Pharmaceutical Composition for Imaging

Abstract

Intraoperative ureteral identification helps reduce the risk of ureteral injury. In this first-in-man Phase 1 study, pudexacyaninium chloride was administered intravenously as a single bolus dose to healthy adult participants. This invention relates to new dosages using pudexacyaninium or a pharmacologic acceptable salt thereof for intraoperative NIRF ureteral visualization.

Description

[Technical field]

[0001] The present invention relates to a pharmaceutical composition comprising a suitable amount of pudexacianinium chloride for imaging at least one of organs, body fluids, and ducts in a living body by near-infrared fluorescence, or a method for administering the pharmaceutical composition. [Background technology]

[0002]

[0002] Ureteral injuries are rare, with 75% of all cases occurring during abdominal or pelvic surgery. 1 , primarily due to the proximity of the ureter to the anatomical structures encountered during the procedure. 2 Most iatrogenic ureteral injuries (IUI) occur as a result of gynecological surgery. 3 However, the incidence rate in non-tumor surgery is reported to be 0.1% to 1.5%. 4 Colorectal surgery is the second most common cause of IUI. An analysis of more than 2 million colorectal surgeries performed in the United States over a 10-year period identified a rate of IUI of 0.28%, which corresponds to 6,027 injuries. 5 If not detected and treated promptly, IUI increases the risk of serious sequelae, including ureteral strictures and long-term reduced renal function. 6 , which may contribute to longer hospital stays, increased hospital costs, and increased mortality 5 In addition, IUI is not without medicolegal and financial implications for surgeons. 7 For IUI, the single greatest prognostic factor is time to diagnosis; superior outcomes are associated with intraoperative diagnosis and repair. 4、8 .

[0003] However, detecting IUI can be difficult, with only about one-third of IUIs being diagnosed intraoperatively. 1、8~10Prevention of IUI is by far the most desirable course of action, but it is often hindered by the burden of identifying the ureter, especially during laparoscopic procedures. 11~13 Prophylactic ureteral stenting aids in visualization of the ureter and is often employed in complex procedures. 14 , which remains controversial and may itself induce IUI 5 Although it is considered acceptable for high-risk procedures, current guidelines do not call for its routine use. 8、15 Preoperative imaging techniques, such as intravenous (IV) urography and computed tomography, can be used but do not provide real-time visualization and may not prevent IUI. 8 There is clearly a need for better, non-invasive methods of identifying the ureter, and one survey showed that the majority of surgeons (54.5%) would consider implementing such a technique into their routine practice. 14 .

[0004] Near-infrared fluorescence (NIRF) imaging is a promising technique for real-time visualization of anatomical structures. 2、12、16~19 Preoperative injection of a renally excreted NIRF contrast agent that can be detected by intraoperative imaging systems allows real-time ureteral visualization without the use of radionuclides. Near-infrared (NIR) light can penetrate 5 millimeters of tissue. 18 Provides a strong visible signal due to low tissue autofluorescence and weak absorption in the NIR range 18 , does not change the visual appearance of the surgical field, thereby providing "enhanced realism beyond standard white-light visual inspection and visualization" 12 Critical to these desirable properties, however, is the contrast agent itself. First-in-human trials of this technology for ureteral identification used the dye methylene blue. 19 However, this agent did not have sufficient optical properties to provide any visualization advantage over white light when used with NIR. 16As a result, improving NIFR contrast agents for ureteral visualization has become an active area of ​​research. 12 . [Prior art documents] [Non-patent literature]

[0005] [Non-Patent Document 1] Dobrowolski Z, Kusionowicz J, Drewniak T, et al. Renal and ureteric trauma: diagnosis and management in Poland. BJU Int. 2002;89(7):748-751. [Non-Patent Document 2] Ahn CB, Kim JH, Park GK, et al. Prognostic imaging of iatrogenic and traumatic ureteral injury by near-infrared fluorescence. Quant Imaging Med Surg. 2019;9(6):1056-1065. [Non-Patent Document 3] Summerton DJ, Kitrey ND, Lumen N, Serafetinidis E, Djakovic N, European Association of U. EAU guidelines on iatrogenic trauma. Eur Urol. 2012;62(4):628-639. [Non-Patent Document 4] Abboudi H, Ahmed K, Royle J, Khan MS, Dasgupta P, N'Dow J. Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol. 2013;10(2):108-115. [Non-Patent Document 5] Halabi WJ, Jafari MD, Nguyen VQ, et al. Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States. This Colon Rectum. 2014;57(2):179-186.

Outdoor Configuration6

Direct Environment 7

Outdoor Track 8

Outdoor Tools9

Wood 10

Fashion 11

Wood 12

Wood 13

Non-Patent Document 14

Non-Patent Document 15

Non-Patent Document 16

Non-Patent Document 17

[0006]

[0005] Therefore, there is a need for a NIFR contrast agent to aid in ureteral identification. [Means for solving the problem]

[0007]

[0006] Provided herein is a pharmaceutical composition comprising pdexacyaninium or a pharma- ceutically acceptable salt thereof for imaging at least one of organs, body fluids, and ducts in a subject by near-infrared fluorescence (NIRF), the pharmaceutical composition comprising 0.3 mg to 24.0 mg of pdexacyaninium in free form, the pharmaceutical composition being administered to the subject in a first dose, and optionally, after the first dose, the pharmaceutical composition comprising 0.3 mg to 24.0 mg of pdexacyaninium in free form is administered again to the subject. In some embodiments, the pharmaceutical composition is administered again to the subject after the first dose. In some embodiments, the pdexacyaninium or a pharma- ceutically acceptable salt thereof is pdexacyaninium chloride. In various embodiments, the pharmaceutical composition comprises 0.3 mg to 3.0 mg of pdexacyaninium in free form. In some embodiments, the pharmaceutical composition comprises between 1.0 mg and 3.0 mg of pedexacyaninium in free form.

