How to Treat Lymphedema

Abstract

Methods of treating lymphedema, reducing skin thickening, improving skin turgor, structure, histology and / or function, and / or improving lymphatic flow and / or vascular function in a patient in need thereof are described comprising administering to the patient an effective amount of a selective LTA4H inhibitor.

Description

[Technical field]

[0001] Related Applications This application claims the benefit of U.S. Provisional Application No. 63 / 287,748, filed December 9, 2021. The entire contents of the above-referenced applications are hereby incorporated by reference. [Background technology]

[0002] 2. Background of the Invention Lymphedema is a debilitating chronic condition with no clear pharmacological treatment. Although mortality is low, lymphedema-related hospitalizations represent a significant burden to the U.S. health care system. 4 Lymphedema affects approximately 200 million people worldwide, including at least 3 million people in the United States. 6 However, lymphedema is poorly understood and poorly documented, so currently accepted incidence and prevalence rates likely underestimate its magnitude. 7 .

[0003] Lymphedema occurs when impaired fluid transport through the lymphatic circulation is not relieved, causing fluid retention that does not remain gradually depressed. 9、10 The disease is caused by relative lymphatic insufficiency. 11 The natural history of lymphedema is defined by increased limb girth, fibrosis, inflammation, abnormal fat deposition, and prominent skin pathology that increases the risk of recurrent skin infections. 12 In addition to being of cosmetic concern, lymphedema can substantially affect a patient's quality of daily life, as it causes discomfort and affects the ability to perform daily tasks.

[0004] Lymphedema is caused by an imbalance of growth factors 13 and the presence of persistent tissue inflammation. 10Therapeutic approaches that promote reparative lymphangiogenesis may have the potential to reverse lymphedema in the future, but the relationship between persistent inflammation and impaired lymphangiogenesis has not been fully explored to date. 14 .

[0005] In future exploration of informed pharmacological approaches, a mechanistic role for leukotriene B4 (LTB4) in the molecular pathogenesis of experimental lymphedema in both humans and mice has been identified. 14、15 Previous translational investigations of mouse models of human lymphedema 16 suggested a role for leukotrienes both in the pathogenesis of lymphedema and as potential therapeutic targets. 16 5-Lipoxygenase (5-LO) pathway 18 Ketoprofen, an NSAID with a recognized dual anti-inflammatory mechanism of action that includes inhibition of 17 has been investigated as a treatment for lymphedema. See, e.g., U.S. Patent No. 8,965,708. When ketoprofen was administered systemically to mice with experimental acquired lymphedema, disease burden was reversed, including a significant normalization of pretreatment lymphedema histopathology. 17 Results from the first human pilot clinical trials of a drug therapy for human lymphedema have also been published. 55 An open-label, subsequent placebo-randomized study of this trial in adult lymphedema subjects confirmed the drug's ability to improve clinically measured skin thickness and reverse the skin histopathological changes of lymphedema. 19 These results highlight the promise of such an approach to help repair defective lymphatic circulation, but clinical application is hampered by concerns about cardiovascular morbidity associated with long-term NSAID use.

[0006] US Patent No. 10,500,178 describes the use of certain inhibitors of LTB4 for the prevention and treatment of lymphedema.Also, LTA4 hydrolase inhibitor, ubenimex (also referred to as "bestatin" in the literature), has been investigated in Phase II clinical trials for the treatment of lymphedema of the lower limbs.In clinical trials, no improvement in skinfold thickness and limb volume and bioimpedance for ubenimex versus placebo was identified.

[0007] Currently, there are no approved therapies for the treatment of lymphedema, and thus there remains a significant need for therapies that can safely and effectively treat this chronic, debilitating condition. Summary of the Invention

[0008] Summary of the Invention The present invention relates to a method of treating lymphedema, reducing skin thickness, improving skin turgor, structure, histology and / or function, and / or improving lymphatic flow and / or vascular function in a patient in need thereof, comprising administering to the patient an effective amount of acebilustat or another selective LTA4H inhibitor.Lymphedema that may be treated by the methods of the present invention includes, for example, primary and secondary (or acquired) lymphedema.The treatments described herein may result in a reduction in skin thickness and / or improvement in skin turgor, structure, histology or function, and / or an increase in lymphatic flow and / or vascular function.

[0009] The present invention encompasses a method of treating lymphedema, e.g., secondary lymphedema, in a patient in need of such treatment, comprising administering to the patient an effective amount of acebilstat, wherein the treatment results in a reduction in skinfold thickness. In a further aspect, the present invention is a method of treating acromyelitis, in a patient in need of such treatment, comprising administering to the patient an effective amount of acebilstat, wherein the treatment results in a reduction in skinfold thickness.

[0010] The invention also includes a method of treating lymphedema, e.g., secondary lymphedema, in a patient in need of such treatment, comprising administering to the patient an effective amount of acebilstat, which treatment results in a reduction in skin thickness and / or an improvement in skin turgor, structure, histology and / or function.The invention also includes a method of treating acrolymphedema, in a patient in need of such treatment, comprising administering to the patient an effective amount of acebilstat, which treatment results in an improvement in skin turgor, structure, histology and / or function.

[0011] The invention further includes a method of treating lymphedema, e.g., secondary lymphedema, in a patient in need of such treatment, comprising administering to the patient an effective amount of acebilstat, wherein the treatment results in improved lymphatic flow and / or vascular function. In a further aspect, the invention is a method of treating acromyelitis, in a patient in need of such treatment, comprising administering to the patient an effective amount of acebilstat, wherein the treatment results in improved lymphatic flow.

[0012] The present invention also includes a method of treating lymphedema in a patient in need of such treatment, comprising administering to the patient an effective amount of a selective LTA4H inhibitor, wherein the treatment results in a reduction in skin thickness, and the selective LTA4H inhibitor is selective for epoxide hydrolase over aminopeptidase. In one aspect, the present invention relates to a method of treating acromyelitis in a patient in need of such treatment, comprising administering to the patient an effective amount of a selective LTA4H inhibitor, wherein the treatment results in a reduction in skin thickness, and the selective LTA4H inhibitor is selective for epoxide hydrolase over aminopeptidase.

[0013] The present invention also encompasses a method for reducing skin thickness in a patient in need of such reduction, comprising administering to the patient an effective amount of a selective LTA4H inhibitor, wherein the selective LTA4H inhibitor is selective for epoxide hydrolase over aminopeptidase.In yet a further aspect, the present invention relates to a method for reducing skin thickness in a patient in need of such reduction, comprising administering to the patient an effective amount of acebilstat.The patient may be, for example, a patient suffering from lymphedema, a patient in need of improved skin softness, or a patient suffering from scleroderma.

[0014] The present invention also includes a method for treating lymphedema, such as secondary lymphedema, in a patient in need of lymphedema, such as secondary lymphedema, comprising administering to the patient an effective amount of a selective LTA4H inhibitor, and the treatment results in an increase in the improvement of turgor, structure, histology or function of skin.In yet another aspect, the present invention relates to a method for improving turgor, structure, histology or function of skin, in a patient in need of lymphedema, such as secondary lymphedema, comprising administering to the patient an effective amount of a selective LTA4H inhibitor.The patient may be, for example, a patient suffering from lymphedema, a patient in need of improvement of skin softness or a patient suffering from scleroderma.

[0015] The present invention also includes a method for treating lymphedema, such as secondary lymphedema, in a patient in need of lymphedema, such as secondary lymphedema, comprising administering to the patient an effective amount of a selective LTA4H inhibitor, and the treatment results in increased lymphatic flow and / or improved vascular function.In yet another aspect, the present invention relates to a method for improving lymphatic and / or vascular flow in a patient in need of increased lymphatic and / or vascular flow, comprising administering to the patient an effective amount of a selective LTA4H inhibitor.The patient may be, for example, a patient suffering from lymphedema, a patient in need of improved skin softness, or a patient suffering from scleroderma.

[0016] In a further aspect, the present invention relates to a method for treating lymphedema in a patient in need of lymphedema treatment, comprising administering to the patient an effective amount of a combination of acevirstat or other selective LTA4H inhibitor and a second active agent, the second active agent being selected from the group consisting of COX-1 inhibitors, COX-2 inhibitors, coumarins, antihistamines, montelukast and related leukotriene modifiers, antifibrotic compounds, diuretics, statins, mTOR inhibitors and pirfenidone.In yet another embodiment, the second active agent is selected from the group consisting of COX-1 inhibitors, COX-2 inhibitors, coumarins, antihistamines, antifibrotic compounds, diuretics, statins, mTOR inhibitors and pirfenidone.In one aspect, the lymphedema is acromyelitis.

[0017] The reduction in skin thickness may be measured, for example, by skin ultrasound, skin calipers or any other method.

[0018] Increased lymphatic flow and / or vascular function can be measured, for example, by lymphoscintigraphy and / or indocyanine green lymphography.

[0019] In some aspects, the lymphedema is secondary lymphedema, including but not limited to, in patients who have previously undergone surgery and radiation therapy for cancer. In some instances, the cancer is a solid tumor. In one instance, the patient suffers from breast cancer treatment associated with upper extremity lymphedema. In another instance, the patient suffers from head and neck region lymphedema.

[0020] In some embodiments, the method comprises administering a selective LTA4H inhibitor.A selective LTA4H inhibitor is a drug or compound that has higher selectivity for inhibiting LTA4H than other aminopeptidase enzymes and / or a drug that has higher selectivity for inhibiting the epoxide hydrolase activity of LTA4H than the aminopeptidase activity of LTA4H.In the context of LTA4H inhibitors, selectivity refers to the ability of inhibition.For example, an LTA4H inhibitor has an IC50 value for epoxide hydrolase inhibition. 50 IC for aminopeptidase activity 50 In one embodiment, the LTA4H inhibitor is at least about 2-fold selective for LTA4H over other aminopeptidase enzymes, including but not limited to the group of aminopeptidase N, aminopeptidase M, aminopeptidase P, leucine aminopeptidase, etc. In another embodiment, the LTA4H inhibitor is at least about 1.5-fold selective for inhibiting epoxide hydrolase activity over inhibiting aminopeptidase activity of LTA4H. In a further aspect, the LTA4H inhibitor is at least about 1.5- or about 2-fold selective for inhibiting epoxide hydrolase activity of LTA4H over inhibiting aminopeptidase activity of LTA4H. In still further embodiments, the LTA4H inhibitor is at least 2-fold selective for LTA4H over other aminopeptidases and greater than about 1.5-fold selective for the epoxide hydrolase activity over the aminopeptidase activity of LTA4H.

[0021] The present invention also includes a method of reducing the incidence of soft tissue infections, such as cellulitis, in a patient with lymphedema comprising administering acevirstat or other selective LTA4H inhibitors.

[0022] In one aspect, the method includes administering to the patient an effective amount of acevirstat. For example, acevirstat can be administered at least once a day, for example orally. In one embodiment, the method includes orally administering to the patient acevirstat at a total daily dose of about 200 mg or less, about 150 mg or less, about 100 mg or less, about 50 mg or less, about 50 mg to about 100 mg, about 100 mg, or about 50 mg.

[0023] In other aspects, the methods include local administration of acevirstat or other selective LTA4H inhibitors. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0024] Detailed Description of the Invention A description of preferred embodiments of the invention follows.

[0025] As used herein, the words "a" and "an" mean to include one or more unless otherwise specified. For example, the term "an additional therapeutic agent" encompasses both a single additional therapeutic agent and a combination of two or more additional therapeutic agents.

[0026] When a range of doses or amounts of a drug or active ingredient (e.g., acevirstat) is described as "between" the lower limit of the range and "between" the upper limit of the range, it is understood that the range is intended to include both the lower limit and the upper limit, and the doses between the lower limit and the upper limit. For example, for a "dose of about 50 mg to about 100 mg," the range is understood to include a lower limit of the range of about 50 mg and an upper limit of the range of about 100 mg, as well as doses in between, such as about 75 mg. Also, a "dose of about 50 mg or less" is intended to include a dose of about 50 mg and a dose less than about 50 mg.

