, or Parkinson's disease), or gastrointestinal motility disorder (e.g., gastroparesis and primary and secondary esophageal motility disorders). In some embodiments, the BH4-related disease is BH4 deficiency or phenylketonuria.

[0022] definition In this application, unless otherwise clear from the context, (i) the term "a" may be understood to mean "at least one," (ii) the term "or" may be understood to mean "and / or," (iii) the terms "comprise" and "including" may be understood to encompass the listed elements or steps, whether presented by themselves or with one or more additional elements or steps, and (iv) the terms "about" and "approximately" may be understood to allow for standard variations as understood by one of ordinary skill in the art, and (v) when ranges are provided, the endpoints are included.

[0023] As used herein, the term "administration" refers to the administration of a composition to a subject. Administration to an animal subject (e.g., a human) may be by any suitable route. For example, in one embodiment, administration includes bronchial (including bronchial instillation), buccal, enteral, interdermal, intraarterial, intradermal, intragastric, intramedullary, intramuscular, intranasal, intraperitoneal, intrathecal, intravenous, intraventricular, mucosal, nasal, oral, rectal, subcutaneous, sublingual, topical, intratracheal (including intratracheal instillation), transdermal, intravaginal, or intravitreal.

[0024] An "effective amount" of a compound may vary depending on factors such as the individual's condition, age, sex, and weight, as well as the ability of the compound to elicit a desired response. A therapeutically effective amount encompasses an amount in which any toxic or detrimental effects of the compound are outweighed by the therapeutically beneficial effects. An effective amount also encompasses an amount sufficient to provide a benefit, e.g., a clinical benefit.

[0025] As used herein, the term "food" refers to solid food that has sufficient bulk and fat content so as not to be rapidly dissolved and absorbed in the stomach. For example, a meal such as breakfast, lunch, or dinner. As used herein, the term "with food" refers to administering the composition from about 30 minutes before a meal (e.g., eating a meal) to about 2 hours after a meal. The terms "without food," "fasting," or "starving" further refer to the state of not consuming solid food for at least about 2 hours, up to about 30 minutes before consuming solid food.

[0026] The term "pharmaceutical composition" as used herein refers to a composition comprising a compound described herein formulated with a pharmaceutically acceptable excipient. The pharmaceutical composition can be formulated, for example, for oral administration (e.g., tablet, capsule, caplet, gel cap, suspension, solution, or syrup) in a unit dosage form, for topical administration (e.g., cream, gel, lotion, or ointment), for intravenous administration (e.g., particulate-free, sterile solution in a solvent system suitable for intravenous use), or in any other pharmaceutically acceptable formulation.

[0027] The term "pharmaceutically acceptable salt" as used herein refers to any pharmaceutically acceptable salt of sepiapterin. For example, pharmaceutically acceptable salts of sepiapterin include those that are within the scope of sound medical judgment, are suitable for use in contact with human and animal tissues without undue toxicity, irritation, or allergic reaction, and are commensurate with a reasonable benefit / risk ratio. Pharmaceutically acceptable salts are well known in the art. For example, pharmaceutically acceptable salts are described in Berge et al., J. Pharmaceutical Sciences 66:1-19, 1977, and Pharmaceutical Salts: Properties, Selection, and Use, (Eds. P.H. Stahl and C.G. Wermuth), Wiley-VCH, 2008. Salts can be prepared in situ during the final isolation and purification of the compounds described herein, or can be prepared separately by reacting the free base group with a suitable organic acid.

[0028] In many cases, compounds are prepared or used as pharmaceutically acceptable salts prepared as addition products of pharmaceutically acceptable acids.Suitable pharmaceutically acceptable acids and methods for preparing suitable salts are well known in the art.Salts may be prepared from pharmaceutically acceptable non-toxic acids, including inorganic and organic acids.

[0029] Representative acid addition salts include acetate, adipate, alginate, ascorbate, aspartate, benzenesulfonate, benzoate, besylate, bisulfate, borate, butyrate, camphorate, camphorsulfonate, citrate, cyclopentanepropionate, digluconate, dodecylsulfate, ethanesulfonate, fumarate, gentisate, glucoheptonate, glycerophosphate, glycolate, hemisulfate, heptonate, hexanate, hydrobromide, hydrochloride, hydroiodide, 2-hydroxybenzoate ... -hydroxy-ethanesulfonate, lactobionate, lactate, laurate, lauryl sulfate, malate, maleate, malonate, methanesulfonate, 2-naphthalenesulfonate, nicotinate, nitrate, oleate, oxalate, palmitate, pamoate, pectinate, persulfate, 3-phenylpropionate, phosphate, picrate, pivalate, propionate, stearate, succinate, sulfate, tallate, thiocyanate, toluenesulfonate, undecanoate, and valerate salts.

[0030] As used herein, the term "subject" or "patient" refers to any organism to which a compound or composition according to the invention can be administered, e.g., for experimental, diagnostic, prophylactic, and / or therapeutic purposes. Typical subjects include any animal (e.g., mammals such as mice, rats, rabbits, non-human primates, and humans). A subject may be a human or animal in need of treatment, currently undergoing treatment, or in the future to undergo treatment, or who is under the care of a trained professional for a particular disease or condition.

[0031] As used herein, the term "BH4-associated disease" refers to any disease or disorder that can derive therapeutic benefit from modulation of BH4 levels or activity. BH4-related disorders include, but are not limited to, primary BH4 deficiency, GTPCH deficiency, 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency, DHPR deficiency, sepiapterin reductase deficiency, dopamine-responsive dystonia, Segawa syndrome, tyrosine hydroxylase deficiency, phenylketonuria, DNAJC12 deficiency, Parkinson's disease, depression due to Parkinson's disease, impulsivity in Parkinson's disease patients, major depression, autism spectrum disorder, ADHD, schizophrenia, bipolar disorder, cerebral ischemia, restless legs syndrome, obsessive-compulsive disorder, anxiety disorder, aggression in Alzheimer's disease, cerebrovascular accident, convulsions after subarachnoid hemorrhage, myocarditis, coronary vasospasm, cardiac hypertrophy, arteriosclerosis, hypertension, thrombosis, infection, endotoxic shock, liver cirrhosis, hypertrophic pyloric stenosis, gastric mucosal injury, pulmonary hypertension, renal dysfunction, impotence, or hypoglycemia. In some embodiments of any of the above aspects, the BH4-related disease is phenylketonuria, BH4 deficiency (e.g., primary BH4 deficiency), a CNS disorder (e.g., Segawa syndrome, depression, schizophrenia, autism, or Parkinson's disease), or a gastrointestinal motility disorder (e.g., gastroparesis and primary and secondary esophageal motility disorders). In some embodiments, the BH4-related disease is BH4 deficiency or phenylketonuria.