[0008]

[0007] Further provided in the present specification is a method for imaging at least one of an organ, body fluid, and duct in a subject by near-infrared fluorescence (NIRF), comprising administering to the subject a first pharmaceutical composition comprising pdexacyaninium or a pharma- ceutically acceptable salt thereof, at a dosage of 0.3 mg to 24.0 mg of pdexacyaninium in the free form; subjecting the subject to NIRF to obtain an image of at least one of an organ, body fluid, and duct in the subject; and optionally, administering to the subject a subsequent pharmaceutical composition comprising pdexacyaninium or a pharma- ceutically acceptable salt thereof, at a dosage of 0.3 mg to 24.0 mg of pdexacyaninium in the free form. In some embodiments, the first pharmaceutical composition comprises pdexacyaninium or a pharma- ceutically acceptable salt thereof in a dosage of 0.3 mg to 3.0 mg of pdexacyaninium as a free form, or the subsequent pharmaceutical composition comprises pdexacyaninium or a pharma- ceutically acceptable salt thereof in a dosage of 0.3 mg to 3.0 mg of pdexacyaninium as a free form, or both. In various embodiments, the first pharmaceutical composition comprises pdexacyaninium or a pharma- ceutically acceptable salt thereof in a dosage of 1.0 mg to 3.0 mg of pdexacyaninium as a free form, or the subsequent pharmaceutical composition comprises pdexacyaninium or a pharma- ceutically acceptable salt thereof in a dosage of 1.0 mg to 3.0 mg of pdexacyaninium as a free form, or both. In some embodiments, the pdexacyaninium or a pharma- ceutically acceptable salt thereof is pdexacyaninium chloride.

[0009] Further provided herein is a use of pdexacyaninium or a pharma- ceutically acceptable salt thereof for the manufacture of a medicament for imaging at least one of an organ, a body fluid, and a duct in a subject by near-infrared fluorescence, the medicament comprising 0.3-24.0 mg of pdexacyaninium in a free form in a first administration, and optionally in a second administration after the first administration. In some embodiments, the medicament comprises 0.3-3.0 mg of pdexacyaninium in a free form. In various embodiments, the medicament comprises 1.0 mg-3.0 mg of pdexacyaninium in a free form. In some embodiments, the pdexacyaninium or a pharma- ceutically acceptable salt thereof is pdexacyaninium chloride.

[0010]

[0009] A more detailed appreciation of the present disclosure and many of its attendant advantages can be readily obtained as the same becomes better understood by reference to the following detailed description, when considered in conjunction with the accompanying drawings. [Brief description of the drawings]

[0011] [Figure 1] FIG. 1 is a clinical trial consisting of a screening period, a surveillance period, and a follow-up period for the evaluation of pedexacyaninium as a NIFR contrast agent. [Figure 2A] FIG. 2A shows the arithmetic mean plasma concentrations of pedexacyaninium. [Figure 2B]

[0012] FIG. 2B shows quantifiable urinary pedexacyaninium concentrations up to 6 hours post-dose in the 0.1 mg and 0.5 mg cohorts and up to 24 hours post-dose in the 2 mg, 8 mg, and 24 mg cohorts. [Figure 3A]

[0013] FIG. 3A shows the increase in AUCinf of pdexacyaninium at doses ranging from 0.1 mg to 24 mg. [Figure 3B]

[0014] FIG. 3B shows the increase in Cmax of pedexacyaninium at doses ranging from 0.1 mg to 24 mg. [Figure 4]

[0015] FIG. 4 is a simulation of the urinary prudexacyaninium concentration-time course in a patient under anesthesia during a surgical procedure. [Diagram 5]

[0016] FIG. 5 is a simulation of the percentage of patients exceeding the target urinary concentration (1 μg / mL). DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0012]

[0017] Pdexacyaninium is a novel indocyanine green (ICG) derivative containing a β-cyclodextrin moiety. 20 Its molecular size and hydrophilic nature allows its excretion in the urine, imparts a green color visually, and, due to its even higher sensitivity, allows for ureter-specific imaging and visualization using existing near-infrared ICG detection devices. 21 Preclinical results showed that pedexacyaninium, administered IV as a free agent at 0.01 mg / kg, enabled visualization of the ureter up to 3 hours after administration. 22 Briefly, the percentage of animals in which the ureter was visualized up to 3 hours after administration of 0.001 mg / kg and 100% of animals, respectively, were treated with 0.01 mg / kg prsexacyaninium chloride. In addition, prsexacyaninium chloride was well tolerated and without toxicity-related changes in cynomolgus monkeys when administered once daily for 4 weeks at doses up to 300 mg / kg (free form). 22 .

[0013]

[0018] Pdexacyaninium as a free form is in cationic form having the following structure, and can be provided in the form of a salt with a coordinating anion, which can be produced by removing one or more protons from an acid, such as chloride to provide pdexacyaninium chloride. Examples of such salts include salts with a coordinating anion derived from an inorganic acid, such as hydrochloric acid, hydrobromic acid, hydroiodic acid, sulfuric acid, nitric acid, phosphoric acid, and the like, and salts with a coordinating anion derived from an organic acid, such as formic acid, acetic acid, propionic acid, oxalic acid, malonic acid, succinic acid, fumaric acid, maleic acid, lactic acid, malic acid, mandelic acid, tartaric acid, dibenzoyltartaric acid, ditoluoyltartaric acid, citric acid, methanesulfonic acid, ethanesulfonic acid, benzenesulfonic acid, p-toluenesulfonic acid, aspartic acid, glutamic acid, and the like.

[0014] [ka]

[0015]

[0019] A phase 1 study of pdexacyaninium chloride assessed the safety and tolerability, as well as pharmacokinetics (PK), of a single dose of pdexacyaninium chloride administered to healthy human volunteers. The optimal dose of pdexacyaninium in free form for administration to patients was investigated from multiple pharmacological perspectives, based on preclinical results and phase 1 studies.