[0027] The term "about" as used herein in reference to a numerical value or range allows for a degree of variability in the value or range, for example, within 10%, within 5%, or within 4% of the value or range, or within 2% or within 1% of the value or range.

[0028] The present invention relates to the use of acevirstat and other selective LTA4H inhibitors to inhibit the enzymatic production of LTB4 in lymphedema patients, e.g., patients with upper extremity lymphedema, thereby reversing the pathological skin stigmata of the disease that causes morbidity, loss of function and quality of life.

[0029] As used herein, lymphedema is edema of an area or areas of the body due to abnormalities in lymphatic development (primary lymphedema) or obstruction, disturbance or dysfunction of lymphatic vessels (secondary or acquired lymphedema). Symptoms and signs may include varying degrees of firm, fibrous, nonpitting edema in one or more areas of the body.

[0030] Primary lymphedema is constitutional and relatively less common than secondary forms. They vary in phenotype and patient age at presentation. The methods of the present invention are applicable to these primary forms, but it will be understood by those skilled in the art that treatment may be more effective in some forms than others due to different disease etiology. Primary forms of lymphedema include, but are not limited to, Milroy's disease, Meige's disease, (primary lymphedema), lymphedema distichiasis, lymphedema tarda, etc., as well as other genetic syndromes with prominent lymphedema, such as Turner's syndrome and Hennekam's syndrome. For example, congenital lymphedema may appear at birth or within a few months thereafter and may be due to lymphatic hypoplasia or aplasia. Milroy's disease is an autosomal dominant familial form of congenital lymphedema caused by FLT4 gene mutations and associated with edema and sometimes diarrhea and / or hypoproteinemia due to protein-losing enteropathy caused by intestinal lymphatic dilation. Lymphoedema tarda is an autosomal dominant familial form of primary lymphedema caused by mutations in a transcription factor gene (FOXC2) and associated with excess eyelashes (distichiasis) and edema of the legs, arms, and sometimes the face. Lymphoedema tarda occurs after aging. 35Both familial and sporadic forms exist; the genetic basis for both is unknown. Clinical findings are similar to those of primary lymphedema, but may be less severe. Hereditary lymphedema type II (Meige's disease, primary lymphedema) develops around puberty or shortly thereafter in most individuals. It is the most common type of primary lymphedema. In addition to lymphedema of the limbs, other areas of the body may be affected, such as the arms, face, and larynx. Some individuals may develop yellow nails. Lymphedema is prominent in several other genetic syndromes, such as Turner's syndrome; yellow nail syndrome, characterized by pleural effusion, chronic lung disease, lymphedema, and yellow nails; and Hennekam's syndrome, a rare congenital syndrome of generalized lymphatic abnormalities, facial deformities, and intellectual disability. The methods and compositions of the present invention may be used to treat any of these primary lymphedemas and their symptoms.

[0031] Secondary (acquired) lymphedema is much more common than primary lymphedema.It is generally caused by surgery (especially lymph node dissection, typically for cancer staging and treatment), radiation therapy (especially in the axilla or groin), trauma, lymphatic obstruction by tumor, and in developing countries, lymphatic filariasis.In some aspects, the methods described herein are used to treat secondary lymphedema.

[0032] In certain embodiments, the method includes treating patients with established secondary lymphedema, for example as a result of cancer treatment. It is estimated that more than 15% of breast cancer survivors experience secondary lymphedema. Surgical removal of lymph nodes or therapeutic radiation of lymph nodes increases the risk of lymphedema. After axillary intervention, 15%-30% of breast cancer survivors experience clinically relevant lymphedema, but other types of cancer and their associated treatments may also cause secondary lymphedema. The prevalence of lymphedema associated with other malignancies (cancers) was as follows: soft tissue sarcoma 30%, lower extremity melanoma 28%, gynecological cancer 20%, genitourinary cancer 10% and head and neck cancer 3%. Lymphedema may also result from increased lymph production in patients with chronic venous insufficiency, congestive heart failure and other causes of venous hypertension. The method of the present invention is applicable to all such patients with secondary lymphedema. In one aspect, the method relates to the treatment of acromymphedema. In a further aspect, the invention relates to the treatment of acromymphedema following breast cancer treatment (referred to herein as breast cancer treatment-related acromymphedema). In a further aspect, the lymphedema is associated with head and neck cancer.

[0033] The cardinal sign of acquired lymphedema is soft tissue edema, which is graded in four stages. The term "established lymphedema" may generally refer to any of stages 1-3 of the disease, including, but not limited to, more advanced stages of the disease, such as stages 2 and 3, where structural changes in the affected tissues are observed. In stage 0, the affected area is physically normal, but clinical evaluation may show lymphatic insufficiency. In stage 1, the edema is pitted, and the affected area often returns to normal after the elevation of the affected limb(s). In stage 2, the edema is pitted, and chronic soft tissue inflammation causes structural changes in the tissues with pitted edema. In stage 3, the edema is thickened and irreversible due to large chronic soft tissue structural changes.

[0034] Acevirstat and other LTA4H inhibitors are described, for example, in U.S. Patent No. 7,737,145, U.S. Patent No. 9,820,974 and U.S. Patent Application Publication No. 20100210630A1, the contents of each of which are incorporated herein by reference. The chemical name of acevirstat is 4-{[(1S,4S)-5-({4-[4-oxazol-2-yl-phenoxy]phenyl}methyl)-2,5-diazabicyclo[2.2.1]heptan-2-yl]methyl}benzoic acid (also called CTX-4430). Acevirstat is a potent inhibitor of leukotriene A4 hydrolase (LTA4H), which is the rate-limiting enzyme in the production of leukotriene B4 (LTB4).

[0035] The method of the present invention comprises administering an effective dose of acevirstat (also known as CTX-4430) to a human patient. In some aspects, acevirstat is administered orally. This compound and the method for its preparation are described in detail in U.S. Patent No. 7,737,145, U.S. Patent No. 9,820,974 and U.S. Patent Application Publication No. 20100210630A1, the contents of each of which are incorporated herein by reference. Acevirstat has the chemical structure shown below: [ka]

[0036] In vitro, acevirstat had an IC50 value of 6.3 ng / mL for LTB4 production. 50 In human whole blood tested ex vivo, acevirstat has an approximate IC of 30.8 ng / mL. 50 Acebilstat 48 ng / mL has also been shown to reduce neutrophil swarming by 80% in vitro in response to factors present in human cystic fibrosis (CF) sputum. In pharmacodynamic studies in humans, acebilstat has an estimated in vivo EC 50In CF patients, acevirstat inhibits LTB4 production at 10 mg / kg / day. In CF patients, sputum leukocytes decreased by 31% from baseline in all treated subjects (50 or 100 mg doses) and by 60% from baseline in the 100 mg acevirstat group. Sputum neutrophils decreased by 34% in all treated patients (50-100 mg doses) and by 65% ​​in the 100 mg group. In a recent Phase II study of adult patients with CF, acevirstat showed promise in reducing the rate of pulmonary exacerbations over the course of 48 weeks of treatment without evidence of increased risk of infection (e.g., as described in U.S. Pat. No. 10,898,484; the contents of which are expressly incorporated herein by reference). This effect was most pronounced in patients with early stage disease.

[0037] In some examples, the effective amount of acevirstat administered orally can be 200 mg or less. Thus, the present invention encompasses oral administration of about 200 mg or less of acevirstat to a patient. In some aspects, a patient is administered 200 mg of acevirstat; for example, chronic oral administration (e.g., for more than about 1 day, at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 1 month, at least about 2 months, at least about 3 months, at least about 4 months, at least about 5 months, or at least about 6 months, or 24 weeks and / or throughout the patient's treatment). The present invention encompasses oral administration of about 100 mg of acevirstat to the patient; for example, chronic oral administration (e.g., for more than about 1 day, at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 1 month, at least about 2 months, at least about 3 months, at least about 4 months, at least about 5 months, or at least about 6 months, or 24 weeks and / or throughout the patient's treatment). The present invention also encompasses administration of 50 mg of acevirstat to the patient; for example, chronic oral administration (e.g., for at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 1 month, at least about 2 months, at least about 3 months, at least about 4 months, at least about 5 months, or at least about 6 months or 24 weeks and / or throughout the treatment of the patient). Acevirstat can be administered, for example, at a dose of about 50 mg every 12 or 24 hours (or once or twice a day) or at a dose of about 100 mg every 12 or 24 hours (or once or twice a day). In some aspects, acevirstat is administered at a dose of 100 mg every 24 hours (or once a day). The total daily dose of acevirstat can be about 200 mg or less, about 100 mg or less, or about 50 mg or less. The total daily dose of acevirstat can be 100 mg to 200 mg, for example, about 150 mg. The total daily dose of acevirstat can be about 50 mg to about 100 mg, for example about 75 mg. In some aspects, the dose of acevirstat is administered at a dose of about 25 mg once or twice a day, or at a dose of about 25 to 50 mg once or twice a day. Acevirstat can be administered with or without food.

[0038] In some aspects, an effective amount of acebilstat or other selective LTA4H hydrolase inhibitor is administered in an effective amount, and the effective amount is less than that which provides the maximum inhibition of LTA4H epoxide hydrolase activity.In some examples, the effective amount can provide at least about 50%, at least about 60%, at least about 70%, at least about 80% or about at least about 85% inhibition of LTA4H epoxide hydrolase activity, such as at least about 50%, at least about 60%, at least about 70%, at least about 80% or at least about 85% inhibition of LTB4 production.For example, in human pharmacodynamics test, it has been shown that 50mg dose of acebilstat provides 63% or more of LTB4 inhibition, 100mg dose of acebilstat provides about 74% or more of LTB4 inhibition, 150mg dose of acebilstat provides about 82% or more of LTB4 inhibition, and 200mg dose of acebilstat provides about 85% or more of LTB4 inhibition.

[0039] In a further aspect, acevirstat or other selective LTA4 hydrolase inhibitors are administered locally.

[0040] The present invention also includes a method in which acebilstat or other selective LTA4 hydrolase inhibitors are administered by pulsatile administration or acebilstat is in a pulsatile release pharmaceutical composition. Pulsatile administration includes administration or release of an active agent or drug after a predetermined release-free or delayed period. Thus, pulsatile administration can include rapid and complete drug delivery after a period of drug-free release. For example, the concentration of the active agent or drug in plasma is reduced to less than about 50% inhibition of LTA4H activity or less than about 50% of LTB4 production before the next dose is administered. Acebilstat or other selective LTA4H inhibitors can also be administered in a controlled release, sustained release and / or delayed release manner. Acebilstat or other selective LTA4H inhibitors can also be administered in a controlled release formulation, such as a sustained release formulation and / or delayed release formulation. "Controlled release" refers to a drug-containing formulation or unit dosage form thereof in which the release of the drug is not immediate, i.e., using a controlled release formulation, and administration does not result in the immediate release of all of the drug administered to the absorption pool. The term is used interchangeably with "non-immediate release" as defined in Remington: The Science and Practice of Pharmacy, Nineteenth Ed. (Easton, Pa.: Mack Publishing Company, 1995). In general, controlled release formulations include sustained release and delayed release formulations. "Sustained release" and "extended release" refer to drug formulations that provide a gradual release of drug over an extended period of time, typically, but not necessarily, resulting in a substantially constant blood level of drug over an extended period of time. "Delayed release" refers to drug formulations that provide a measurable delay in time before drug is released from the formulation into the patient's body after administration to the patient.