[0032] As used herein, the terms "treat," "treated," or "treating" refer to both therapeutic treatment and prophylactic or preventative measures, the purpose of which is to prevent or slow (alleviate) an undesirable physiological condition, disorder, or disease, or to obtain a beneficial or desired clinical result. Beneficial or desired clinical results include, but are not limited to, alleviation of symptoms, a decrease in the extent of a condition, disorder, or disease, a stable (i.e., not worsening) appearance of a condition, disorder, or disease, a delay in the onset or progression of a condition, disorder, or disease, an improvement (partial or total) in the condition, disorder, or pathology or remission, whether detectable or undetectable, an improvement in at least one measurable physical parameter, which need not necessarily be discernible by the patient, or an improvement or amelioration of a condition, disorder, or disease. Treatment includes eliciting a clinically significant response without excessive levels of side effects. Treatment also includes prolonging survival as compared to expected survival if not receiving treatment. [Brief explanation of the drawings]

[0033] [Figure 1] FIG. 1 is a graph showing the mean plasma concentrations of BH4 over time in fed and fasted subjects. [Figure 2] FIG. 2 is a graph showing the mean plasma concentrations of sepiapterin over time in fed and fasted subjects. DETAILED DESCRIPTION OF THE INVENTION

[0034] The present inventors have discovered that administering sepiapterin or a pharmaceutically acceptable salt thereof with food unexpectedly increases plasma BH4 exposure in a subject. Accordingly, the present invention features a composition comprising sepiapterin or a pharmaceutically acceptable salt thereof and a method for treating a BH4-related disorder. The composition and method can result in increased plasma BH4 exposure.

[0035] Sepiapterin Sepiapterin enters the cell and is converted to 7,8-dihydrobiopterin by sepiapterin reductase, which is then converted to BH4 via reduction by dihydrofolate reductase.

[0036] Without being bound by theory, administering sepiapterin with food increases plasma exposure of BH4, for example, by slowing the absorption rate of sepiapterin. Rapid absorption of administered sepiapterin (e.g., by administration on an empty stomach) may increase intracellular sepiapterin reductase and / or dihydrofolate reductase activity. max The V of the substrate saturation of sepiapterin reductase and / or dihydrofolate reductase is reached, resulting in at least a portion of the administered sepiapterin leaving the cell without being reduced to 7,8-dihydrobiopterin and subsequently to BH4. This excess sepiapterin may be excreted without being converted to BH4, thereby decreasing or prolonging the absorption rate of sepiapterin and / or prolonging the absorption rate. max Administration of sepiapterin with food unexpectedly resulted in lower plasma BH4 levels compared to administration with food, resulting in lower, equal, or slightly higher plasma BH4 maximum concentration (Cmax) and time zero to final concentration (AUC) values ​​compared to administration without food. 0-last ) increases the degree of exposure as measured by the area under the concentration-time curve.

[0037] Sepiapterin has the following structure: JPEG2024178188000001.jpg3044

[0038] Sepiapterin or a pharmaceutically acceptable salt thereof can be incorporated into a pharmaceutical composition. In some embodiments, the pharmaceutical composition of the present invention contains 20-30% sepiapterin or a salt thereof by total weight, e.g., 20%, 22%, 25%, 27%, or 30%. In some embodiments, the pharmaceutical composition contains more than 20% sepiapterin by total weight, e.g., more than 25%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% sepiapterin. In some embodiments, the pharmaceutical composition contains less than 20% sepiapterin by total weight, e.g., less than 20%, less than 15%, less than 10%, or less than 5%.

[0039] In some embodiments, the invention features a pharmaceutical composition comprising sepiapterin or a salt thereof and less than 10% (e.g., 9%, 7%, 5%, 3%, 1%, 0.5%, 0.25%, or 0.1%) of an antioxidant by total weight. The antioxidant may be ascorbic acid. In some embodiments, the ratio of sepiapterin or a pharmaceutically acceptable salt thereof to the antioxidant is 1:1, e.g., 2:1, 5:1, 7:1, or 10:1. The pharmaceutical composition may comprise 20-30% sepiapterin or a pharmaceutically acceptable salt thereof by total weight, e.g., 20%, 22%, 25%, 27%, or 30%. The pharmaceutical composition may further comprise a dispersing agent, e.g., croscarmellose sodium. The pharmaceutical composition may comprise 0.1-1.5% dispersing agent by total weight, e.g., 0.1%, 0.5%, 1%, or 1.5%. In some embodiments, the pharmaceutical composition comprises at least one anti-caking agent, such as colloidal silicon dioxide or microcrystalline cellulose. The pharmaceutical composition may comprise 65-75% of the anti-caking agent by total weight, for example, 65%, 67%, 70%, 73%, or 75%. In some embodiments, the pharmaceutical composition comprises both colloidal silicon dioxide and microcrystalline cellulose. In some embodiments, the pharmaceutical composition comprises 60-65% of the microcrystalline cellulose by total weight and 5-7% of the colloidal silicon dioxide by total weight. In some embodiments, the sepiapterin crystalline form is formulated as particles of less than 140 μm (e.g., 120 μm, 110 μm, 100 μm, 90 μm, 80 μm, 70 μm, 60 μm, 50 μm, 40 μm, 30 μm, 20 μm, 10 μm, or 5 μm). In some embodiments, the pharmaceutical composition contains less than 1% of impurities such as lactoylpterin, e.g., less than 0.9%, less than 0.8%, less than 0.7%, less than 0.6%, less than 0.5%, less than 0.4%, less than 0.3%, or less than 0.2%.