[0016]

[0020] As a result, a particular dose of pdexacyaninium as a free base was found to be a suitable dose for imaging at least one of organs, body fluids, and ducts in a living body by near-infrared fluorescence. The term "suitable dose" refers to an amount that, when administered to a subject, produces beneficial or desirable results, including clinical results, such as a safe or effective dose for imaging at least one of organs, body fluids, and ducts in a living body by near-infrared fluorescence. In some embodiments, the dosage may be in the range of about 0.3-5.0 mg per subject based on the amount of pdexacyaninium as a free base. In some embodiments, the dosage may be in the range of about 0.3-3.0 mg per subject based on the amount of pdexacyaninium as a free base. In some embodiments, the dosage may be in the range of about 0.3-1.0 mg per subject based on the amount of pdexacyaninium as a free base. In some embodiments, the dosage can be in the range of about 1.0-3.0 mg per subject based on the amount of pdexacyaninium as free form.In some embodiments, the dosage can be 0.3, 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, or 5.0 mg / subject based on the amount of pdexacyaninium as free form.In some embodiments, the dosage can be 0.3, 0.5, 1.0, 1.5, 2.0, 2.5, or 3.0 mg / subject based on the amount of pdexacyaninium as free form.In some embodiments, the dosage can be 0.5, 1.0, 1.5, 2.0, 2.5, or 3.0 mg / subject based on the amount of pdexacyaninium as free form. In some embodiments, the dosage is based on the amount of pudexacyaninium as free form and can be 1.0, 1.5, 2.0, 2.5 or 3.0 mg / subject. In some embodiments, the dosage is based on the amount of pudexacyaninium as free form and can be 1.0 or 3.0 mg / subject. In some embodiments, the dosage is based on the amount of pudexacyaninium as free form and can be 1.0 mg / subject. In some embodiments, the dosage is based on the amount of pudexacyaninium as free form and can be 3.0 mg / subject.The dosage for the first administration and the dosage for the second administration can be the same or different, and can be any combination of the dosages described above.In some embodiments, the dosage for the first administration and the dosage for the second administration can be the same.

[0017]

[0021] Specifically, the present specification discloses a pharmaceutical composition comprising pdexacyaninium or a pharma- ceutical acceptable salt thereof (e.g., chloride) for imaging at least one of organs, body fluids, and ducts in a subject by near-infrared fluorescence, the pharmaceutical composition comprising 0.3 mg to 24.0 mg of pdexacyaninium in free form being administered to the subject first, and optionally, after the first administration, 0.3 mg to 24.0 mg of pdexacyaninium in free form is administered again to the subject. Also disclosed herein is a method for imaging at least one of organs, body fluids, and ducts in a subject by near-infrared fluorescence, the method comprising first administering 0.3 mg to 24.0 mg of pdexacyaninium in free form to the subject, and optionally, after the first administration, administering 0.3 mg to 24.0 mg of pdexacyaninium in free form again to the subject. Further provided herein is the use of pudexacyaninium or a pharma- ceutically acceptable salt thereof (e.g., chloride) for the manufacture of a medicament for imaging at least one of an organ, a body fluid, and a duct in a subject by near-infrared fluorescence, the medicament comprising 0.3 to 24.0 mg of pudexacyaninium in free form in a first administration, and optionally in a second administration after the first administration.

[0018]

[0022] The terms "administer", "administering", "administration" and the like, as used herein, refer to methods that can be used to allow delivery of a composition to a desired site of biological action. These methods include, but are not limited to, intra-articular (into a joint), intravenous, intramuscular, intradermal, intraperitoneal, subcutaneous, topical, and the like. In some embodiments, administration is intravenous administration.

[0019]

[0023] Pdexacyaninium, for example, pdexacyaninium chloride, can be administered as a pharmaceutical composition in the methods disclosed herein. The pharmaceutical composition may contain pharma- ceutically acceptable carriers and additives depending on the administration. The type of pharma- ceutically acceptable carriers and additives is not particularly limited, but carriers and additives well known to those skilled in the art can be used. In some embodiments, the pharmaceutical composition is a solution, for example, an aqueous solution for administration. The concentration of pdexacyaninium as a free form in the aqueous solution composition may be in the range of about 0.1 to 8.0 mg / mL. In some embodiments, the concentration may be in the range of 0.5 to 4.0 mg / mL. In some embodiments, the concentration may be in the range of 1.0 to 4.0 mg / mL. In some embodiments, the concentration may be 0.5, 1.0, 2.0, 3.0 or 4,0 mg / mL. In some embodiments, the concentration may be 1.0 mg / mL. In some embodiments, the concentration may be 2.0 mg / mL. In some embodiments, the concentration may be 3.0 mg / mL. In some embodiments, the concentration may be 4.0 mg / mL.

[0020]

[0024] In some embodiments, the timing of administration of the pharmaceutical composition disclosed herein is before surgery (e.g., before laparoscopic surgery) or during surgery (e.g., during laparoscopic surgery).In some embodiments, the first administration is before surgery, and optionally further comprises the second administration of the pharmaceutical composition, for example, further comprises administering it again during surgery.

[0021]

[0025] To detect puedexacyaninium for diagnosis, the following devices can be used: the device is a device used to measure at least a part of a living body to which the diagnostic composition of the present invention described above is administered (see U.S. Pat. No. 9,056,131, the disclosure of which is incorporated by reference in its entirety). EXAMPLES

[0022]

[0026] Hereinafter, the disclosed methods and compositions will be described in more detail with reference to examples. Furthermore, the disclosure of the present invention is not limited to the following examples.

[0023]

[0027] Example 1 - Dose Level Rationale

[0028] The starting dose was 0.1 mg of pdexacyaninium per subject as the free form. The rationale for the starting dose was based on the results of safety studies in cynomolgus monkeys and the estimated clinically effective dose in humans.