[0041] Treatment may include administration of the same dose and / or dosing regimen throughout the treatment of the patient.The method may also include maintenance therapy, including an initial dose(s) of acevirstat or other selective LTA4H inhibitor, followed by one or more maintenance doses, where the one or more maintenance doses are different from the initial dose.For example, the one or more maintenance doses may be lower than the initial dose and / or less frequent than the initial dosing regimen.In another example, the one or more maintenance doses may be higher than the initial dose and / or more frequent than the initial dosing regimen.

[0042] Treatment may be initiated (e.g., an initial dose may be administered) for example, immediately or within one week or one to three days after surgery. Treatment may also be initiated after surgical wound healing is complete, or immediately or within one week or one to three days after the initiation of radiation therapy or cancer treatment, or at a time prior to the onset or diagnosis of stage 0 lymphedema. Treatment may also be initiated after the onset or diagnosis of stage 0 lymphedema or after the onset or diagnosis of clinically evident lymphedema.

[0043] The present invention also encompasses a method of treating lymphedema using a selective LTA4H inhibitor other than acevirstat. LTA4H is an epoxide hydrolase that generates LTB4 from LTA4. Since LTB4 is a proinflammatory mediator, inhibiting LTA4H activity inhibits the production of proinflammatory LTB4. LTA4H is also an aminopeptidase that degrades the tripeptide Pro-Gly-Pro (PGP), a neutrophil chemoattractant (Low et al. (2017), Scientific Reports 7, 44449 (2017). https: / / doi.org / 10.1038 / srep44449; the contents of which are expressly incorporated herein by reference). The accumulation of PGP is associated with proinflammatory effects. Thus, LTA4H plays an important anti-inflammatory role in the degradation of PGP, which is paradoxical to its proinflammatory epoxide hydrolase activity. The present invention is based, at least in part, on the discovery that lymphedema, such as secondary lymphedema, can be advantageously treated using selective LTA4H inhibitors, such as acevirstat.Selective LTA4H inhibitors are agents or compounds that have higher selectivity for LTA4H than other aminopeptidase enzymes and / or agents that have higher selectivity for the epoxide hydrolase activity of LTA4H than the aminopeptidase activity of LTA4H.In the context of LTA4 inhibitors, selectivity refers to the ability to inhibit.For example, LTA4H inhibitors have IC50 for epoxide hydrolase inhibition. 50 IC for aminopeptidase activity 50 In another example, an LTA4H inhibitor is selective for the epoxide hydrolase activity of LTA4H over the aminopeptidase activity of LTA4H when the IC for the LTA4H inhibitor is less than 50 IC for other aminopeptidases 50When the epoxide hydrolase activity of LTA4H is lower than that of other aminopeptidases, the selective LTA4H inhibitor is more selective than the aminopeptidase activity of LTA4H for the inhibition of LTA4H. The selective LTA4H inhibitor is more selective than the aminopeptidase activity of LTA4H for the epoxide hydrolase activity of LTA4H, and inhibits the production of LTB4 while having minimal effect on PGP degradation. Acebilstat is a selective LTA4H inhibitor that is more selective than the aminopeptidase activity of LTA4H for the epoxide hydrolase activity of LTA4H and is more selective than aminopeptidase inhibition for LTA4H inhibition. Specifically, acebilstat has a two-fold preference for the inhibition of epoxide hydrolase activity over aminopeptidase activity (Bhatt et al. (2017), Seminars in Immunology 33: 65-73; the contents of which are expressly incorporated herein by reference). Specifically, Bhatt et al. teach that acevirstat shows a 2-fold functional selectivity for LTA4H epoxide hydrolase (12nM) versus LTA4H aminopeptidase (27nM), and is highly selective for LTA4H versus other metalloenzymes.In contrast, some other LTA4H inhibitors, such as SC567461A (Searle / Pharmacia), DG-051 (DeCODE Pharmaceuticals) and JNJ-40929837 (Johnson and Johnson), have similar abilities to inhibit LTB4 production and PGP degradation, and thus may have proinflammatory effects by causing PGP accumulation.Such inhibitors are referred to herein as "non-selective LTA4H inhibitors". Ubenimex is a non-selective LTA4H inhibitor and a broad-spectrum aminopeptidase inhibitor (Bhatt et al. (2017); Inoi et al. (1995), Anticancer Res. 15(5B): 2081-2087; the contents of which are expressly incorporated by reference herein).

[0044] IC of LTA4H epoxide hydrolase activity 50can be measured using methods known in the art, for example, using the LTA4 hydrolase homologous time-resolved fluorometric assay described in U.S. Pat. Nos. 7,737,145 and 10,202,362, the contents of which are expressly incorporated herein by reference. The hydrolase homologous time-resolved fluorometric assay is a two-step assay that measures the hydrolysis of LTA4 to LTB4 by analyzing the amount of LTB4 produced. The first step involves the enzymatic conversion of LTA4 to LTB4, and the second step involves the quantification of the LTB4 formed by a homologous time-resolved fluorometric assay. LTA4H epoxide hydrolase activity can also be measured in a whole blood assay, for example, using human whole blood, using the methods described in Penning, TD et al., J. Med. Chem. (2000), 43(4): 721-735 and U.S. Pat. No. 7,737,145, the contents of each of which are expressly incorporated herein by reference. In a whole blood assay, inhibitor compounds are tested for their ability to inhibit LTB4 release upon stimulation with calcium ionophore, and LTB4 levels in the supernatant are measured by ELISA. LTA4H epoxide hydrolase activity can also be measured according to the method described in Low et al. (2017). IC for LTA4H aminopeptidase activity 50can be measured using methods known in the art, such as those described in Kull et al., The Journal of Biological Chemistry 274(49): 34683-34690, U.S. Pat. No. 10,202,362, and / or Low et al. (2017), the contents of each of which are expressly incorporated by reference herein. Other methods for measuring LTA4H epoxide hydrolase activity and / or LTA4H peptidase activity are described, for example, in Askonas, LJ, et al., The Journal of Pharmacology and Experimental Therapeutics 2002, 300(2): 577-582; Penning, TD, J. Med. Chem. 2000, 43(4): 721-735; Kull, F. et al., The Journal of Biological Chemistry 1999, 274 (49): 34683-34690, the contents of which are expressly incorporated by reference herein.

[0045] The present invention includes a method for treating lymphedema, comprising administering an effective amount of a selective LTA4H inhibitor to a patient in need of lymphedema treatment.The selective LTA4H inhibitor may have, for example, at least about 1.5-fold or at least about 2-fold higher selectivity for the epoxide hydrolase activity of LTA4H over the aminopeptidase activity of LTA4H.The selective LTA4H inhibitor may additionally or alternatively have at least about 1.5-fold, at least about 2-fold, at least about 2.5-fold, at least about 3-fold, at least about 5-fold, or at least about 10-fold higher selectivity for LTA4H than other aminopeptidases.In yet another embodiment, the LTA4H inhibitor is at least about 2-fold more selective for LTA4H than other aminopeptidases, and is more than about 1.5-fold more selective for epoxide hydrolase activity than the aminopeptidase activity of LTA4H. The LTA4H inhibitor may also be at least about 2.5-fold, at least about 3-fold, at least about 5-fold, or at least about 10-fold selective for epoxide hydrolase activity over the aminopeptidase activity of LTA4H. In still further embodiments, the LTA4H inhibitor is at least about 2-fold selective for LTA4H over other aminopeptidases, and more than about 2-fold selective for epoxide hydrolase activity over the aminopeptidase activity of LTA4H. Selective LTA4H inhibitors include, for example, acevirstat. Other selective LTA4H inhibitors are described in Low et al., including compounds having a resveratrol core as described therein. Non-limiting examples of LTA4H inhibitors include, for example, cis-resveratrol, trans-resveratrol, the isoflavone daidzein, and 7,8,4'-trihydroxyisoflavone. Further non-limiting examples of LTA4H inhibitors are shown in the following table: [Table 1] [Table 2] [Table 3]

[0046] In some embodiments, an effective dose of acevirstat is administered to an individual with lymphedema, including but not limited to established lymphedema, for a time sufficient to reduce or reverse the histopathology of affected (lymphadematous) tissues compared to untreated controls. Treatment may be continued as required to maintain therapeutic benefit: if required, maintenance therapy may be maintained at the same dose and schedule as the previous treatment or may be achieved by transitioning to an alternative maintenance schedule, e.g., at a lower dose, less frequent dose, etc. In some embodiments, the treating physician may determine that the treatment is effective by verifying changes in the structure of the affected tissue. The tissue may be assayed by any number of means described herein to verify the therapeutic benefit when visual inspection alone is insufficient. While a convenient measure of efficacy in some applications is skin thickness, those skilled in the art will understand upon conception of the present disclosure that a variety of signs may be used to monitor the treatment and determine efficacy. Additional methods for determining whether a treatment is effective include lymphoscintigraphy and indocyanine green (ICG) lymphography.

[0047] In some embodiments, an effective dose of acevirstat or other selective LTA4H inhibitor is provided to an individual suspected of having lymphedema, such as, but not limited to, an individual who has undergone surgery or radiation for cancer. In a further aspect, the lymphedema is secondary or acquired lymphedema.

[0048] In other embodiments, the invention relates to methods of treating lymphedema, where a patient has lymphedema (stages 0-3) as a result of cancer treatment, such as surgery or radiation therapy or other therapy that damages the lymphatic system. In some embodiments, the individual has been treated with surgery, typically as a result of cancer diagnosis and treatment, but other surgeries that affect lymph nodes may cause lymphedema treatable according to the invention. In such embodiments, treatment with acebilstat or other selective LTA4H inhibitors may be initiated immediately after surgical wound healing, or may be initiated at a time after surgical wound healing has occurred, such as after some or even substantial wound healing has occurred, for example 3-14 days after surgery, but before the patient is diagnosed with stage 0 lymphedema. In still further aspects, the patient may be treated with radiation therapy, itself followed by surgery for cancer treatment. In such embodiments, treatment with acevirstat or other selective LTA4H inhibitors may be initiated during radiation therapy, immediately after radiation therapy, or may begin at a time after radiation therapy, such as after some or even substantial wound healing has occurred as described above, but before the patient is diagnosed with stage 0 lymphedema.

[0049] The present invention includes a method of treating acromymphedema in a patient following cancer surgery and / or radiation therapy. The present invention further includes a method of treating acromymphedema in a patient following breast cancer surgery and / or radiation therapy. Arm or upper extremity lymphedema is caused by interruption of the axillary lymphatic system, due to surgery or radiation therapy, resulting in the accumulation of fluid in the subcutaneous tissue of the arm.

[0050] The present invention also includes a method of preventing or inhibiting the progression of lymphedema in a treated individual who is being treated or has been treated for cancer, but has not yet developed lymphedema. The present invention may also be practiced in other preventative formats, such as after successful treatment. Some patients may be treated according to the present invention and obtain a complete or significantly complete recovery, and will not benefit from further treatment. However, other patients may benefit from continued administration of acevirstat or other selective LTA4H inhibitors after successful treatment to prevent disease recurrence. Thus, for prophylactic purposes of lymphedema prevention, after treatment with the method of the present invention, the structure of the skin of the affected patient, for example, the skin of the extremities, will maintain a substantially normal structure, consistent with successful treatment. After prophylactic treatment with the method of the present invention, the volume of tissue, for example, upper extremities, lower extremities, etc., should be stable over time, compared to a control group in the absence of treatment. The time to see treatment benefit may be about 1 week, about 2 weeks, about 3 weeks, about 1 month, about 2 months, about 3 months, about 4 months, or more. In some embodiments, the volume and / or structure of diseased or at-risk tissue, i.e., lymphedematous tissue, is measured or otherwise assayed or evaluated at various times over time, for example, at least at the beginning and at some designated end points for the study.In some embodiments, the structure of diseased tissue is assayed by measuring skin thickness or by histological evaluation; the absence of lymphedema can be confirmed by serial measurement of limb bioimpedance.The effect on the lymphatic system can also be evaluated, for example, using lymphoscintigraphy and / or indocyanine green lymphography.In some embodiments, the structure of diseased tissue after treatment resembles or more closely resembles the structure of unaffected tissue.