[0040] In some embodiments, the sepiapterin is a salt of sepiapterin, for example, a salt with sulfuric acid, p-toluenesulfonic acid, methanesulfonic acid, benzenesulfonic acid, malonic acid, tartaric acid (e.g., L-tartaric acid), phosphoric acid, gentisic acid, fumaric acid, glycolic acid, acetic acid, or nicotinic acid.

[0041] In some embodiments, the sepiapterin or a pharmaceutically acceptable salt thereof is in a crystalline form. The crystalline form of the crystalline sepiapterin free base or a salt of sepiapterin can occur as an anhydrate (e.g., without any bound water or solvent or hydration or solvation), or as a hydrate, partial hydrate (e.g., hemihydrate, sesquihydrate, etc.), dihydrate, trihydrate, etc., where the crystalline form binds water of hydration or solvent molecules associated with the sepiapterin crystalline form or salt thereof. In one embodiment, the crystalline sepiapterin occurs as a monohydrate or hemihydrate.

[0042] In some embodiments, sepiapterin is present in a crystalline form. In some embodiments, the sepiapterin crystalline form is characterized by a powder X-ray diffraction pattern obtained by irradiation with CuKα X-rays having peaks expressed in degrees 2θ of at least about 9.7°, about 10.2°, and about 11.3°. In other embodiments, the sepiapterin crystalline form is characterized by a powder X-ray diffraction pattern obtained by irradiation with CuKα X-rays having peaks expressed in degrees 2θ of at least about 9.7°, about 10.2°, about 11.3°, about 14.0°, about 14.6°, about 19.9°, about 22.2°, about 25.3°, and about 32.4°.

[0043] The present invention provides a pharmaceutical composition comprising a pharmaceutically acceptable excipient and an effective amount of sepiapterin or a pharmaceutically acceptable salt thereof.

[0044] The pharmaceutically acceptable excipients may be any of those conventionally used and are limited only by physicochemical considerations such as solubility, route of administration, etc. Those skilled in the art will appreciate that in addition to the pharmaceutical compositions described below, sepiapterin can be formulated as an inclusion complex, such as a cyclodextrin inclusion complex, or as liposomes.

[0045] The pharmaceutically acceptable excipients described herein, such as vehicles, adjuvants, fillers, or diluents, are well known to those skilled in the art and are readily available. Preferably, the pharmaceutically acceptable excipients are chemically inert to sepiapterin and have no adverse side effects or toxicity under the conditions of use.

[0046] Formulations that increase gastric and / or foregut residence time Gastroretentive drug delivery is an approach where the drug formulation is designed to remain in the stomach for a longer period until drug release is complete.

[0047] Bioadhesive formulations utilize polymers that can adhere to a surface and provide controlled release of the drug. Bioadhesive polymers can be anionic (e.g., carboxymethylcellulose, alginic acid, polyacrylic acid, pectin, carrageenan, polycarbophil, or carbomer), cationic (e.g., chitosan, polylysine, or polybrene), or nonionic (e.g., polyethylene glycol, polyvinylpyrrolidone, dextran, or hydroxypropylmethylcellulose).

[0048] High-density formulations are designed to reside in the stomach at a level below the pyloric sphincter, thus avoiding emptying. Suitable excipients for high-density formulations include iron powder, barium sulfate, zinc oxide, titanium oxide, etc.

[0049] Bulking formulations are designed to expand beyond the pyloric sphincter in the stomach, thus avoiding hunger. For example, a formulation comprising a drug core, a swellable hydrocolloid, and an outer semipermeable polymer is suitable as a bulking formulation.

[0050] Superporous hydrogel formulations, like expandable formulations, are designed to expand beyond the pyloric sphincter in the stomach and may contain polymers such as croscarmellose sodium.

[0051] Floating formulations are designed to have a density lower than that of gastric fluid and may include compositions containing ion exchange resins, raft systems, inflatable chambers, effervescent mixtures, swellable hydrocolloids, or multiparticulate systems.

[0052] antioxidants Sepiapterin tends to oxidize rapidly when exposed to air. Therefore, the pharmaceutical composition of the present invention may contain an antioxidant. The antioxidant may minimize oxidative degradation of sepiapterin. Examples of antioxidants include, but are not limited to, ascorbic acid, tocopherol, retinol, ascorbyl palmitate, N-acetylcysteine, glutathione, ethylenediaminetetraacetic acid, sodium bisulfite, sodium metabisulfite, thiourea, butylated hydroxytoluene, butylated hydroxyanisole, and vitamin E. In some embodiments, the pharmaceutical composition of the present invention contains ascorbic acid, tocopherol, retinol, ascorbyl palmitate, N-acetylcysteine, glutathione, butylated hydroxytoluene, and / or butylated hydroxyanisole as the antioxidant.

[0053] In some embodiments, the pharmaceutical composition contains less than 10% by weight of antioxidant, e.g., less than 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, or substantially no antioxidant. In some embodiments, the pharmaceutical composition contains 2-9% by total weight of antioxidant, e.g., 2-4%, 3-5%, 4-6%, 5-7%, 6-8%, or 7-9%. In some embodiments, the pharmaceutical composition contains 5-100% of the USP maximum daily dose of antioxidant, e.g., in some embodiments, the pharmaceutical composition contains 5%, 10%, 15%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100% of the USP maximum daily dose of antioxidant. In some embodiments, the ratio of sepiapterin to antioxidant is at least 1:1, for example, 2:1, 3:1, 4:1, 5:1, 6:1, 7:1, 8:1, 9:1, or 10:1.

[0054] Dispersants In some embodiments, the pharmaceutical compositions of the present invention contain at least one dispersing agent. The dispersing agent may separate particles in the formulation, e.g., release its active ingredient upon contact with moisture. Examples of dispersing agents include, but are not limited to, cross-linked polyvinylpyrrolidone, carboxymethylcellulose (e.g., a croscarmellose salt, e.g., croscarmellose sodium), starch (e.g., sodium starch glycolate), or alginic acid. In some embodiments, the dispersing agent in the pharmaceutical composition is carboxymethylcellulose, such as a pharmaceutically acceptable salt of croscarmellose. In some embodiments, the pharmaceutical composition may contain 0.1 to 1.5% (e.g., 0.1%, 0.5%, 1%, or 1.5%) of dispersing agent by total weight. In some embodiments, the pharmaceutical composition contains less than 1.5% (e.g., less than 1%, less than 0.5%, or less than 0.1%) of dispersing agent.