[0024]

[0029] The estimated clinically effective dose is 0.5 mg of pedexacyaninium as the free form per subject. In an ex vivo imaging study of isolated porcine ureters using pedexacyaninium chloride as the NIR-F agent, 1 Adequate ureteral visualization was defined as sufficient visual recognition of the ureter at 1 μg / mL in images captured under fluorescent imaging. 1 Three hours after intravenous administration of 0.01 mg / kg of pudexacyaninium in the free form, the ureter was visually identifiable under fluorescent imaging with a urinary concentration greater than 1 μg / mL. These observations support the clinically effective dose selected in the study, which allowed adequate intraoperative visualization of the ureter for up to 3 hours, exceeding the typical length of a routine surgical procedure (approximately 2 hours). The estimated clinically effective dose was therefore calculated as the dose resulting in a urinary concentration greater than 1 μg / mL 3 hours after intravenous administration of pudexacyaninium, corrected for body weight using the following equation: Estimated clinically effective dose = 0.01 mg / kg (animal dose) x (40 kg [animal body weight] / 60 kg [human body weight]) 0.33 × 60 kg (human body weight) = 0.5 mg / subject.

[0025]

[0030] Criteria for handling concentrations below the limit of quantification in pharmacokinetic analysis

[0031] Values ​​for concentrations below the lower limit of quantification (BLQ) were set to zero, with exceptions defined as follows: Any sandwiched (between two quantifiable concentrations) BLQ values ​​and those following the last quantifiable concentration in the profile were considered missing for the purposes of pharmacokinetic (PK) analysis.

[0026] If there were clear concentration values ​​after the two BLQ concentration values ​​in the late apparent terminal phase, these were evaluated. If these values ​​were considered irregular, they were marked as missing.

[0027] If the entire concentration-time profile was a BLQ, the profile was excluded from the PK analysis.

[0028] If pre-dose concentrations were missing, these values ​​were set to zero by default in Phoenix WinNonlin.

[0029]

[0032] Study design

[0033] The study (ClinicalTrials.gov Identifier: NCT03698305) was a randomized, double-blind, placebo-controlled, ascending IV bolus group study conducted at a single site in the United States (Covance Clinical Research Unit, Inc.). The objectives were to evaluate the safety and tolerability of a single dose of pudexacyaninium chloride IV administered to healthy participants, as well as to evaluate the single-dose PK profile of pudexacyaninium in plasma and urine.

[0030]

[0034] The study population was 30 participants overall, consisting of five cohorts of six healthy volunteers (three females and three males) per cohort. Participants were randomly assigned 2:1 (n=4 and n=2 in each cohort) to receive a single IV bolus of pudexacyaninium chloride or placebo. The study consisted of a screening period, a study period, and a follow-up period (Figure 1). Participants were admitted to the clinic on study day-1 after successful screening. On day 1, participants had an indwelling urinary catheter placed 1-2 hours before dosing and left in place until ≥8 hours after dosing. Under fasting conditions, participants in cohort 1 randomized to pdexacyaninium received an intravenous bolus of 0.1 mg of pdexacyaninium in the free form; subsequent cohorts received sequential boluses of 0.5 mg, 2 mg, 8 mg, and 24 mg of pdexacyaninium in the free form. The estimated clinically effective dose of pdexacyaninium in the free form is 0.5 mg per subject. In an imaging study in Göttingen minipigs, 3 hours after IV administration of pdexacyaninium in the free form, the ureter was visually identifiable under fluorescent imaging and had a urinary concentration greater than 1 μg / mL. 22 Therefore, the effective dose in humans was calculated as the dose that resulted in a urinary concentration of >1 μg / mL 3 hours after IV administration of pdexacyaninium chloride. To evaluate the dose-dependent nature of pdexacyaninium chloride PK in first-in-human studies, a starting dose of 0.1 mg was chosen, which is one-fifth of the estimated clinically effective dose (0.5 mg of pdexacyaninium as free form).

[0031]

[0035] After at least 5 of 6 patients in the cohort completed the study procedures, a dose escalation committee reviewed all PK and safety data and determined whether to proceed with dose escalation, stop dose escalation, repeat the same dose level, or consider a lower dose level intermediate between the current and previous doses. Pdexacyaninium chloride solution for injection was supplied as an aqueous solution for IV injection of 4 mg / mL pdexacyaninium as the free form. Pdexacyaninium chloride solution was provided in 10 mL amber glass vials.

[0032]

[0036] Blood and urine samples were collected over a 24-hour period. Participants were discharged on day 2, returned to the clinic for a follow-up visit on day 7, and completed the study with a follow-up phone call on day 14. To prevent accidental unblinding due to urine discolouration, catheter and tubing collection bags were covered and replaced so participants could not see these or the collection vials. Urine sample collection and processing was performed by additional unblinded staff who were not involved in the study evaluations.

[0033]

[0037] Informed consent was obtained from each participant and the protocol was approved by the Institutional Review Board (Advarra IRB, Columbia, MD, USA). The study was further performed in accordance with the principles of the Declaration of Helsinki, Good Clinical Practice, and the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use guidelines. Amendments were made to the study protocol as discussed below (see "Participants" and "Evaluation") but did not affect the outcome of this study.

[0034]

[0038] Pdexacyaninium chloride is used as follows: Molecular weight 3079.44 (chloride salt) 3043.99 (free form) Storage conditions: Store in freezer (-80℃, actual temperature: -81.5℃~-74.6℃), Light-shielded, nitrogen gas filled Use 10% or lower relative humidity.

[0035]

[0039] participants

[0040] Eligible participants were aged 18–55 years and had a mean body weight of 18.5–32.0 kg / m 2 Participants had a body mass index (BMI) of 0.01 (inclusive) and weighed >40 kg (women) or >50 kg (men). Female participants were excluded if pregnant and were required to abstain from breastfeeding throughout the treatment period and for at least 30 days after the last drug dose. All participants were required to follow contraception guidelines. All participants had normal liver function (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyltransferase, and total bilirubin < upper limit of normal [ULN]) and normal renal function (blood urea nitrogen and creatinine ≤ ULN) on day -1, the latter of which was added as an amendment to the protocol on October 31, 2018. History or evidence of clinically significant disease or malignancy was not permitted. All participants provided written informed consent.