[0051] Acevirstat can be administered to patients with knowledge of their current treatment regimen or with knowledge of the standard of care. Standards of care for the treatment of lymphedema include, but are not limited to, diuretics, antibiotics, exercise, manual lymphatic drainage, compression bandages and compression garments. The method of the present invention can also include administration of a therapeutically effective amount of at least one additional active agent other than an LTA4H inhibitor. The additional agent can be selected from the group consisting of, for example, selective COX-1 inhibitors, selective COX-2 inhibitors, non-selective COX-1 / COX-2 inhibitors, coumarins, antihistamines, montelukast and other related leukotriene inhibitors, antifibrotic compounds, diuretics, statins, mTOR inhibitors and pirfenidone. In certain aspects, the additional agent can be selected from the group consisting of, for example, selective COX-1 inhibitors, selective COX-2 inhibitors, non-selective COX-1 / COX-2 inhibitors, coumarins, antihistamines, antifibrotic compounds, diuretics, statins, mTOR inhibitors, and pirfenidone. Non-limiting examples of non-selective COX-1 / COX-2 inhibitors include salicylic acid derivatives such as aspirin, sodium salicylate, choline magnesium trisalicylate, salsalate, diflunisal, sulfasalazine and olsalazine; para-aminophenol derivatives such as acetaminophen, indole and indene acetic acids such as indomethacin and sulindac, heteroaryl acetic acids such as tolmetin, diclofenac and ketorolac, arylpropionic acids such as ibuprofen, naproxen, flurbiprofen, ketoprofen, fenoprofen and oxaprozin, anthranilic acids (fenamates) such as mefanamic acid and meclofenamic acid, enolic acids such as oxicams such as piroxicam and meloxicam and alkanones such as nabumetone, and pharma- ceutically active esters, salts, isomers, conjugates and prodrugs thereof. In yet a further aspect, the non-selective COX-1 / COX-2 inhibitor is a propionic acid derivative, such as ketoprofen.Selective COX-2 inhibitors include, for example, celecoxib.Non-limiting examples of diuretics are furosemide, torasemide and hydrochlorothiazide, recombinant angiotensin converting enzyme-2 and acetylsalicylic acid. Statins include, for example, atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin and / or ezetimibe / simvastatin combination. mTOR inhibitors include, for example, rapamycin, everolimus and sirolimus and rapalogs. Antifibrotic agents include, for example, the following non-limiting examples: pirfenidone, transforming growth factor beta (TGFβ) inhibitors, such as galunisertib, and connective tissue growth factor (CTGF) inhibitors, such as FG-3019. The additional active agent may also be any other agent used in the treatment of lymphedema and / or pro-lymphangiogenic drugs, such as retinoic acid (such as 9-cis retinoic acid). In another example, the additional active agent is a drug, such as a biologic or small molecule that targets and / or inhibits anti-lymphangiogenic growth factors or cytokines, such as, but not limited to, anti-TGF-β1 antibodies, anti-IFN-γ antibodies, anti-IL-4 antibodies, and anti-IL-13 antibodies. For example, the additional agent can be an antibody (e.g., a monoclonal antibody) that targets and / or inhibits anti-lymphangiogenic growth factors or cytokines, such as, but not limited to, anti-TGF-β1 antibodies, anti-IFN-γ antibodies, anti-IL-4 antibodies, and anti-IL-13 antibodies. The antibody can be one that targets one or more anti-lymphangiogenic growth factors or cytokines, such as, but not limited to, dupilumab (a monoclonal antibody that inhibits IL-4 and IL-13) and pascolizumab (a humanized anti-IL-4 monoclonal antibody). The additional agent can also be pitrakinra, a human recombinant protein that is an antagonist of IL-4 and IL-13.

[0052] The present invention also provides pharmaceutical formulations comprising acevirstat or other selective LTA4H inhibitors and additional active agents, such as selective COX-1 inhibitors, selective COX-2 inhibitors, non-selective COX-1 / COX-2 inhibitors, coumarins, antihistamines, montelukast and related leukotriene modifiers, antifibrotic compounds, diuretics, statins, mTOR inhibitors and pirfenidone. In another aspect, the pharmaceutical formulation comprises acevirstat or other selective LTA4H inhibitors and additional active agents selected from selective COX-1 inhibitors, selective COX-2 inhibitors, non-selective COX-1 / COX-2 inhibitors, coumarins, antihistamines, antifibrotic compounds, diuretics, statins, mTOR inhibitors and pirfenidone. The present invention also includes methods of treating lymphedema, including combination therapy, in which a patient in need of treatment is administered an effective dose of acevirstat or other selective LTA4H inhibitors in combination with one or more drugs or other therapies approved or used in the treatment of lymphedema and / or pro-lymphangiogenic agents, such as retinoic acid (e.g., 9-cis retinoic acid, etc.). The present invention further includes methods of treating lymphedema, including combination therapy, in which a patient in need of treatment is administered an effective dose of acevirstat or other selective LTA4H inhibitors in combination with one or more additional active agents (e.g., biologics or small molecules) that target and / or inhibit anti-lymphangiogenic growth factors or cytokines, such as, but not limited to, anti-TGF-β1 antibodies, anti-IFN-γ antibodies, anti-IL-4 antibodies, and anti-IL-13 antibodies. For example, the additional agent may be an antibody (e.g., a monoclonal antibody) that targets and / or inhibits anti-lymphangiogenic growth factors or cytokines, such as, but not limited to, anti-TGF-β1 antibodies, anti-IFN-γ antibodies, anti-IL-4 antibodies, and anti-IL-13 antibodies. The antibody may be one that targets one or more anti-lymphangiogenic growth factors or cytokines, such as, but not limited to, dupilumab (a monoclonal antibody that inhibits IL-4 and IL-13) and pascolizumab (a humanized anti-IL-4 monoclonal antibody). The additional agent may also be pitrakinra, a human recombinant protein that is an antagonist of IL-4 and IL-13.

[0053] In yet another aspect, acevirstat or other selective LTA4H inhibitor is administered in combination with one or more other drugs useful in preventing or treating lymphedema.In some of these embodiments, acevirstat or other selective LTA4H inhibitor is administered with a different LTB4 inhibitor.For example, the different LTB4 inhibitor can be a BLT1 / BLT2 antagonist class of LTB4 inhibitor.

[0054] It is understood that when acevirstat or other selective LTA4H inhibitors are co-administered with at least one additional active agent (e.g., selective COX-1 inhibitors, selective COX-2 inhibitors, non-selective COX-1 / COX-2 inhibitors, coumarins, antihistamines, montelukast and related leukotriene modifiers, antifibrotic compounds, diuretics, statin mTOR inhibitors and pirfenidone, and / or other therapeutic agents such as retinoic acid, and / or agents targeting one or more anti-lymphangiogenic growth factors or cytokines), acevirstat or other selective LTA4H inhibitors may be administered simultaneously with, before or after the administration of one or more additional active agents. Such combination therapy includes administration of a single pharmaceutical dosage formulation containing acevirstat or other selective LTA4H inhibitors and one or more additional active agents, as well as administration of acevirstat and each active agent in its own separate pharmaceutical dosage formulation.

[0055] Acebilstat or other selective LTA4H inhibitors may continue to be administered if it is determined that the treatment is effective.The method may include maintaining, tapering, reducing or stopping the dosage of acebilstat or other selective LTA4H inhibitors in treatment if it is determined that the treatment is effective.The method may include increasing the dosage of acebilstat or other selective LTA4H inhibitors in treatment if it is determined that the treatment is not effective or if the dosage is increased in daily amount or through a change in administration schedule, it may be more effective.Alternatively, the method may include stopping treatment if it is determined that the treatment is not effective.

[0056] For example, treatment may begin at any time after the onset of stage 0 lymphedema, e.g., treatment stabilizes or reverses the patient's condition to an asymptomatic state. Treatment with the methods of the invention may begin, e.g., after the onset of any clinically evident lymphedema, e.g., stage 1. Treatment with the methods of the invention may also begin, e.g., after the onset of stage 2 lymphedema. Treatment with the methods of the invention may begin after the onset of stage 3 lymphedema. Treatment may also begin before the onset of stage 0 lymphedema, but after surgery, radiation therapy or other medical intervention that increases the risk of developing lymphedema.

[0057] Swelling, which may accompany disease progression, may be unilateral or bilateral and may worsen when the weather is warm, before menstruation occurs, after physical exertion and / or after the limb is left in a hanging position for a long period of time. Swelling may affect any part of the limb (isolated proximal or distal) or the entire limb, or the face, head and neck, trunk, chest or genitalia; swelling may limit range of motion. Disability and emotional distress may be significant, especially when lymphedema results from medical or surgical procedures. Skin changes are common and include hyperkeratosis, hyperpigmentation, lichenification, warts, papillomas and fungal infections. Methods of the invention include methods of treating any and all of these conditions and symptoms, for example, but not limited to, by administration of acebilstat as described herein.

[0058] Lymphangitis or cellulitis may develop, for example, when bacteria pass through the skin barrier, which is compromised in lymphedema. Cellulitis in lymphedema may be characterized by only very subtle changes in the limb and may be difficult to diagnose or eradicate. Lymphangitis is frequently streptococcal, resulting in erysipelas; sometimes it is staphylococcal. The affected limb becomes red and feels hot; red streaks may extend proximally from the point of entry, and lymphadenopathy may develop. Rarely, the skin breaks down. Rarely, long-lasting lymphedema causes lymphangiosarcoma (Stuart-Treves syndrome), usually in mastectomy patients and patients with filariasis. The methods of the present invention include methods of treating any and all of these conditions and symptoms, for example, but not limited to, by administration of acebilstat as described herein.

[0059] Without treatment, cell hyperproliferation, fat deposition and fibrosis promote progressive anatomical distortion and loss of function of the affected area. Furthermore, impaired transport of antigen-presenting cells in lymph impedes local immune surveillance of lymphedematous area(s) to draining lymph nodes. Thus, there is chronic inflammation, infection and skin hardening, which then leads to further lymphatic damage and distortion of the shape of the affected body part. Furthermore, there is a high degree of dysfunction due to physical factors such as reduced movement size, increased weight of the extremities, increased pain and reduced joint mobility that causes impaired ability to perform daily tasks. The methods of the present invention include methods of treating any and all of these conditions and symptoms, for example, but not limited to, by administration of acebilstat or other selective LTA4H inhibitors as described herein.

[0060] Pathological skin changes associated with lymphedema include cellularity of the skin layers, accumulation of glycoproteins, loss of elasticity, and an increase in the subcutaneous fat layer. The methods of the present invention include methods of treating any and all of these conditions and symptoms, for example, but not limited to, by administration of acevirstat or other selective LTA4H inhibitors described herein.

[0061] Thus, those skilled in the art will appreciate that the methods of the present invention are applicable to the treatment and prevention of lymphedema, including its signs and symptoms, such as those associated with the following clinical signs of lymphedema. Some clinical signs can be used to diagnose lymphedema and monitor the effectiveness of treatment, including treatment with the compositions and methods of the present invention. The present invention provides a method for determining the effectiveness of lymphedema treatment in a subject in need of lymphedema treatment by (a) measuring an endpoint of a clinical indicator in a patient, where the endpoint is measured after treatment has begun, (b) comparing the endpoint of the clinical indicator with a baseline or reference, where the baseline or reference is measured in the same subject or a similar subject population before treatment has begun, and (c) determining the effectiveness of lymphedema treatment based on the comparison step.