[0055] Anti-caking agent In some embodiments, the pharmaceutical compositions of the present invention comprise at least one anti-caking agent. In some embodiments, the pharmaceutical compositions of the present invention comprise at least two anti-caking agents. Exemplary anti-caking agents include colloidal silicon dioxide, microcrystalline cellulose, tricalcium phosphate, microcrystalline cellulose, magnesium stearate, sodium bicarbonate, sodium ferrocyanide, potassium ferrocyanide, calcium ferrocyanide, calcium phosphate, sodium silicate, colloidal silicon dioxide, calcium silicate, magnesium trisilicate, talcum powder, sodium aluminosilicate, potassium aluminum silicate, calcium aluminosilicate, bentonite, aluminum silicate, stearic acid, and polydimethylsiloxane. In some embodiments, the at least one anti-caking agent is colloidal silicon dioxide or microcrystalline cellulose. In some embodiments, the pharmaceutical composition may comprise 65-75% (e.g., 65%, 67%, 70%, 73%, or 75%) of the anti-caking agent by total weight. In some embodiments, the pharmaceutical composition comprises both colloidal silicon dioxide and microcrystalline cellulose. In some embodiments, the pharmaceutical composition comprises 60-65% microcrystalline cellulose by total weight and 5-7% colloidal silicon dioxide by total weight.

[0056] Dosing Vehicle In some embodiments, the pharmaceutical compositions of the present invention are combined with a dosing vehicle prior to administration (e.g., a dosing vehicle having a viscosity of about 50 to 1750 centipoise (cP)). One type of suspending agent that can be used is a combination of glycerin and sucrose in water (e.g., MEDISCA suspending agent, which contains 2.5% glycerin and 27% sucrose in water). (R) An appropriate amount of the composition can be added to the administration vehicle mixture and stirred to suspend the composition immediately prior to administration.

[0057] Other suspending agents may also be used as administration vehicles. Exemplary suspending agents include agar, alginic acid, sodium carboxymethylcellulose, carrageenan, dextrin, gelatin, guar gum, hydroxyethyl cellulose, hydroxypropyl cellulose, hypromellose, methylcellulose, polyethylene glycol, povidone, tragacanth, xanthan gum, or other suspending agents known in the art.

[0058] dose Sepiapterin or a pharmaceutically acceptable salt thereof can be used in any suitable dose. Appropriate doses and dosage regimens are within the skill of the art. Generally, treatment is initiated with a dose that is smaller than the optimal dose. Thereafter, the dosage is increased in small increments until the optimum effect under the circumstances is achieved. For convenience, the total daily dose can be divided and administered throughout the day, if desired. With appropriate doses and appropriate administration of a particular compound, the present invention provides a wide range of responses. Typically, the dosage ranges from about 2.5 to about 150 mg / kg body weight / day of the patient being treated. For example, in embodiments, sepiapterin or a pharmaceutically acceptable salt thereof can be administered at about 20 mg / kg to about 150 mg / kg, about 40 mg / kg to about 100 mg / kg, about 100 mg / kg to about 150 mg / kg, about 60 mg / kg to about 120 mg / kg, about 80 mg / kg to about 100 mg / kg, about 40 mg / kg to about 60 mg / kg, about 2.5 mg / kg to about 20 mg / kg, about 2.5 mg / kg to about 10 mg / kg, or about 2.5 mg / kg to about 5 mg / kg of subject body weight per day, once or more times per day, to achieve the desired therapeutic effect.

[0059] In some embodiments, the administered amount is sufficient to produce a level of BH4 in the CNS (e.g., brain), e.g., as measured in the CSF, and / or to produce a therapeutic result and / or response, e.g., an increase in serotonin or dopamine in the CNS. In some embodiments, the increase in BH4 in the CNS is measured by determining the level of a metabolite of a monoamine, e.g., serotonin and / or dopamine (e.g., homovanillic acid or 5-hydroxyindoleacetic acid (5-HIAA)), in the CSF, wherein an increase in the metabolite in the CSF indicates an increase in BH4 levels in the CNS (e.g., brain). In some embodiments, the administered amount is sufficient to increase the level of BH4 measured in the plasma or an organ of the subject (e.g., the liver of the subject) by at least 2-fold (e.g., at least 10-fold, at least 20-fold, at least 50-fold, at least 100-fold, or at least 150-fold) the level of BH4 before administration.

[0060] In some embodiments, sepiapterin or a pharmaceutically acceptable salt thereof can be formulated as a unit solid oral dosage form, such as particles. In these embodiments, each unit solid oral dosage form can contain any suitable amount of sepiapterin or a pharmaceutically acceptable salt thereof. For example, each unit solid oral dosage form can contain about 2.5 mg, about 5 mg, about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 50 mg, about 60 mg, about 70 mg, about 80 mg, about 90 mg, about 100 mg, about 125 mg, about 150 mg, about 175 mg, about 200 mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about 325 mg, about 350 mg, about 375 mg, about 400 mg, about 425 mg, about 450 mg, about 475 mg, or about 500 mg.

[0061] Sepiapterin or a pharmaceutically acceptable salt thereof can be used to prepare liquid preparations, such as solutions, suspensions, or emulsions. Preparations suitable for oral administration can consist of (a) solids or granules, such as capsules, sachets, tablets, lozenges, and troches, each containing a predetermined amount of active ingredient; (b) powders; (c) liquids, such as an effective amount of the compound dissolved in a diluent such as water, saline, or orange juice; (d) suspensions in a suitable liquid; and (e) suitable emulsions. Solid oral preparations, such as capsules, tablets, and powders, are preferred. Capsule forms can be ordinary hard- or soft-shelled gelatin types containing, for example, surfactants, lubricants, and inert fillers, such as lactose, sucrose, calcium phosphate, and cornstarch. Tablet forms may contain one or more of lactose, sucrose, mannitol, corn starch, potato starch, alginic acid, microcrystalline cellulose, acacia, gelatin, guar gum, colloidal silicon dioxide, croscarmellose sodium, talc, magnesium stearate, calcium stearate, zinc stearate, stearic acid, and other excipients, coloring agents, diluents, buffers, disintegrants, wetting agents, preservatives, flavoring agents, and pharmacologically compatible excipients. Lozenge forms may contain the active ingredient in addition to a flavor (usually sucrose and acacia or tragacanth), and similarly, pastilles may contain the active ingredient in an inert base such as gelatin and glycerin, or sucrose and acacia, emulsions, gels, etc., such excipients being known in the art.