[0036]

[0041] evaluation

[0042] Safety and tolerability were assessed at each dose level via monitoring for adverse events (AEs) related to pdexacyaninium chloride, clinical laboratory tests, vital signs, electrocardiograms (ECGs), and physical examinations. Safety and tolerability endpoints were the nature, frequency, and severity of AEs, as well as clinical laboratory tests, vital signs, routine 12-lead ECGs, and physical examinations. If a subject developed a hypersensitivity reaction, an additional blood sample for determination of histamine concentration was obtained as soon as possible after the onset of the hypersensitivity reaction.

[0037]

[0043] Adverse events were graded according to the National Cancer Institute-Common Terminology Criteria for Adverse Events, version 5.0, as specified in the protocol amendment of October 31, 2018. Adverse events were classified by organ class and preferred term using the Glossary of Regulatory Terms, version 21.1. Green coloration of urine was not considered an AE as it is an expected, known, reversible effect and there were no untoward clinical symptoms.

[0038]

[0044] Time points for blood and urine PK sample collection are shown (Table 1). Urine sampling intervals were between -1 h and the time of dosing and between each subsequent time point for consecutive urine sample collection. End points for plasma prudexacyaninium PK parameters were back-extrapolated plasma concentrations at time zero (C 0 ); maximum observed plasma concentration (C max ); from 0 hours to 24 hours after administration (AUC 0-24 ) area under the plasma concentration-time curve; area under the plasma concentration-time curve from time zero to the time of the last quantifiable concentration (AUC last ); from time zero to infinity (AUC inf ) area under the plasma concentration-time curve; the percentage of the area under the plasma concentration-time curve from the time of the last quantifiable concentration to infinity relative to the total area under the concentration-time curve (AUC inf [%extrap]); total body clearance of drug from plasma (CL tot ); Time to peak blood concentration (t max ); apparent terminal elimination half-life (t 1 / 2 ); and terminal volume of distribution (Vz). The PK parameter endpoints of pedexacyaninium measured in urine were urinary excretion of unchanged drug (Ae), urinary excretion rate relative to dose (Ae%), cumulative urinary excretion of unchanged drug (CumAe), percentage of CuMAe (CumAe%), urinary excretion of unchanged drug from time zero to the time of last quantifiable concentration (Ae last ), Ae last Percentage of Ae last %), renal clearance (CLR ), and the mean urinary concentration of pdexacyaninium at each time point.

[0039]

[0045] The time intervals for the onset and cessation of green urine staining were recorded for the 8 mg and 24 mg free puedexacyaninium cohorts according to the protocol amendment of April 17, 2019. Detection of urine staining was performed by unblinded nursing staff by visual inspection only. Records of staining were kept in a secure location until the postmortem database was locked to avoid possible unblinding of blinded staff.

[0040]

[0046] statistical methods

[0047] The safety population included all participants who received a single dose of the study drug. The PK population included participants in the safety population for whom data were available to derive one or more PK parameters. Pharmacokinetic parameters were calculated by noncompartmental analysis using Phoenix Winnonlin version 8.1 and summarized by treatment group. Descriptive statistics were presented for plasma concentrations, urinary excretion and cumulative urinary excretion of pedexacyaninium, and urinary concentrations of pedexacyaninium at urine collection points by treatment group and scheduled sample time.

[0041]

[0048] result

[0049] There were 30 participants, of whom 20 (4 per cohort) received pudexacyaninium chloride and 10 (2 per cohort) received placebo. All 30 participants completed the study according to protocol and were all included in the safety population. All 20 participants who received pudexacyaninium chloride were included in the PK population. Within each cohort and overall, 50% of participants were female (Table 1). Overall mean age was 43 years (standard deviation [SD], 11.3 years), and mean BMI was 27.3 kg / m 2 (SD, 2.96), and 66.7% were white. Mean age and BMI were similar across all cohorts.

[0042] [Table 1]

[0043]

[0050] Safety and Tolerability

[0051] Treatment-emergent AEs (TEAEs) throughout the study were reported in three participants (15.0%) who received pdexacyaninium chloride and two participants (20.0%) who received placebo. Infusions did not cause histamine release or hypersensitivity. Among participants receiving pdexacyaninium chloride, one who received pdexacyaninium as a free form at a dose of 0.5 mg experienced oral herpes and fainting dizziness (both grade 1), one who received pdexacyaninium as a free form at a dose of 8 mg experienced a grade 1 urinary tract infection, and one who received the 24 mg dose experienced a grade 1 headache, grade 2 dysuria, and grade 3 pyelonephritis (Table 2).

[0044] [Table 2]

[0045]

[0052] No TEAEs were considered by the investigators to be related or possibly related to pdexacyaninium chloride. Participants who experienced oral herpes, urinary tract infection, and pyelonephritis received reversible medications.

[0046]

[0053] The case of grade 3 pyelonephritis was a serious AE that began on day 2 after administration of pudexacyaninium chloride and was due to a urinary catheter. The participant was admitted to the hospital on day 3 and treated with ceftriaxone. On day 6, the participant was discharged after being switched to oral bactrim, pyridium, and ibuprofen, at which point the serious AE was considered resolved. There were no clinically serious findings or trends in serum chemistry data, hematology data, vital sign measurements, ECG parameters, or physical examinations, and no withdrawals from the study due to AEs or on-study deaths.

[0047]

[0054] Pharmacokinetics

[0055] The arithmetic mean plasma concentrations of pedexacyaninium are shown in FIG. 2A.

[0048]

[0056] The mean terminal elimination half-life of pdexacyaninium ranged from 2.1 to 3.6 hours, and the total body clearance and terminal volume of distribution did not vary across the dose range (Table 3).