[0062] Analysis of clinical signs may include measurements of skinfold thickness; changes in lymphedema volume in the legs / arms / hands; changes in fluid stagnation at shoulder / trunk level; changes in extracellular fluid in the arms; changes in thickness and reflexivity of the cutis and subcutis of the arms / shoulders / trunk; changes in elasticity of the skin and subcutaneous tissue of the arms; changes in lymphatic structure and function; changes in venous circulation in the arms / trunk; and the number of episodes of cellulitis.

[0063] When imaging is used to diagnose lymphedema or assess disease state or progression, the most common modality for diagnosis is indirect radionuclide lymphoscintigraphy. This procedure involves the use of a suitable radiolabeled tracer, e.g. 99m Tc-Antimony Sulfide Colloid or 99mIt requires subcutaneous injection of Tc-labeled human serum albumin. The criteria for the diagnosis of lymphatic dysfunction include: (1) delayed, asymmetric, or absent visualization of regional lymph nodes; (2) asymmetric visualization of lymphatic channels; (3) collateral lymphatic channels; (4) cutaneous reflux; (5) interrupted vasculature; and (6) visualization of lymph nodes in the deep lymphatic system. The presence of "cutaneous reflux" is considered abnormal. It is interpreted as indicating extravasation of lymphatic fluid from lymphatic vessels into the interstitial spaces as a result of lymphatic and / or venous hypertension. Besides lymphoscintigraphy, magnetic resonance imaging and computed axial tomography have clinical utility. These imaging techniques allow for objective documentation of the structural changes caused by lymphedema. Recent advances in magnetic resonance approaches have improved visualization of lymphatic abnormalities in both unenhanced and contrast-enhanced applications (see, e.g., Pankaj et al. (2013) World J Surg Oncol. 2013; 11: 237). As an alternative, bioelectrical impedance, which uses frequency-dependent current flow characteristics to quantify changes in extracellular fluid, has been used to detect and monitor upper limb lymphedema (see, Ridner et al. (2009) Lymphat Res Biol. 7(1): 11-15). In various embodiments, such techniques are used to monitor the progress of treatment in patients treated according to the present invention or to identify patients who may benefit from such treatment. Imaging may also include indocyanine green (ICG) fluorescence lymphangiography, e.g., as described in Suami et al., BMC Cancer 19, 985 (2019). https: / / doi.org / 10.1186 / s12885-019-6192-1, the contents of which are expressly incorporated by reference herein.

[0064] Efficacy of treatment by the methods of the invention is evidenced by an improvement in disease symptoms and pathology. The individual being treated and the medical practitioner may choose to assess success, monitor the course of treatment, adjust dosage and timing, etc., by any convenient indicia.

[0065] In some embodiments of the present invention, for example, treating patients with established disease, the improvement of skin structure provides a convenient way to evaluate the success of treatment. For example, skin thickness reflects structural changes in lymphedema. See, for example, Mellor et al., Breast J 2004; 10:496-503; Hacard et al. Skin Res Technol 2014; 20: 274-81, each of which is specifically incorporated herein by reference. The present invention encompasses a method of reducing skin thickness associated with lymphedema. Skin thickness can be measured, for example, using a factory calibrated skinfold caliper, such as the Lange skinfold caliper, model EQ0014921. In a further aspect, skin thickness or reduction in skin thickness is measured using ultrasound. In some embodiments, the treatment provided herein is effective if, after a time period (e.g., 2 weeks, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months or more) from the start of treatment, there is a reduction in the skin thickness of at least one affected area (e.g., limb) compared to the skin thickness of at least one affected area before the start of treatment.The reduction in skin thickness observed with successful treatment can be at least about 1 mm, at least about 2.5 mm, at least about 5 mm, at least about 7.5 mm, at least about 10 mm, and can be at least about 12.5 mm, at least about 15 mm or more compared to before the start of treatment (referred to herein as "baseline") or at an early time point in the treatment regimen.In yet a further aspect, the skin thickness can be reduced by at least about 5%, about 10%, about 20% or more compared to before the start of treatment (referred to herein as "baseline") or at an early time point in the treatment regimen. Further measurements to determine correction of skin structure pathology may include, for example, DEXA scanning, direct biopsy, visual inspection, etc. Skin thickness and structure in the affected limb may be monitored, for example, the presence of hyperkeratosis, dermal collagen and fat deposition.

[0066] In some embodiments, the change in volume of the affected limb is measured as a measure of successful treatment, i.e., the volume decreases with successful treatment. The volume can be measured by any of several methods in the art, such as circumference measurements, water displacement volume measurements, etc. For example, the assessor can use a standardized tape measure for circumference measurements taken every 2-6 cm and calculate the volume, for example, by the cutting cone method. Successful treatment can reduce or decrease the volume of the lymphedematous body part (both fluid and tissue contents). In some instances, the volume is reduced by more than 2-fold after treatment, i.e., compared to the volume before treatment, e.g., by more than 2-fold, more than 3-fold, more than 4-fold, sometimes more than 5-fold, more than 10-fold, more than 15-fold, in some instances more than 20-fold, more than 50-fold, etc. That is, the volume is reduced by about 50 milliliters or more, more than 100 milliliters, more than 200 milliliters, more than 300 milliliters, more than 400 milliliters, more than 500 milliliters, or more. In some instances, the volume is restored to normal volume, i.e., the volume before the onset of lymphedema, e.g., the volume of unaffected bilateral tissue.

[0067] In some embodiments, the level of serum LTB4 can be used for diagnosis or to select or grade patients for treatment or to monitor efficacy. Normal LTB4 reference levels can be up to about 50 pg / mL or more, up to about 100 pg / mL or more, up to about 200 pg / mL or more, up to about 250 pg / mL or more, up to about 300 pg / mL (depending on the assay type and format and individual laboratory implementation). Individuals with lymphedema can have an increased baseline level of serum LTB4, where the serum level is up to about 1000 pg / ml or more, and can range from about 500 pg / ml to about 1500 pg / ml. In some aspects, the level of serum LTB4 in a sample obtained from a patient is measured, and if it exceeds a predetermined threshold level, the patient is administered acevirstat or other selective LTA4H inhibitor. The treatment provided in the present invention can be determined to be effective if the subject's endpoint LTB4 level is reduced from the baseline LTB4 level after the treatment is initiated. In other embodiments, the treatment provided in the present invention is effective when the endpoint LTB4 level is 2 times or more, 3 times or more, 4 times or more, 5 times or more, 10 times or more, 15 times or more lower than the baseline LTB4 level after the treatment is started.For example, in some embodiments, a higher or increased level of LTB4 in blood sample is at least 3 times higher than the control value, at least 4 times higher, at least 5 times, at least about 10 times higher, at least about 15 times higher, indicates that the patient needs treatment using the treatment of the present invention or that the patient may respond to the treatment of the present invention.A standard method for assessing LTB4 level is utilized.The method further includes administering an effective amount of acevirstat or other selective LTA4H inhibitor to the patient who is determined to be likely to benefit from, need or respond to the treatment of the present invention, thereby treating or preventing lymphedema in the patient.

[0068] The present invention also includes a method for reducing the incidence of soft tissue infection, such as cellulitis, in patients with lymphedema, comprising administering acevirstat or other selective LTA4H inhibitors.Skin infection or cellulitis is a common complication of lymphedema.The method described herein, comprising administering acevirstat or other selective LTA4H inhibitors to patients who need to reduce the risk of cellulitis in lymphedema, can be used to reduce the risk of cellulitis in lymphedema.

[0069] As used herein, "therapeutically effective amount" or "effective amount" refers to an amount of a compound or drug that, when administered to a mammal, preferably a human, is sufficient to perform the treatment of a disease or condition of interest in the mammal, preferably a human, as defined below. The amount of the compound of the present invention that constitutes a "therapeutically effective amount" or "effective amount" varies depending on, for example, the activity of the specific compound used; the metabolic stability and duration of action of the compound; the age, weight, general health, sex and diet of the patient; the mode and time of administration; the rate of excretion; drug combination; the severity of the particular disorder or condition; and the subject to be treated, but can be routinely determined by a person skilled in the art having regard to his own knowledge and this disclosure. In one aspect, the effective amount or therapeutically effective amount of acebilstat or other selective LTA4H inhibitor is an amount that inhibits LTA4H or inhibits LTB4, and / or treats or inhibits or reduces the severity of a disease, and / or reduces the thickness of the skin, and / or improves the turgor, history and / or function of the skin, or increases lymphatic flow and / or improves vascular function.

[0070] "Treating" or "treatment", as used herein, covers the treatment of lymphedema, preferably humans, and includes, for example: (i) inhibiting or reducing the severity of a disease or condition or one or more symptoms thereof, i.e. arresting or delaying the onset or progression of a disease or condition and / or reducing skin thickness and / or improving skin turgor, history and / or function and / or increasing lymphatic flow, and / or improving or reducing one or more symptoms; (ii) alleviating a disease or condition, i.e. causing remission of a disease or condition or one or more symptoms thereof; and / or (iii) stabilizing a disease or condition. "Treating" or "treatment" may include reducing the risk of progression of lymphedema.

[0071] As used herein, the terms "disease" and "condition" may be used interchangeably or may differ in that a particular malady or condition may not have a known causative agent (so that an etiology is not yet at work) and therefore it is not yet recognized as a disease, but only as an undesirable state or symptom, where a more or less specific set of symptoms has been identified by a clinician.

[0072] "Pharmaceutical composition" refers to a formulation of a compound described herein, such as acevirstat or other selective LTA4H inhibitors and / or an additional therapeutic agent, and a vehicle generally accepted in the art for the delivery of biologically active compounds to a mammal, such as a human. Such vehicles include any pharma- ceutically acceptable carrier, diluent, or excipient.

[0073] "Optional" or "optionally" means that the subsequently described event or circumstance may or may not occur, and that the description includes instances in which the event or circumstance occurs and instances in which it does not occur.

[0074] "Pharmaceutically acceptable excipients" include, without limitation, any adjuvant, carrier, filler, glidant, sweetener, diluent, preservative, pigment / colorant, flavor enhancer, surfactant, wetting agent, dispersing agent, suspending agent, stabilizer, isotonicity agent, solvent, or emulsifier approved as acceptable for use in humans or domestic animals, e.g., by the U.S. Food and Drug Administration.

[0075] The administration of the compounds or drugs described herein includes the administration of pharmaceutically acceptable salts of the compounds or drugs, such as acevirstat or other selective LTA4H inhibitors. The administration of the compounds or drugs described herein (e.g. acevirstat or other additional therapeutic agents) or their pharmaceutically acceptable salts in pure form or in a suitable pharmaceutical composition can be carried out by any of the accepted administration forms of drugs to provide similar benefits. As described herein, an exemplary administration form for acevirstat is oral administration. The pharmaceutical compositions described herein can be prepared by combining the compounds or drugs with suitable pharmaceutically acceptable carriers, diluents or excipients, and can be formulated into preparations in solid, semi-solid, liquid or gaseous form, such as tablets, capsules, powders, granules, ointments, solutions, suppositories, injections, inhalants, gels, microspheres and aerosols.

[0076] The routes of administration of such pharmaceutical compositions include, but are not limited to, oral, topical, transdermal, inhalation, parenteral, sublingual, rectal, vaginal and intranasal. The term parenteral, as used herein, includes subcutaneous injection, intravenous, intramuscular, intrasternal injection or infusion techniques. The pharmaceutical compositions of the present invention are formulated so that the active ingredients contained therein are bioavailable upon administration of the composition to a patient. The composition administered to a subject or patient takes the form of one or more dosage units, where, for example, a tablet may be a single dosage unit and a container of the compound of the present invention in the form of an aerosol may hold multiple dosage units. The actual methods of preparing such dosage forms are known or will be apparent to those skilled in the art; see, for example, The Science and Practice of Pharmacy, 20 th Edition (Philadelphia College of Pharmacy and Science, 2000). The composition to be administered will, in any event, contain a therapeutically effective amount of a compound or drug, or a pharma- ceutically acceptable salt thereof, for treatment of the disease or condition of interest in accordance with the teachings of the present invention.