[0062] Formulations suitable for oral and / or parenteral administration include aqueous and non-aqueous isotonic sterile injection solutions, which may contain antioxidants, buffers, bacteriostats, and solutes that render the formulation isotonic with the blood of the intended recipient, and aqueous and non-aqueous sterile suspensions, solubilizing agents, thickeners, stabilizers, and preservatives. The compounds of the present invention may be administered in physiologically acceptable diluents in pharmaceutical vehicles such as water, saline, aqueous dextrose and related sugar solutions, alcohols such as ethanol, benzyl alcohol, or hexadecyl alcohol, glycols such as propylene glycol or polyethylene glycol and polyethylene alcohol, glycerol ketals such as 2,2-dimethyl-1,3-dioxolane-4-methanol, ethers such as poly(ethylene glycol) 400, oils, fatty acids, fatty acid esters or glycerides, or acetylated fatty acid glycerides with or without the addition of pharmaceutically acceptable surfactants such as soaps or detergents, suspending agents such as pectin, carbomers, methylcellulose, hydroxypropylmethylcellulose, or carboxymethylcellulose, or emulsifiers and other pharmaceutical adjuvants.

[0063] The present invention features a pharmaceutical composition in an orally acceptable formulation, comprising a therapeutically effective amount of sepiapterin and less than 10% antioxidant. In some embodiments, the pharmaceutical composition is a granular formulation dispersed in a pharmaceutically acceptable excipient; for example, the composition can be mixed with water and ingested by a patient (e.g., within 5 to 10 minutes). Suitable formulations for use in the present invention are described in Remington's Pharmaceutical Sciences, Mack Publishing Company, Philadelphia, PA 22nd ed., 2010. Use of any conventional excipient in the pharmaceutical composition of the present invention is contemplated unless it is incompatible with the active ingredient. Furthermore, for animal (e.g., human) administration, it will be understood that formulations should meet sterility, pyrogenicity, general safety, and purity standards as required by the FDA Office of Biological Standards.

[0064] Oils that can be used in parenteral formulations include petroleum, animal, vegetable, and synthetic oils. Specific examples of oils include peanut, soybean, sesame, cottonseed, corn, olive, petrolatum, and mineral. Fatty acids suitable for use in parenteral formulations include oleic acid, stearic acid, and isostearic acid. Ethyl oleate and isopropyl myristate are examples of suitable fatty acid esters. Suitable soaps for use in parenteral formulations include fatty acid alkali metal, ammonium, and triethanolamine salts, and suitable detergents include (A) cationic detergents (e.g., dimethyldialkylammonium halides, alkylpyridinium halides, etc.), (b) anionic detergents (e.g., alkyl, aryl, and olefin sulfonates, alkyl, olefin, ether, and monoglyceride sulfates, and sulfosuccinates, etc.), (c) nonionic detergents (e.g., fatty amine oxides, fatty acid alkanolamides, and polyoxyethylene-polypropylene copolymers, etc.), (d) amphoteric detergents (e.g., alkyl-β-aminopropionates, and 2-alkyl-imidazoline quaternary ammonium salts, etc.), and mixtures thereof.

[0065] Parenteral formulations typically contain about 20% to about 30% by weight of sepiapterin or a pharmaceutically acceptable salt thereof in solution. Suitable preservatives and buffers can be used in such formulations. To minimize or eliminate irritation at the injection site, such compositions may contain one or more nonionic surfactants having a hydrophilic-lipophilic balance (HLB) of about 12 to about 17. The amount of surfactant in such compositions ranges from about 5% to about 15% by weight. Suitable surfactants include polyethylene sorbitan fatty acid esters, such as sorbitan monooleate, and high molecular weight adducts of hydrophobic bases with ethylene oxide formed by the condensation of propylene oxide with propylene glycol. Parenteral formulations can be placed in unit-dose or multi-dose hermetically sealed containers, such as ampoules and vials, and can be stored in a lyophilized (lyophilized) condition requiring only the addition of a sterile liquid vehicle for injection, e.g., water, immediately prior to use. Extemporaneous injection solutions and suspensions may be prepared from sterile powders, granules and tablets of the kind previously described.

[0066] The sepiapterin or pharmaceutically acceptable salt thereof of the present invention can be prepared as an injectable formulation. The requirements for an effective pharmaceutical excipient for an injectable composition are well known to those skilled in the art. Remington: The Science and Practice of Pharmacy, 22 nd Edition, Lippincott Williams & Wilkins, (2012), and Encyclopedia of Pharmaceutical Technology, eds. J. Swarbrick and JC Boylan, 2006, Marcel Dekker, New York, which are incorporated herein by reference.

[0067] Topical formulations, including those useful for transdermal drug delivery, are well known to those skilled in the art and are suitable for application to the skin in the context of the present invention. Topically applied compositions are typically in the form of liquids, creams, pastes, lotions, and gels. Topical administration includes application to oral mucosa, including the oral cavity, oral epithelium, palate, gums, and nasal mucosa. In some embodiments, the composition comprises sepiapterin or a pharmaceutically acceptable salt thereof and a suitable vehicle or excipient. It may also contain other ingredients, such as an anti-irritant. The excipient may be a liquid, solid, or semi-solid. In embodiments, the composition is an aqueous solution. Alternatively, the composition may be a dispersion of various components, an emulsion, a gel, a lotion, or a cream vehicle. In one embodiment, the primary vehicle is water or a substantially neutral or substantially neutralized biocompatible solvent. The liquid vehicle may contain other materials, such as buffers, alcohol, glycerin, mineral oil, and various emulsifiers or dispersants, as known in the art, to achieve the desired pH, consistency, and viscosity. The compositions can be prepared as solids, such as powders or granules, which can be applied directly or dissolved in water or a biocompatible solvent to form a substantially neutral or substantially neutralized solution that can be applied to the target area prior to use. In embodiments of the present invention, vehicles for topical application to the skin can include water, buffer solutions, various alcohols, glycols such as glycerin, lipid materials such as fatty acids, mineral oils, phosphoglycerides, collagen, gelatin, and silicone-based materials.