[0049] [Table 3]

[0050]

[0057] The AUC of pdexacyaninium at doses ranging from 0.1 mg to 24 mg of free pdexacyaninium inf (Figure 3A) and C max (Figure 3B) was approximately proportional to increasing dose. These dose-proportional increases in exposure, combined with unchanged half-life and total body clearance estimates, indicate linear PK for pdexacyaninium over the dose range evaluated.

[0051]

[0058] Pdexacyaninium appeared in the urine rapidly in quantifiable concentrations after IV administration, which was observed at the first post-dose sample collection point (0.5 h) in all participants. Urinary pdexacyaninium concentrations were quantifiable up to 6 h post-dose in the 0.1 mg and 0.5 mg cohorts, and up to 24 h post-dose in the 2 mg, 8 mg, and 24 mg cohorts (Figure 2B). Across the entire dose range, urinary excretion was nearly complete by 24 h. The mean amounts of intact pdexacyaninium recovered in urine were 0.0768, 0.403, 1.68, 8.01, and 23.1 mg after administration of 0.1, 0.5, 2, 8, or 24 mg of pdexacyaninium as the free form, respectively. The corresponding percentages of the administered pdexacyaninium dose recovered unchanged in urine (Ae last% ) ranged from 76.8% to 100% (Table 4).

[0052] [Table 4]

[0053]

[0059] For reference, in a preclinical study using a miniature pig model, pedexacyaninium was completely excreted (95%) within 6 hours after IV administration. 22 .

[0054]

[0060] Visible green urine coloration occurred in participants receiving the 8 mg and 24 mg doses of pdexacyaninium as free form but not in participants receiving placebo. In seven of these eight participants, green urine coloration was first observed during the first urine collection interval (0–0.5 hours) (Table 5).

[0055] [Table 5]

[0056]

[0061] In the remaining participants (8 mg cohort), green urine color first appeared at the 2-2.5 hour interval. Green urine color was observed 3-3.5 hours after dosing in 3 of 4 participants in the 8 mg cohort and 12-24 hours after dosing in 2 of 4 participants in the 24 mg cohort. In all cases, green urine color was no longer observed by 24 hours after dosing.

[0057]

[0062] Summary of Results of Example 1

[0063] Currently, there are no FDA-approved agents to facilitate intraoperative NIRF visualization of the ureter, based on validation studies of methylene blue and indocyanine green, dyes approved for use in other indications. 23~25 , each of which has deficiencies in optical properties and routes of administration and clearance, making them unsuitable for such treatments. 12 To address this unmet need, novel NIRF agents are under development. Some of these, e.g., IS-001 17 , IRDye®800-BK 26、27 , and ZW800-1 28 These have recently progressed to first-in-human trials.

[0058]

[0064] Provided herein are first-in-human data for pdexacyaninium chloride, which is designed for high water solubility, low self-aggregation (which can reduce fluorescence), and high optical and chemical stability. 20 These results, obtained in healthy volunteers, provide key information regarding the safety and PK profile of pdexacyaninium, including dose inferences for Phase 2 study design. Single ascending IV bolus doses up to 24 mg did not result in any pdexacyaninium-related TEAEs and there were no withdrawals due to AEs. One serious TEAE, grade 3 pyelonephritis, occurred in one participant, which is consistent with decades of urological observations. 29、30, was found to be a complication related to the urinary catheter. No significant trends were observed in serum chemistry data, hematology data, vital sign measurements, ECG parameters, or physical examinations in any of the participants.

[0059]

[0065] Pharmacokinetic analysis revealed that pedexacyaninium was primarily excreted unchanged in the urine, and that excretion appeared to be rapid and nearly complete by 24 hours. A single 8 mg or 24 mg dose resulted in significant green urinary coloration for at least 3 hours in most participants. Linear and dose-proportional pedexacyaninium plasma PK was observed over the dose range evaluated.

[0060]

[0066] In conclusion, based on preclinical results demonstrating that 0.01 mg / kg IV administration of pudexacyaninium chloride allows clear and distinct NIRF visualization of the ureter. 22 The urinary concentrations and PK parameters of pdexacyaninium found in this study support intraoperative NIRF ureteral visualization using pdexacyaninium as the free form in the dose range of 0.1 mg to 24 mg. Collectively, these safety and PK results support further evaluation of pdexacyaninium chloride for ureteral detection during abdominal and pelvic surgery.

[0061]

[0067] Example 2 - Clinical Dosing of Pdexacyaninium Chloride

[0068] Near-infrared fluorescence (NIR-F) ureter visualization depends on the urinary concentration of pdexacyaninium in the ureter. The (real-time) urinary concentration of pdexacyaninium is likely to be a good pharmacodynamic (visualization) surrogate marker. Ureter imaging studies in minipigs suggested that a sufficient urinary pdexacyaninium concentration in the urinary tract is expected to be 1 μg / mL for NIR-F ureter imaging, based on ex vivo studies using porcine ureters (Mol Imaging Biol (2021)).

[0062]

[0069] The target product profile of intraoperative ureteral imaging with pudexacyaninium chloride is such that almost all patients achieve clear ureteral visualization during surgery (over 3 hours after intravenous bolus administration).

[0063]

[0070] Therefore, a target dose was investigated that would achieve a urinary concentration of >1 μg / mL for 3 hours after administration.In a phase 1 healthy volunteer study (ClinicalTrials.gov Identifier: NCT03698305), the mean point urinary concentration of pdexacyaninium at 3 hours after a 2 mg intravenous bolus dose was 0.5 μg / mL under conditions of unrestricted water intake.