[0077] As mentioned above, the pharmaceutical compositions described herein can be administered in a variety of different ways. Examples include administering the composition with a pharma-ceutically acceptable carrier by oral, intranasal, rectal, topical, intraperitoneal, intravenous, intramuscular, subcutaneous, subdermal, transdermal and intrathecal methods. Formulations suitable for parenteral administration, such as intra-articular (intra-articular), intravenous, intramuscular, intradermal, intraperitoneal and subcutaneous routes, include aqueous and non-aqueous isotonic sterile injection solutions that may contain antioxidants, buffers, bacteriostatic agents, and solutions that make the formulation isotonic with the blood of the intended recipient, as well as aqueous and non-aqueous sterile suspensions that may contain suspending agents, solubilizers, thickeners, stabilizers and preservatives. Formulations suitable for intestinal administration, such as topical administration (e.g., solutions, lotions, creams, pastes, emulsions, suspensions, etc.), oral, rectal, vaginal or by inhalation, include capsules, liquid solutions, emulsions, suspensions and elixirs. For example, when prepared for topical application, the composition may include a biocompatible organic solvent, such as isopropyl esters, such as isopropyl myristate and isopropyl palmitate; polar lipids, such as lecithin, phosphatidylcholine, and the like; surfactants, such as sodium docusate, sodium docusate benzoate, calcium docusate, tween 80, polysorbate 80; water; and / or urea (present at a concentration of about 5-20% by weight of the final composition). In some examples, the topical formulation includes a skin permeation enhancer, such as SEPA 09. Examples of topical formulations may be found, for example, in U.S. Pat. Nos. 5,654,337, 5,093,133, 5,210,099, 3,957,971, and 5,016,652, the complete disclosures of which are incorporated herein by reference.

[0078] Ingredients used to formulate pharmaceutical compositions are preferably of high purity and substantially free of potentially harmful contaminants (e.g., at least National Food (NF) grade, generally at least analytical grade and more typically at least pharmaceutical grade). Moreover, compositions intended for in vivo use are usually sterile. To the extent that a given compound must be synthesized prior to use, the resulting product is typically substantially free of any potentially toxic agents, particularly any endotoxins that may be present during the synthesis or purification process. Compositions for parenteral administration are also sterile, substantially isotonic, and made under GMP conditions.

[0079] The pharmaceutical composition may be in solid or liquid form. In one aspect, the carrier(s) are particulate, so that the composition is, for example, in tablet or powder form. In one aspect, the composition may be in encapsulated powder or granule form. In another aspect, the encapsulated powder or granule formulation may be opened and sprinkled in food or administered by gastric intubation. The carrier(s) may be liquid, so that the composition is, for example, oral syrup, injectable liquid or aerosol, for example, useful for inhalation administration. When intended for oral administration, the pharmaceutical composition may be in either solid or liquid form, where semi-solid, semi-liquid, suspension and gel forms are included in the forms considered as either solid or liquid herein.

[0080] As a solid composition for oral administration, the pharmaceutical composition may be formulated into the form of powder, granules, compressed tablets, pills, capsules, chewing gum, wafers, etc. Such solid compositions typically contain one or more inert diluents or edible carriers. Also, one or more of the following may be present: binders, such as carboxymethylcellulose, ethylcellulose, microcrystalline cellulose, tragacanth or gelatin; excipients, such as starch, lactose or dextrin; disintegrants, such as alginic acid, sodium alginate, primogel, corn starch, etc.; lubricants, such as magnesium stearate or Sterotex; glidants, such as colloidal silicon dioxide; sweeteners, such as sucrose or saccharin; flavorings, such as peppermint, methyl salicylate or orange flavoring; and colorings.

[0081] When the pharmaceutical composition is in the form of a capsule, e.g., a gelatin capsule, it may contain, in addition to materials of the above type, a liquid carrier such as polyethylene glycol or oil.

[0082] Pharmaceutical compositions can be in the form of liquid, such as elixir, syrup, solution, emulsion or suspension.Liquid can be for oral administration or delivery by injection, as two examples.When intended for oral administration, the composition can contain one or more sweeteners, preservatives, pigments / colorants and flavor enhancers in addition to the compound of the present invention.In the composition intended for administration by injection, one or more of surfactants, preservatives, wetting agents, dispersing agents, suspending agents, buffers, stabilizers and isotonic agents can be included.

[0083] The liquid pharmaceutical composition of the present invention, whether in solution, suspension or other similar form, may contain one or more of the following adjuvants: sterile diluents, such as water for injection, saline solution, preferably saline, Ringer's solution, isotonic sodium chloride or saline, fixed oils, such as synthetic mono- or diglycerides, polyethylene glycols, glycerin, propylene glycol or other solvents that can act as solvents or suspending media; antibacterial agents, such as benzyl alcohol or methylparaben; antioxidants, such as ascorbic acid or sodium bisulfite; chelating agents, such as ethylenediaminetetraacetic acid; buffers, such as acetates, citrates or phosphates, and agents for adjusting isotonicity, such as sodium chloride or dextrose. Parenteral preparations may be enclosed in glass or plastic ampoules, disposable syringes or multiple dose vials. Saline is the preferred adjuvant. The injectable pharmaceutical composition is preferably sterile.

[0084] The invention is illustrated by the following non-limiting examples. EXAMPLES

[0085] Example 1: A Pilot Placebo-Controlled Study of Acevirstat (CTX-4430) for the Treatment of Human Upper Extremity Lymphedema 1. Test Drugs Acevirstat, also known by the code name CTX-4430, is a novel synthetic small molecule leukotriene A4 hydrolase (LTA4H) inhibitor being developed for the treatment of inflammatory conditions. The chemical name of CTX-4430 is 4-[[(1S,4S)-5-[[4-[4-(2-oxazolyl)phenoxy]phenyl]methyl]-2,5-diazabicyclo[2.2.1]hept-2-yl]methyl]-benzoic acid. It is a chiral molecule manufactured as a single isomer. The investigational product is manufactured as a powder mixture in size 0, white, opaque, hard gelatin capsules and is supplied in white high density polyethylene (HDPE) bottles in quantities of 30-36 capsules per unit. The investigational product is stable for at least four years at controlled room temperature (15-25°C / 59-77°F) when protected from exposure to ultraviolet (UV) light.

[0086] Mechanistically, acevirstat has an IC of 0.013 μM in vitro. 50 (concentration producing 50% inhibitory effect) and an IC of 0.064 μM in ex vivo derived human whole blood. 50 Acebilstat is a potent and selective inhibitor of LTA4H-mediated production of the potent inflammatory mediator leukotriene B4 (LTB4). Pharmacodynamic (PD) studies in animals and humans orally treated with acebilstat show a strong correlation between the plasma concentration of acebilstat and the percent inhibition of LTB4 production in ex vivo derived whole blood. In human clinical PD studies, the 50% effective concentration (EC 50 ) was found to be 93 ng / mL (0.19 μM). In addition to reducing LTB4 production, a potential additional pharmacological benefit of LTA4H inhibition is to increase concentrations of the anti-inflammatory mediator lipoxin A4 (LXA4) via a blocking mechanism, although this effect has not been conclusively shown to occur in humans treated with acevirstat. 20 .

[0087] Nonclinical studies of acevirstat included a comprehensive set of pharmacology, pharmacokinetic (PK), metabolism, and toxicity studies conducted to support human clinical trials. Pharmacologically, acevirstat reduces the production of leukotriene B4 (LTB4). LTB4 is an important mediator of inflammation that acts by inducing the migration and activation of neutrophils and other immune cells. Acevirstat is rapidly absorbed and widely distributed to tissues, and is then eliminated primarily via the liver-bile-feces, with less than 3% of the total drug being excreted via the kidneys. Mass balance studies in animals have shown some ability for accumulation and retention of acevirstat in pigmented tissues, particularly the uveal tract, but there has been no evidence of ophthalmological changes in long-term safety studies. In vitro studies suggested a potential for drug interactions with P-glycoprotein (P-gp) substrates and multidrug and toxin extrusion (MATE)-2K, which should be considered for future clinical trials until definitive clinical drug interaction studies are performed. Preclinical studies did not indicate a potential for phototoxic effects. Dose-limiting toxicity observed in long-term animal safety studies across species was failure to gain weight accompanied by reduced food consumption. Nonclinical toxicology studies support chronic administration of acevirstat at doses up to 200 mg / day to humans aged 2 years and older.

[0088] Not including ongoing clinical trials for the treatment of mild COVID-19, 327 adult subjects (including 6 subjects who received a single dose of [14C]-acevirstat) have received at least one dose of acevirstat to date in a total of 6 completed clinical trials supported by Celtaxsys Inc (the former IND holder of Celltaxis LLC); of these, 112 subjects with cystic fibrosis (CF) were treated for 48 weeks. These studies include a 14-day single-dose and multiple-dose first-in-human study in healthy volunteers (CTX-4430-HV-001, NCT01748838), a 15-day multiple-dose study in adult CF patients (CTX-4430-CF-001, NCT01944735), and a cytochrome P450 (CYP) These include a 7-day, multiple-dose drug-drug interaction study in healthy volunteers to evaluate the ability of 3A4 to induce IL-19 (CTX-4430-DI-001, NCT02233244), a Phase 1 mass balance and metabolism study (CTX-4430-ADME-001), and two Phase 2 studies: a 12-week, multiple-dose study in subjects aged 16-44 years with moderate-to-severe facial acne vulgaris (CTX-4430-AV-201, NCT02385760), and a 48-week, multiple-dose study in CF patients aged 18-30 years (CTX-4430-CF-201, NCT02443688).

[0089] In humans, orally administered acevirstat is rapidly absorbed, with a T of approximately 1.5 hours when the drug is taken while fasting and 5 to 6 hours when the drug is taken with a high-fat meal. max (the time at which maximum plasma concentration was observed). 1 / 2 The elimination half-life differed between healthy volunteers (15-18 hours) and CF patients (8-9 hours) for reasons that are still unknown. 1 / 2 Despite the obvious differences in the maximum observed plasma concentration (C max) and area under the time-concentration curve (AUC). Acevirstat exposure increases to steady state over the first 7 days of treatment. In a clinical drug-drug interaction study, steady-state exposure of acevirstat did not induce CYP3A4 / 5, suggesting that acevirstat does not alter the pharmacokinetics of other drugs subject to metabolism by CYP3A4 / 5. A population PK analysis performed as a substudy of a Phase 2 CF study showed a wide range of acevirstat clearance rates in CF patients that depended on both body size and concurrent medications; here, both larger body size and concurrent use of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy (ivacaftor or ivacaftor + lumacaftor) increased the clearance of acevirstat, thereby reducing plasma concentrations.

[0090] Oral dosing up to 200 mg / day once daily for 14 days in healthy volunteers was well adjusted. Acevirstat was generally well adjusted in CF patients at doses of 50 mg and 100 mg per day for 48 weeks in CTX-4430-CF-201. Adverse events (AEs) in these studies were generally mild to moderate. Headache was the most common adverse event seen in clinical trials, with 8% considered related to acevirstat. Infectious pulmonary exacerbations were also the most frequently observed TEAEs (prevalence higher in placebo than in acevirstat) in the CF-201 clinical trials. Infectious pulmonary exacerbations were an expected adverse reaction given the context of the CF population. Acevirstat treatment did not alter circulating neutrophil counts or sputum microbiology.