[0068] Sepiapterin or a salt thereof, alone or in combination with other suitable components, can be prepared as an aerosol formulation for administration via inhalation. The aerosol formulations can be placed into pressurized acceptable propellants, such as dichlorodifluoromethane, propane, nitrogen, etc. They can also be formulated as pharmaceuticals for non-pressurized preparations, such as in nebulizers or atomizers.

[0069] Furthermore, the sepiapterin or a pharmaceutically acceptable salt thereof of the present invention may be mixed with various bases, such as emulsifying bases or water-soluble bases, to prepare a suppository. Formulations suitable for vaginal administration may be present as pessaries, tampons, creams, gels, pastes, foams, or spray formulations, which contain, in addition to the active ingredient, excipients known in the art to be appropriate.

[0070] Oral solid dosage forms Formulations for oral use include particles containing the active ingredient in a mixture with non-toxic pharmaceutically acceptable excipients, and such formulations are known to those skilled in the art (e.g., U.S. Patent Nos.: 5,817,307, 5,824,300, 5,830,456, 5,846,526, 5,882,640, 5,910,304, 6,036,949, 6,036,949, 6,372,218, which are incorporated herein by reference). Examples of excipients include inert diluents or fillers (e.g., sucrose, sorbitol, sugar, mannitol, microcrystalline cellulose, starch including potato starch, calcium carbonate, sodium chloride, lactose, calcium phosphate, calcium sulfate, or sodium phosphate), granulating and disintegrating agents (e.g., cellulose derivatives including microcrystalline cellulose, starch including potato starch, croscarmellose sodium, alginates, or alginic acid), binders (e.g., sucrose, glucose, sorbitol, acacia, alginic acid, sodium alginate, gelatin, starch, pregelatinized starch, microcrystalline cellulose, magnesium aluminum silicate, sodium carboxymethylcellulose, methylcellulose, hydroxypropylmethylcellulose, ethylcellulose, polyvinylpyrrolidone, etc.), and the like. Other pharmaceutically acceptable excipients may include colorants, flavorings, plasticizers, humectants, and buffering agents. In some embodiments, the excipients (e.g., colloidal silicon dioxide, microcrystalline cellulose, tricalcium phosphate, microcrystalline cellulose, magnesium stearate, sodium bicarbonate, sodium ferrocyanide, potassium ferrocyanide, calcium ferrocyanide, calcium phosphate, sodium silicate, colloidal silicon dioxide, calcium silicate, magnesium trisilicate, talcum powder, sodium aluminosilicate, potassium aluminum silicate, calcium aluminosilicate, bentonite, aluminum silicate, stearic acid, polydimethylsiloxane) may be present. Other pharmaceutically acceptable excipients may include colorants, flavorings, plasticizers, humectants, and buffering agents. In some embodiments, the excipients (e.g., flavorings) are packaged with the composition.In some embodiments, excipients (eg, flavorings) are packaged separately from the composition (eg, combined with the composition prior to administration).

[0071] The solid compositions of the present invention may include a coating adapted to protect the composition from unwanted chemical changes (e.g., chemical degradation prior to release of the active agent). Coatings may be applied to solid dosage forms in a manner similar to that described in the Encyclopedia of Pharmaceutical Technology, supra.

[0072] Powders and granules may be prepared from the above ingredients by a conventional method, for example, using a mixer, a fluidized bed apparatus, a melt-congealing apparatus, a rotor granulator, an extrusion / spheronizing apparatus, or a spray-drying apparatus.

[0073] Treatment method Sepiapterin is a therapeutic agent for diseases associated with decreased intracellular BH4 levels, including primary BH4 deficiency, GTPCH deficiency, 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency, DHPR deficiency, sepiapterin reductase deficiency, dopamine-responsive dystonia, Segawa syndrome, tyrosine hydroxylase deficiency, phenylketonuria, DNAJC12 deficiency, Parkinson's disease, Parkinson's disease-related depression, impulsivity in Parkinson's disease patients, major depression, autism spectrum disorder, and ADHD. Sepiapterin or a salt thereof in the various forms of the present invention may be useful for treating diseases associated with dysfunction of various BH4-dependent metabolic pathways, including, but not limited to, schizophrenia, bipolar disorder, cerebral ischemia, restless legs syndrome, obsessive-compulsive disorder, anxiety disorder, aggression in Alzheimer's disease, cerebrovascular accident, convulsions after subarachnoid hemorrhage, myocarditis, coronary vasospasm, cardiac hypertrophy, arteriosclerosis, hypertension, thrombosis, infection, endotoxin shock, liver cirrhosis, hypertrophic pyloric stenosis, gastric mucosal damage, pulmonary hypertension, renal dysfunction, impotence, and hypoglycemia. Therefore, the various forms of sepiapterin or a salt thereof of the present invention can be administered to a patient in an effective amount to treat or improve a disease, disorder, or condition.

[0074] In some embodiments of any of the above-mentioned methods, the food is a high-protein food. In some embodiments of any of the above-mentioned methods, the food is a high-fat food (e.g., at least 25, 30, 40, or 50% of the calories are from fat). In some embodiments of any of the above-mentioned methods, the food is a high-protein and high-fat food. In some embodiments, the food is a high-calorie food (e.g., the food contains at least 100 calories, e.g., at least 200 calories, at least 300 calories, at least 400 calories, at least 500 calories, e.g., 500-1500 or 800-1000 calories). In some embodiments of any of the above-mentioned methods, the food is a meal, e.g., breakfast, lunch, or dinner.