[0064]

[0071] In general, urinary drug concentrations in humans are highly variable because the concentration is affected by the urine formation volume (urinary excretion volume). In fact, the urinary concentrations observed in healthy volunteers in a US Phase 1 trial (ClinicalTrials.gov identifier: NCT03698305) are highly variable and affected by fluctuations in urine volume. In patients under anesthesia during surgery, it is recommended to control the urine production rate at a low level of about 1 mL / min [Davison A and Ross JA, 2016 31 and Puckett et al., 2017 32 ], whereas in a US Phase 1 trial, participants consumed water ad libitum throughout the study and large variations in urinary concentrations were observed. It was deemed necessary to use a quantitative approach based on pharmacological mechanisms to accurately estimate the clinical dose of pdexacyaninium in patients under anesthesia during surgical procedures.

[0065]

[0072] A population pharmacokinetic model was constructed by nonlinear mixed-effects modeling using data from a US Phase 1 healthy volunteer study. A three-compartment model explained well the plasma concentration-time profile of pdexacyaninium, and simultaneously urinary pdexacyaninium concentrations were analyzed using output compartments. The model was successful in explaining individual urinary pdexacyaninium concentrations. Using the developed model, plasma and urinary pdexacyaninium concentration-time profiles in individual patients under anesthesia during surgery were simulated for clinical dose setting. The targeted product profile for intraoperative ureteral imaging with pdexacyaninium is that almost all patients achieve clear ureteral visualization during surgery (over 3 hours after intravenous bolus administration).

[0066]

[0073] Simulations were run assuming that the following three points were all considered important: (1) The urine production rate during surgery is controlled at 1 mL / min. (2) the absence of interindividual variation in urine production rate; and (3) There is no delay between plasma concentration and urinary excretion.

[0067]

[0074] A total of 1000 real patient populations were created to simulate the plasma and urinary prudexacyaninium concentration-time profiles for each dose (0.1, 0.3, 1, 2, and 3 mg). Sequential simulations were performed including the 2 mg dose in the Phase 1 study, which shows a mean urinary concentration close to the target concentration. A simulated urinary prudexacyaninium concentration-time course in a patient under anesthesia during a surgical procedure is shown.

[0068]

[0075] The effect of changes in urine production rate was also examined over the range of 0.5 to 2 mL / min. Simulations of the percentage of patients exceeding the target urinary concentration (1 μg / mL) predicted that for a 1 mg dose in patients with urine production rates of 0.5 to 1.0 mL / min, greater than 99% of patients would achieve a urinary concentration greater than 1 μg / mL over 3 hours following a single IV dose.

[0069]

[0076] In the Phase 2 trial, three dose levels were proposed as starting doses per participant: 0.3, 1 and 3 mg, by selecting 1 mg as the central dose and using a common ratio of "3" to distinguish between doses.

[0070] References 1. Dobrowolski Z, Kusionowicz J, Drewniak T, et al. Renal and ureteric trauma: diagnosis and management in Poland. BJU Int. 2002;89(7):748-751. 2. Ahn CB, Kim JH, Park GK, et al. Prognostic imaging of iatrogenic and traumatic ureteral injury by near-infrared fluorescence. Quant Imaging Med Surg. 2019;9(6):1056-1065. 3. Summerton DJ, Kitrey ND, Lumen N, Serafetinidis E, Djakovic N, European Association of U. EAU guidelines on iatrogenic trauma. Eur Urol. 2012;62(4):628-639. 4. Abboudi H, Ahmed K, Royle J, Khan MS, Dasgupta P, N'Dow J. Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol. 2013;10(2):108-115. 5. Halabi WJ, Jafari MD, Nguyen VQ, et al. Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States. Dis Colon Rectum. 2014;57(2):179-186. 6. Lucarelli G, Ditonno P, Bettocchi C, et al. Delayed relief of ureteral obstruction is implicated in the long-term development of renal damage and arterial hypertension in patients with unilateral ureteral injury. J Urol. 2013;189(3):960-965. 7. Nachiappan S CA, Askari A, Faiz O. Intraoperative ureteric injuries and litigation in the NHS. J Clin Urol. 2015;8(1):9-13. 8. Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int. 2004;94(3):277-289. 9. Tan-Kim J, Menefee SA, Reinsch CS, et al. Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization. J Minim Invasive Gynecol. 2015;22(7):1278-1286. 10. Parpala-Sparman T, Paananen I, Santala M, Ohtonen P, Hellstrom P. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scand J Urol Nephrol. 2008;42(5):422-427. 11. de Valk KS, Handgraaf HJ, Deken MM, et al. A zwitterionic near-infrared fluorophore for real-time ureter identification during laparoscopic abdominopelvic surgery. Nat Commun. 2019;10(1):3118. 12. Slooter MD, Janssen A, Bemelman WA, Tanis PJ, Hompes R. Currently available and experimental dyes for intraoperative near-infrared fluorescence imaging of the ureters: a systematic review. Tech Coloproctol. 2019;23(4):305-313. 13. Wallis CJ, Cheung DC, Garbens A, et al. Occurrence of and Risk Factors for Urological Intervention During Benign Hysterectomy: Analysis of the National Surgical Quality Improvement Program Database. Urology. 2016;97:66-72. 14. Douissard J, Meyer J, Ris F, Liot E, Morel P, Buchs NC. Iatrogenic ureteral injuries and their prevention in colorectal surgery: results from a nationwide survey. Colorectal Dis. 2019;21(5):595-602. 15. Lynch TH, Martinez-Pineiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol. 2005;47(1):1-15. 16. Al-Taher M, van den Bos J, Schols RM, Bouvy ND, Stassen LP. Fluorescence Ureteral Visualization in Human Laparoscopic Colorectal Surgery Using Methylene Blue. J Laparoendosc Adv Surg Tech A. 2016;26(11):870-875. 17. Farnam RW, Arms RG, Klaassen AH, Sorger JM. Intraoperative ureter visualization using a near-infrared imaging agent. J Biomed Opt. 2019;24(6):1-8. 18. Hyun H, Henary M, Gao T, et al. 700-nm Zwitterionic Near-Infrared Fluorophores for Dual-Channel Image-Guided Surgery. Mol Imaging Biol. 2016;18(1):52-61. 19. Verbeek FP, van der Vorst JR, Schaafsma BE, et al. Intraoperative near infrared fluorescence guided identification of the ureters using low dose methylene blue: a first in human experience. J Urol. 2013;190(2):574-579. 20. Kurahashi T, Iwatsuki K, Onishi T, Arai T, Teranishi K, Hirata H. Near-infrared indocyanine dye permits real-time characterization of both venous and lymphatic circulation. J Biomed Opt. 2016;21(8):86009. 21. Gioux S, Choi HS, Frangioni JV. Image-guided surgery using invisible near-infrared light: fundamentals of clinical translation. Mol Imaging. 2010;9(5):237-255. 22. Fushiki H, Yoshikawa T, Matsuda T, Sato T, Suwa A. Preclinical Development and Validation of ASP5354: A Near-Infrared Fluorescent Agent for Intraoperative Ureter Visualization. Molecular Imaging and Biology. 2021; May 11 online ahead of print. 23. Carr JA, Franke D, Caram JR, et al. Shortwave infrared fluorescence imaging with the clinically approved near-infrared dye indocyanine green. Proc Natl Acad Sci U S A. 2018;115(17):4465-4470. 24. Liu Y, Jia Q, Zhou J. Recent Advance in Near-Infrared (NIR) Imaging Probes for Cancer Theranostics. Advanced Therapeutics. 2018;1(8):1800055. 25. Said SM, Marey G, Hiremath G. Intraoperative fluorescence with indocyanine green in congenital cardiac surgery: Potential applications of a novel technology. JTCVS Techniques. 2021. 26. Al-Taher M, van den Bos J, Schols RM, Kubat B, Bouvy ND, Stassen LPS. Evaluation of a novel dye for near-infrared fluorescence delineation of the ureters during laparoscopy. BJS Open. 2018;2(4):254-261. 27. van den Bos J, Al-Taher M, Bouvy ND, Stassen LPS. Near-infrared fluorescence laparoscopy of the ureter with three preclinical dyes in a pig model. Surg Endosc. 2019;33(3):986-991. 28. Choi HS, Nasr K, Alyabyev S, et al. Synthesis and in vivo fate of zwitterionic near-infrared fluorophores. Angew Chem Int Ed Engl. 2011;50(28):6258-6263. 29. Prather GC, Sears BR. Pyelonephritis: in defense of the urethral catheter. J Urol. 1960;83:337-344. 30. Cortese YJ, Wagner VE, Tierney M, Devine D, Fogarty A. Review of Catheter-Associated Urinary Tract Infections and In Vitro Urinary Tract Models. J Healthc Eng. 2018;2018:2986742. 31. Davison A, Ross JA. Chapter 55 Patient with poor urine output. In: Coomarasamy A. Shafi MI, Davila GW, Chan KK, editors. Gynecologic and obstetric surgery: challenges and management options. John Wiley & Sons Inc. (NY): 2016;167-9 32. Puckett JR, Pickering JW, Palmer SC, McCall JL, Kluger MT, De Zoysa J, et al. Low versus standard urine output targets in patients undergoing major abdominal surgery: A Randomized Noninferiority Trial. Ann Surg. 2017;265(5):874-81.