[0091] In the 48-week Phase 2 CF study, results of the primary efficacy endpoint analysis of change from baseline in percent predicted FEV1 showed no statistically significant differences between acevirstat and placebo. Secondary efficacy analyses showed consistent numerical benefits in both reduced rate of pulmonary exacerbations and increased time to first pulmonary exacerbation from treatment with acevirstat. Furthermore, clinically significant numerical benefits in reduced rate of pulmonary exacerbations and increased time to first pulmonary exacerbation were observed in prespecified subgroups of subjects with milder disease (baseline ppFEV1 >75) and in subjects with concurrent CFTR modulator treatment.

[0092] Oral doses of 50 mg and higher once daily in humans showed significant engagement of pharmacological mechanisms in the blood over the entire 24-hour dosing interval and throughout the dosing period in Phase 1 trials. However, in Phase 2 CF trials, a 100 mg once daily dose provided more consistent engagement of pharmacological mechanisms over the 24-hour dosing interval compared to the 50 mg dose. This was particularly evident for CF patients of larger body size and those receiving concurrent CFTR modulator therapy. Thus, 100 mg once daily is the currently recommended dose for clinical proof of concept trials.

[0093] 2. Study Design We propose to enroll 70 adult patients with unilateral breast cancer lymphedema. Potential subjects will be recruited from the Stanford Center for Lymphatic and Venous Disorders, a high volume focus specialty clinic previously utilized for successful enrollment on a previous similar clinical trial. The design will utilize a 12-week placebo run-in with assessment of study endpoints before and after placebo exposure. Participants will receive information about receiving placebo for acebilstat for 12 weeks out of 36 weeks of active treatment, but will be blinded as to the exact time frame of the 12-week placebo exposure (all will receive placebo between weeks 0 and 12). This setup will allow for statistical analysis of subjective responses to placebo and facilitate statistical comparison of subjective responses to each of the placebo and active drug. All participants will receive open-label use of acebilstat. Pre- and post-treatment assessments will be performed at the Stanford CTRU. The primary endpoint of the study is change in skinfold thickness as measured by ultrasound examination. The secondary endpoint is the change in caliper skinfold thickness of the affected limb. Study endpoints include limb volume assessments and serial assessments of validated patient-reported outcomes, such as visual analog scale quantification of the perceived impact of treatment on symptoms and function. Paired comparisons of placebo run-in and drug response will be performed. Liver function monitoring will be performed at each patient encounter.

[0094] Correlation test background We plan a correlative study addressing the molecular characterization of the therapeutic response to LTB4 antagonism in lymphedema. The potential interpretation of these molecular data and their relationship to therapeutic response may require correlation with concurrent changes in general plasma LTB4 concentrations. Thus, pre- and post-treatment LTB4 plasma concentrations will be assayed in parallel by ELISA.

[0095] Hoping to elucidate the molecular pathogenesis of lymphedema, we previously investigated a mouse model of acquired post-surgical lymphedema. 16In this previous study, the presence of strong histopathological inflammatory changes in the skin correlated with impaired migration of immunoresponsive cells from lymphedematous areas. Large-scale transcriptional profiling of lymphedematous tissues revealed a clear dominant inflammatory molecule expression profile that led us to hypothesize a role for leukotrienes, both in the pathogenesis of the disease and as potential therapeutic targets. 16 These results and the unmet need for drug therapy led us to develop ketoprofen. 17 , an NSAID agent with a recognized dual anti-inflammatory mechanism of action that involves inhibition of the 5-lipoxygenase (5-LO) pathway. 18 We decided to investigate the impact of treatment with ketoprofen. When we administered ketoprofen systematically to mice with experimental acquired lymphedema, there was a documented reversal of disease burden, including a remarkable normalization of pretreatment lymphedematous histology. 17 Our subsequent preclinical studies, both in vivo and in vitro, 15 These results strongly suggest that the therapeutic benefit of ketoprofen in experimental lymphedema is specifically due to its inhibition of the 5-LO pathway.

[0096] Preclinical investigation of the effects of bestatin, an LTA4H inhibitor, disclosed that LTB4 antagonism, such as ketoprofen, reversed edema, improved lymphatic function, and restored lymphatic structure in a mouse model of lymphedema. Low LTB4 concentrations promoted the development and growth of human lymphatic endothelial cells, whereas higher concentrations (observed in both untreated mice and human lymphedema) inhibited lymphangiogenesis and induced apoptosis. During lymphedema progression, lymphatic fluid LTB4 concentrations rose from early pro-lymphangiogenic concentrations to the anti-lymphangiogenic range. High concentrations of LTB4 inhibited vascular endothelial growth factor receptor 3 and the Notch pathway in cultured human lymphatic endothelial cells. Lymphatic-specific Notch1(- / -) mice were refractory to the beneficial effects of LTB4 antagonism, suggesting that LTB4 suppression of Notch signaling is a critical mechanism for disease maintenance. In summary, we found that LTB4 is detrimental to lymphatic repair at concentrations observed in established disease. These findings support the idea that LTB4 is a promising drug target for the treatment of lymphedema.

[0097] Our subsequent clinical translational investigations involved characterizing the inflammatory molecular signature of human lymphedema. 16 and humans 21 Both prospective and transcriptomic profiling of lymphedema identified a remarkably small number of specific pathways with altered cutaneous expression in lymphedema. Among the identified central pathways in human lymphedema, inflammatory substrates appear to be directly relevant to the pathogenesis of histopathology. In our pilot, placebo-controlled prospective trial of oral ketoprofen treatment for human lymphedema, 19 The beneficial effects of treatment on both skin thickness and skin histopathology were accompanied by clear changes in circulating cytokines and chemokines, as detected by Luminex multiplex assays. We observed a similar pattern of cytokine responses in a small placebo-controlled trial of ubenimex, an LTA4H inhibitor (unpublished observations).

[0098] 3. Participant Selection and Registration Procedures Including criteria: unilateral stage II chronic lymphedema of the upper extremity with affected:unaffected limb volume ratio of ≥1.2 and duration of ≥6 months. If potential participants have had previous microvascular or debulking surgical intervention, at least 1 year must have passed prior to screening. There are no gender or racial-ethnic restrictions. Participants aged 18-75 years are eligible for enrollment. ECOG performance status will be used. ECOG stages 0-2 are eligible. The following statement will be included in the informed consent form: "Participants must have the ability and willingness to understand and sign the informed consent document as described."

[0099] Physical therapeutic intervention for lymphedema must be completed at least 8 weeks prior to screening. No further maintenance modalities may be added after screening until the study protocol is completed. Any potential participant planning elective surgical intervention for lymphedema will be excluded.

[0100] No other investigational agents are permitted.

[0101] Any other medical condition that may result in acute limb edema, including (but not limited to) acute venous thrombosis; other medical conditions that may produce overlapping symptoms of lymphedema in the affected limb (e.g., pain, swelling, reduced range of motion); history of coagulation disorder (hypercoagulable state); chronic (persistent) infection in the affected limb; any other infection (not related to lymphedema) within 1 month of screening; current chemotherapy or radiation therapy; current evidence of active malignancy or history of malignancy within the past 2 years (excluding non-melanoma skin cancer or cervical cancer treated in situ with therapeutic intent). Participants must have had cancer treatment completed >2 years prior to enrollment if they had undergone it; chronic renal failure (defined as serum creatinine >2.5 mg / dL or estimated glomerular filtration rate [eGFR] <30 mL / min at screening) or requiring dialysis support; hepatic insufficiency, defined as alanine transaminase (ALT) or aspartate transaminase (AST) levels >3×upper limit of normal (ULN) and / or bilirubin levels >2×ULN at screening; absolute neutrophil count <1500 mm3 at screening; hemoglobin concentration <9 g / dL at screening; pregnancy or breastfeeding; substance abuse (e.g., alcohol or drug abuse) within 6 months prior to screening; any reason (in addition to those mentioned above) that, in the investigator's opinion, would prevent full participation in the study.

[0102] The requirements for a history of allergic reactions were due to compounds of similar chemical or biological composition as the investigational agent or device: known allergy to any of the chemical components in the investigational agent.

[0103] Drug-specific exclusion criteria: Any current or previous therapeutic use of ketoprofen.

[0104] Pregnant and lactating participants will be excluded.

[0105] All participants must be provided with a consent form that describes the study with enough information for participants to make an informed decision regarding their participation. Participants must sign an IRB-approved informed consent prior to participation in any study-specific procedures. Participants must receive a signed, dated, certified copy of the consent document. The original, signed copy of the consent document must be retained in the medical record or study file.

[0106] Participants will not be randomized.

[0107] Initial completion will occur 24 months after the first participant recruitment. Study completion will occur 30 months after the first participant recruitment.

[0108] 4. Treatment Planning V1 Screening / Visit 1 After obtaining the described informed consent, the following actions will occur: · Complete physical examination, e.g. measurement of height, weight, BMI and vital signs (heart rate, blood pressure, respiration rate, temperature) and weight. Drug evaluation Symptom assessment Blood and urine specimens for clinical laboratory testing including CBC, comprehensive metabolic panel, urinalysis, and β-HCG (premenopausal women only) Plasma samples were banked for future correlation studies. LYMQOL questionnaire and VAS scores to assess impact on quality of life Limb volume measurement of both upper limbs Caliper measurement of skin thickness Skin Ultrasound ·Medication diaries are collected and pill counts are performed Participants will be provided with a three month supply of study medication. Participants will be instructed on the exact form for administering the medication, beginning the morning after Visit 1. A medication diary will be provided to participants. Participants will be instructed to collect and return all study medication bottles.

[0109] V2 visit 2 (13±1 weeks) Collect demographic information ·Review your medical history Complete physical examination, e.g., measurement of height, weight, BMI and vital signs (heart rate, blood pressure, respiration rate, temperature); Drug evaluation Symptom assessment - VAS score to assess impact on quality of life Limb volume measurement of both upper limbs Caliper measurement of skin thickness Skin Ultrasound Medical diaries will be collected and pill counts will be performed Participants will be provided with the next 3 months' supply of study medication and a new medication diary Participants will be instructed to collect and return all study medication bottles.

[0110] V3 visit 3 (25±1 week) Collect demographic information ·Review your medical history. · Complete physical examination, e.g. measurement of height, weight, BMI, and vital signs (heart rate, blood pressure, respiration rate, temperature) and weight. Drug evaluation Symptom assessment Medical diaries will be collected and pill counts will be taken. Participants will be provided with the next 3 months' supply of study medication and a new medication diary Participants will be instructed to collect and return all study medication bottles.

[0111] V4 visit 4 (37±1 week) Collect demographic information ·Review your medical history · Complete physical examination, e.g. measurement of height, weight, BMI, and vital signs (heart rate, blood pressure, respiration rate, temperature) and weight. Drug evaluation Symptom assessment Blood and urine samples for clinical laboratory testing such as CBC, comprehensive metabolic panel, and urinalysis Plasma samples will be banked for future research use LYMQOL questionnaire and VAS scores to assess impact on quality of life Limb volume measurement of both upper limbs Caliper measurement of skin thickness Skin Ultrasound ·Medication diaries are collected and pill counts are performed

[0112] Participants who discontinue the study early will be asked to return for an early termination visit within 1 week of discontinuation of study drug. Any participant who terminates study participation due to an AE will be followed until the AE outcome is reconciled.