[0075] The actual dosage of the compositions of the present invention administered to a patient may be determined by physical and physiological factors such as body weight, severity of the condition, type of disease being treated, previous or concurrent therapeutic interventions, the patient's idiopathies, and the route of administration. Depending on the dosage and route of administration, the preferred dosage and / or frequency of administration of an effective amount may vary depending on the subject's response. The person responsible for administration will, in any event, be able to determine the concentration of active ingredient in the composition and the appropriate dosage for the individual subject.

[0076] In some embodiments, patients receive 2.5 mg / kg / day, 5 mg / kg / day, 10 mg / kg / day, 20 mg / kg / day, 40 mg / kg / day, 60 mg / kg / day, or 80 mg / kg / day. Patients may receive a pharmaceutical composition containing sepiapterin once daily, twice daily, or three times daily during treatment. In some embodiments, patients continue other current medications for BH4-related disorders (e.g., prescribed L-dopa / carbidopa, 5HTP, melatonin, MAO inhibitors, and dopamine receptor agonists) except for BH4 supplements (if taking BH4). Patients may be permitted to take drugs known to inhibit folate synthesis (e.g., methotrexate, pemetrexed, trimetrexate, etc.).

[0077] In some embodiments, patients taking BH4 discontinue administration of BH4 (i.e., BH4 washout). Blood samples for Phe concentration may be obtained during the BH4 washout period 7 days, 5 days, 3 days, and 1 day before treatment with the pharmaceutical compositions of the present invention, or at any time during BH4 washout until the blood Phe concentration is >360 μmol / L. In some embodiments, pre-administration blood samples are tested for sepiapteprin, Phe, BH4, and tyrosine (Tyr).

[0078] Equivalents and Scope Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments in accordance with the invention described herein. The scope of the invention is not intended to be limited to the above Description, but rather is as set forth in the appended claims.

[0079] Furthermore, it is understood that any particular embodiment of the present invention that falls under the prior art can be explicitly excluded from any one or more of the claims.Such an embodiment is considered to be known to those skilled in the art, and therefore can be excluded even if the exclusion is not expressly specified herein.Any particular embodiment of the composition of the present invention (e.g., any compound, any method of production, any method of use, etc.) can be excluded from one or more claims for any reason, regardless of whether it is related to the existence of prior art. [Example]

[0080] Example 1. Evaluation of the effect of food on sepiapterin administration Methods: Subjects received two oral doses of sepiapterin (10 mg / kg) in fasted and fed states, separated by one week. Thirty minutes before the second oral dose of sepiapterin on day 8, subjects were fed a standard high-fat (approximately 50% of the total calorie content of the diet) and high-calorie (approximately 800-1000 calories) meal.

[0081] Sampling for PK analysis was performed pre-dose (within 30 minutes before administration) on Days 1 and 8, and 0.5, 1, 2, 4, 8, 12, and 24 hours after administration on Days 1 and 8.

[0082] Blood concentrations of sepiapterin and BH4 were analyzed at the MNG laboratory.

[0083] Cerebrospinal fluid (CSF) from selected subjects will be collected by lumbar puncture on Day 1 (pre-dose) and Day 7 (i.e., after 7 days of daily dosing) approximately 30 minutes after the maximum observed plasma BH4 concentration (Tmax) as determined by blood analysis.

[0084] Cerebrospinal fluid (CSF) was analyzed in the MNG laboratory. Descriptive statistics are provided to characterize changes in neurotransmitter metabolism between day 1 and day 7 sample results.

[0085] Results: As shown in Tables 1 and 2 below and Figure 1, surprisingly, the Cmax of plasma BH4 was significantly higher in subjects who were fed prior to dosing compared to subjects who fasted prior to dosing. Furthermore, when sepiapterin was administered in the fed vs. fasted state, plasma sepiapterin concentrations decreased, while BH4 concentrations increased (Figure 1). The geometric mean ratio of plasma sepiapterin (fasted / fed, 90% CI) was significantly higher than the AUC last 1.29 (0.84-2.00) and C max The corresponding ratios (90% CI) for plasma BH4 were AUC 1.57 (1.21–2.0). 0-inf 0.58 (0.47-0.71) and C max The AUC0- was 0.55 (0.45-0.68). inf and AUC last Overall BH4 exposure, as measured by , was increased by 1.7-fold when sepiapterin was administered in the fed state compared to the fasted state. [Table 1] [Table 2]

[0086] Furthermore, as shown in Tables 3 and 4 below and FIG. 2, surprisingly, the Cmax of sepiapterin in plasma was significantly lower in subjects who were fed before dosing compared to subjects who were fasted before dosing. [Table 3] [Table 4]

[0087] Example 2. Comparison of Adverse Events in Fed and Fasted Subjects Methods: Twelve subjects received a single dose of sepiapterin (10 mg / kg) under fasted conditions, followed 7 days later under fed conditions. Standard definitions of adverse events (AEs) were used. All-cause AEs were those occurring at any time, and treatment-emergent adverse events (TEAEs) were those occurring during or after administration of study treatment. TEAEs related to study drug were based on the investigator's opinion. Serious AEs were defined as life-threatening or resulting in death, hospitalization, or prolongation of existing hospitalization, or persistent or significant impairment / inability or substantial disruption of the ability to perform normal life functions, or congenital anomaly / birth defect.

[0088] Results: As shown in Table 5, surprisingly, there was a reduced incidence of adverse events when sepiapterin was administered to fed subjects compared to fasted subjects. [Table 5]

[0089] Example 3. Determination of CSF levels of neurotransmitters after administration of sepiapterin Methods: Analysis was performed on CSF samples from subjects receiving sepiapterin 60 mg / kg or placebo. Analytes measured were sepiapterin, BH4, BH2, homovanillic acid (HVA), and 5-hydroxyindoleacetic acid (HIAA). T values ​​for these analytes on days 1 and 7 were maxDescriptive statistics (n, mean, SD, median, min, max) from + / - 30 min and change from baseline on day 7 were determined for each analyte.