Claims

1. 1. A pharmaceutical composition for imaging at least one of an organ, a body fluid, and a duct in a subject by near-infrared fluorescence (NIRF), comprising pdexacyaninium or a pharma- ceutical acceptable salt thereof, The pharmaceutical composition described above, wherein the content of pudexacyaninium or a pharma- ceutically acceptable salt thereof is 0.3 mg to 24.0 mg as the free form of pudexacyaninium.

2. The pharmaceutical composition of claim 1, administered to a subject in a first administration and then administered again to the subject.

3. The pharmaceutical composition according to claim 1, wherein the content of pedexacyaninium or a pharma- ceutical acceptable salt thereof is 0.3 mg to 3.0 mg as the free form of pedexacyaninium.

4. The pharmaceutical composition according to claim 1, wherein the content of pedexacyaninium or a pharma- ceutical acceptable salt thereof is 1.0 mg to 3.0 mg as the free form of pedexacyaninium.

5. 2. The pharmaceutical composition of claim 1, wherein the prudexacyaninium or a pharma- ceutically acceptable salt thereof is prudexacyaninium chloride.

6. The pharmaceutical composition described in claim 1, which is a pharmaceutical composition for imaging the ureter.

7. 1. A method for imaging at least one of an organ, a fluid, and a duct in a subject by near-infrared fluorescence (NIRF), comprising: The above method comprises subjecting a subject to which a pharmaceutical composition according to any one of claims 1 to 5 has been administered to, to NIRF to obtain images of at least one of organs, body fluids, and ducts in the subject.

8. The method of claim 7, which is a method for imaging the ureter.

9. 1. Use of pdexacyaninium or a pharma- ceutical acceptable salt thereof for the manufacture of a medicament for imaging at least one of an organ, a body fluid, and a duct in a subject by near-infrared fluorescence, comprising: The above use, wherein the content of pudexacyaninium or a pharma- ceutical acceptable salt thereof in the medicament is 0.3 to 24.0 mg as the free form of pudexacyaninium.

10. The use of claim 9, wherein the medicament is administered to the subject in a first administration and then again to the subject.

11. The use according to claim 9 or 10, wherein the content of pudexacyaninium or a pharma- ceutical acceptable salt thereof in the medicament is 0.3 to 3.0 mg as the free form of pudexacyaninium.

12. The use according to claim 9 or 10, wherein the content of pudexacyaninium or a pharma- ceutically acceptable salt thereof in the medicament is 1.0 mg to 3.0 mg as the free form of pudexacyaninium.

13. The use according to claim 9 or 10, wherein the pudexacyaninium or a pharma- ceutically acceptable salt thereof is pudexacyaninium chloride.

14. The use of claim 9 or 10, wherein the pharmaceutical is for imaging the ureter.

Images