[0090] Results: Sepiapterin was effective on days 1 and 7 of BH4 T max CSF concentrations of BH4 increased by 4.102 ng / ml in the sepiapterin group but remained unchanged in the placebo group (change from baseline: 0.010 ng / ml). Similarly, CSF concentrations of BH2 increased by 1.368 ng / ml in the sepiapterin group but remained unchanged in the placebo group (change from baseline: 0.020 ng / ml).

[0091] Changes in neurotransmitter concentrations from day 1 also differed between the sepiapterin and placebo groups. HVA concentrations increased by 1.378 ng / mL in the sepiapterin group and decreased by 0.630 ng / mL in the placebo group. 5-HIAA concentrations decreased in both groups, but to a lesser extent in the sepiapterin group than in the placebo group (-1.142 ng / mL vs. -2.440 ng / mL).

[0092] Notably, on Day 1, pre-dose concentrations of HVA (10.02 ng / ml) and 5-HIAA (3.69 ng / ml) in one subject were approximately one-third of those observed in the other subjects (HVA: 22.45 ng / ml to 44.72 ng / ml, 5-HIAA: 9.49 ng / ml to 19.70 ng / ml). However, by Day 7, this subject's HVA (29.93 ng / ml) and 5-HIAA (9.53 ng / ml) concentrations approached the ranges observed in the other sepiapterin-treated groups (HVA: 30.64 ng / ml to 43.19 ng / ml, 5-HIAA: 10.10 ng / ml to 21.59 ng / ml). Both the subject's HVA and 5-HIAA concentrations on Day 7 were higher than the mean concentrations in placebo-treated subjects on Day 7. The data are summarized in Table 6 below. [Table 6]

[0093] Example 4. Pharmacokinetic analysis of multiple doses of sepiapterin Methods: Three cohorts of 8 fed subjects were randomized in a 6:2 ratio to receive either sepiapterin or placebo once daily for 7 days, and a sentinel dosing strategy was used to administer the highest dose of sepiapterin.

[0094] Results: The plasma time concentrations of sepiapterin and BH4 were similar 1 and 7 days after administration of sepiapterin, and no drug accumulation was observed. The pharmacokinetic data are shown in Table 7 below. [Table 7]

[0095] Other embodiments While the present specification has been described in conjunction with a detailed description, it will be understood that the above description is intended to be illustrative and not limiting of the scope of the present disclosure, which is defined by the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims.

Claims

1. 23. A method for treating a BH4-related disorder in a subject in need thereof, comprising administering to the subject an effective amount of sepiapterin or a pharma- ceutically acceptable salt thereof together with food.

2. 23. A method of increasing BH4 plasma exposure in a subject undergoing sepiapterin therapy, comprising administering to the subject an effective amount of sepiapterin or a pharma- ceutically acceptable salt thereof with food.

3. A method for reducing the absorption rate of an oral formulation of sepiapterin or a pharma- ceutically acceptable salt thereof, as measured by the concentration of BH4 achieved in the plasma over time in a subject in need thereof, comprising administering to the subject an effective amount of sepiapterin or a pharma- ceutically acceptable salt thereof together with food.

4. The method of any one of claims 1 to 3, wherein the effective amount is sufficient to produce a concentration of at least 50 ng / ml in the subject's plasma within 10 hours of administration.

5. The method of claim 4, wherein the effective amount comprises a dosage that is at least 20% less than a dosage sufficient to produce a maximum BH4 plasma concentration (Cmax) of at least 50 ng / ml in the subject's plasma within 10 hours after administration of sepiapterin or a pharma- ceutically acceptable salt thereof without food.

6. The method of any one of claims 1 to 5, wherein the effective amount is between 2.5 mg / kg and 100 mg / kg per administration.

7. The method of any one of claims 1 to 6, wherein the administration to the subject occurs less than 30 minutes prior to ingesting food.

8. The method of any one of claims 1 to 7, wherein the administration to the subject is substantially simultaneous with food.

9. The method of any one of claims 1 to 7, wherein the administration to the subject is from immediately after ingestion of food to up to 2 hours after ingestion.

10. The method of any one of claims 1 to 9, wherein the effective amount results in an increase in the maximum plasma concentration (Cmax) of BH4 compared to administration without food.

11. The effective amount is a measure of the time zero to final concentration (AUC 0-last 11. The method of claim 1, wherein the method results in an increase in the area under the concentration-time curve of

12. A pharmaceutical composition comprising sepiapterin or a pharma- ceutically acceptable salt thereof, the pharmaceutical composition being formulated to increase gastric and / or foregut residence time.

13. 13. The pharmaceutical composition of claim 12, wherein the composition is formulated as a bioadhesive formulation, a dense formulation, a swelling formulation, a superporous hydrogel formulation, or a floating formulation.

14. 14. The pharmaceutical composition of claim 13, wherein the buoyant formulation comprises an ion exchange resin, a raft system, an inflatable chamber, an effervescent mixture, a swellable hydrocolloid, or a multiparticulate system.

15. 15. A method for treating a BH4-related disease in a patient in need thereof, comprising administering to the subject an effective amount of a pharmaceutical composition according to any one of claims 12 to 14.

16. A method for increasing BH4 plasma exposure in a subject undergoing sepiapterin therapy, comprising administering to the subject an effective amount of a pharmaceutical composition according to any one of claims 12 to 14.

17. 15. A method for reducing the rate of absorption of an oral formulation of sepiapterin or a pharma- ceutical acceptable salt thereof, as measured by the concentration of BH4 achieved in the plasma over time, in a subject in need thereof, comprising administering to the subject an effective amount of the pharmaceutical composition according to any one of claims 12 to 14.

18. 20. The method of claim 1 or 15, wherein the BH4-related disease is BH4 deficiency or phenylketonuria.

19. 1. A method for increasing homovanillic acid and / or 5-hydroxyindoleacetic acid levels in a subject, comprising administering an effective amount of sepiapteprin or a pharma- ceutically acceptable salt thereof with food.

20. 20. The method of claim 19, wherein the level of homovanillic acid and / or 5-hydroxyindoleacetic acid in the CSF of the subject is increased.

21. 21. The method of claim 19 or 20, wherein the subject's levels of homovanillic acid and / or 5-hydroxyindoleacetic acid are increased by at least 100% compared to pre-administration levels.

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