[0113] 4.1 Common Concomitant Medications and Supportive Care Guidelines Participants will be instructed to avoid prescription ketoprofen for the duration of enrollment. Phlebotomy (SOC and Studies): Risks of phlebotomy include: pain; bruising; bleeding; inflammation; infection; temporary redness of the skin where the venipuncture was performed; and light headedness. Care is taken to avoid these difficulties. Caliper measurements of skin thickness (study): The calipers pinch the skin, which can cause some discomfort. Limb volume quantification by circumferential tape measurement: No associated risks Skin ultrasound (study): No associated risks

[0114] 4.2 Criteria for Removal from the Study It will be documented whether each subject has completed the clinical trial. Participants who discontinue the study early will be asked to return for the final study visit within one week of the decision to withdraw. If a participant withdraws, every effort will be made to complete and report as completely as possible the observations, especially the follow-up examinations. A genuine effort will be made to contact the participant, either by phone, letter or email, to determine the reason why the participant is unable to return for any required visits or withdraws from the study, and the reason(s) will be documented. Reasons why a subject may discontinue participation in a clinical trial may include the following: Intervening illness that prevents continuation of the study The potential health risk to patients as indicated by the prevalence or severity of the AE Subjects may choose to withdraw from the study at any time for any reason. A general or specific change in the patient's condition that, in the investigator's judgment, makes the subject intolerant to further treatment Severe non-compliance with the protocol as determined by the investigator ·death - Completion of the trial

[0115] 4.3 Alternatives The study procedures involve minimal substitutions: if a potential participant chooses not to participate, the substitution is the continuation of maintenance physical interventions to stabilize the edema.

[0116] 5. Investigational Agent / Device / Procedure Information 5.1 Investigational Agents / Devices / Procedures Acebilstat and matching placebo are provided as size 0, white hard gelatin capsules and supplied in white high density polyethylene (HDPE) bottles in quantities of 30-36 capsules per unit. Acebilstat capsules contain 100 mg of active drug and approximately 250 mg of an inert dry powdered excipient mixture. Placebo capsules contain approximately 325 mg of an inert dry powdered excipient mixture. Acebilstat or placebo capsules are administered orally once daily with water at breakfast. The investigational product is stable for at least four years at controlled room temperature (15-25°C / 59-77°F) when protected from exposure to ultraviolet (UV) light.

[0117] For this study, placebo will be administered orally once daily with breakfast for 12 weeks, then acevirstat treatment will be administered orally once daily with breakfast for 24 weeks.

[0118] The investigational drug product, acevirstat, and its matching placebo will be provided by Celltaxis LLC.

[0119] 6. Dose Modification Dose modification is not feasible for this study. The Principal Investigator will terminate treatment whenever an unexpected adverse reaction is suspected to be potentially treatment-related if any of the following conditions are met: - ALT and / or AST are elevated to levels ≥ 3x upper limit of normal (ULN) - ALT and / or AST elevated to levels ≥ 2.5x ULN and T Bili ≥ 1.5x ULN - Any suspected unanticipated serious adverse reactions are identified

[0120] 7. Adverse Events and Reporting Procedures 7.1 Potential Adverse Events A total of 327 subjects, including 145 subjects with cystic fibrosis, received at least one dose of acevirstat across the six clinical trials. Acevirstat doses ranged from 5 to 200 mg; 112 subjects with cystic fibrosis received acevirstat (at doses of 50 and 100 mg) for 48 weeks. Acevirstat was generally safe and well tolerated across the six clinical trials. No clinically significant trends were observed in the healthy volunteer studies. The following table summarizes the most common treatment-emergent adverse events in the safety population: [Table 4-1] [Table 4-2]

[0121] No SARs were reported in Phase 1 studies in healthy volunteers or subjects with CF.

[0122] SARs reported in completed Phase 2 studies and suspected to be potentially drug treatment related are summarized in the table below.

[0123] Serious Adverse Reactions by System Organ Class and Preferred Terminology: Phase 2 Acevirstat Safety Population [Table 5]

[0124] 8. Correlation / Special Tests 8.1 Laboratory correlation tests 8.1.1 Molecular characterization of the therapeutic response to LTB4 antagonism in lymphedema. Upon completion of all of the study's clinical events, we will undertake molecular analysis of pre- and post-treatment samples collected during the study. The goal is to characterize molecular pathways that respond to treatment and to potentially identify pre-treatment variables that may predict beneficial response to treatment. Four sets of analyses involving multi-omics approaches will be performed: 1. Plasma concentrations of LTB4 are determined using a Leukotriene B4 ELISA kit from Cayman Chemicals (#520111). 2. Specific expression of inflammatory cytokines and chemokines will be assessed using the Bio-rad Luminex Human 48-plex Panel Kit (12007283). 3. Extracellular vesicles are purified from plasma by ultracentrifugation. Vesicle purity, size and concentration are assessed using a Nanosight NS300 (Malvern). The composition of these vesicles is determined by mass spectrometry. Exosome analysis for protein biomarkers is performed as previously described. 22 . 4. Perform multi-panel flow cytometry analysis to evaluate cellular components in PBMCs. 5. Use single-cell RNA sequencing to characterize the impact of LTB4 antagonism on the transcriptomic landscape of different immune populations.

[0125] 8.1.1.1 Collection of specimen(s): Perform two phlebotomies: the first at enrollment and the second at study completion. Collect whole blood into CPT tubes and mix by gently inverting the tube 5-10 times.

[0126] 8.1.1.2 Handling of specimen(s): To preserve the biostability of LTB4 and its metabolites, plasma and buffy coat are immediately separated by centrifugation at 1800g for 30 minutes at room temperature in a horizontal rotor. Plasma is pipetted and aliquoted (1 ml each) into clean screw-cap vials. Individual plasma samples are then flash frozen and transferred to a -80°C freezer in the research laboratory.

[0127] Peripheral blood mononuclear cells from the buffy coat are transferred to a 50 ml conical tube. Three cell volumes of phosphate buffered saline (PBS) are added to the tube, mixed with the cells and centrifuged at 300 g for 10 min at room temperature. The PBS addition, mixing and centrifugation steps are repeated three times and a cell count is performed. At the end of the final centrifugation step, the cell pellet is counted at 5x10 6 Suspend cells / ml in freezing medium. Place 1 ml aliquots of cell suspension into pre-labeled cryovials. Store vials in -80°C cell freezing container.

[0128] 8.1.1.3 Site(s) Performed Correlation Studies: Correlation studies will be performed in the investigator's Stanford research laboratory. Plasma aliquots will be stored in -80°C freezers. PBMCs will be stored in liquid nitrogen.

[0129] 8.1.1.4 Encryption of specimens for privacy: Plasma samples for correlation study purposes will be identified with a unique study identifier. Study team members will de-identify participant information. All identifiers (e.g., name, original medical record number, accession number) will be removed. Only the study team will have access to the specimens. Once the participant signs the informed consent, they will be assigned a study participant number. Documentation containing participant names will be securely held by the investigator and the study team. Keys to the encryption will be held by the study protocol manager and study coordinator in a password-protected Stanford computer kept in a secure location and will not be accessible to the public. Study staff will be required to complete HIPAA certification, and study coordinators will be required to complete further training in the Good Clinical Practice guidelines.

[0130] 9. Exam Dates / Evaluation Schedule [Table 6]

[0131] 10. Measurement Main outcome measures: Changes in skinfold thickness in the affected upper limbs (ultrasound measurements) Title: Ultrasound Skin Thickness Changes Time frame: After 36 weeks of enrolment in the protocol · Safety Issues: Does this outcome measure assess safety issues? No Note: Each outcome measure listed within the protocol will require legally required results to be reported to clinicaltrials.gov within 1 year after completion of the primary outcome measure.

[0132] 10.1 Key results The primary outcome measure was change in ultrasound skin thickness. 10.1.1 Relevant subsets: The target population is participants with unilateral upper extremity lymphoedema who are enrolled in this study.

[0133] 10.1.2 Measurement Definition: This is an objective efficacy measure. Skin thickness measurements at enrollment will be compared to measurements at week 12, and the week 12 measurements will be compared to measurements at the end of study (week 36). We will quantitatively assess the difference in ultrasound skin thickness measurements from enrollment to week 12 versus week 12 to week 36. Variance (variability) will be assessed as standard deviation.

[0134] 10.1.3 Measurement Methods: Skin thickness is derived from ultrasound examination of the forearm skin using a Terason 3200T device. The area of ​​interest is identified in the first exam at enrollment, and the same area of ​​interest is interrogated again in each subsequent exam. For final interpretation, assessors are blinded to participant identity and treatment condition. Changes in measurements pre- and post-treatment are utilized and reported.

[0135] 10.1.4 Measurement Time Points: Ultrasound skin thickness will be measured at enrollment, week 12 and at the end of the study (week 36).

[0136] 10.1.5 Response Review: Results will be evaluated by designated independent blinded assessors.

[0137] 10.2 Second result Changes in measurements of skin thickness as measured by caliper skinfold thickness. 10.2.1 Relevant subsets: The target population is participants with unilateral upper extremity lymphoedema who are enrolled in this study.

[0138] 10.2.2 Measurement definition: This is an objective efficacy measure. Skinfold thickness measurements at enrollment are compared to measurements at week 12 and at the end of the study (week 36). This measurement is defined as the arithmetic mean of the values ​​(with standard deviation) obtained at the two eligibility selection screening visits. We quantitatively evaluate the difference in skinfold thickness measurements from enrollment to week 12 versus week 12 to week 36. Variability (variance) is evaluated as the standard deviation.

[0139] 10.2.3 Measurement Methods: Skin thickness measurements (mm) are taken using Lange skinfold calipers (Beta Technology, Santa Cruz, CA). For each participant, three measurements are taken at each assessment: the dorsum of the hand, the midpoint of the volar aspect of the forearm, and the midpoint of the medial aspect of the upper arm. At the initial assessment, a skin marking pencil is used to mark the site of each measurement. Once located, the location is marked (measured from the wrist). These locations are reused for sequential measurements for each follow-up visit. Calipers are calibrated before each use. Assessors are blinded to treatment condition. Pre- and post-treatment changes in measurements are utilized and reported.

[0140] 10.2.4 Measurement Time Points: Skin thickness measurements will be performed at enrollment, week 12 and at the end of the study (week 36).

[0141] 10.2.5 Response Review: Results will be assessed by designated independent blinded assessors.

[0142] 10.3 Survey results 10.3.1 Change in Lymphoedema Quality of Life (LymQOL): Change in Lymphoedema Quality of Life (LymQOL) aggregate score.

[0143] 10.3.1.1 Relevant subsets: The target population is participants with unilateral upper extremity lymphedema who are enrolled in this study.

[0144] 10.3.1.2 Measurement definition: This is an objective validity measurement. The LymQoL survey is a validated, self-reported outcome questionnaire. 23 Questions cover four areas: symptoms, body image / appearance, function and mood. Responses are scored 1 to 4 (less severe to severe impairment). The LymQoL survey will be used to assess change as a result of the treatment intervention. Change = 36 week aggregate score - enrolment aggregate score).

[0145] 10.3.1.3 Measurement Methods: The LymQoL will be completed prior to performance of any efficacy assessments (volume measurements, skin caliper measurements, skin ultrasound).

[0146] 10.3.1.4 Measurement Time Points: Participants will complete LymQoL surveys at enrollment and at the end of the study (36 weeks).

[0147] 10.3.1.5 Response Review: Results will be reviewed by designated independent blinded reviewers.

[0148] 10.3.2 Changes in VAS Symptomatology Change in VAS scores. In previous clinical investigations of LTA4H inhibition, we observed significant subjective improvements in participants receiving active drug. Unfacilitated reports of subjective improvement included the following variables: Lymphoedematous limbs feel less painful - Improved lymphatic flow sensation Softer skin and tissue Reduced number of infections Reduced need for self-care Retention of lymphedema with lower grade compression Edema became more responsive to treatment Improved fit of clothing Improved self-confidence, self-esteem Reduced embarrassment · Life becomes more enjoyable

[0149] Therefore, we constructed and validated a set of VAS analogue scales for the assessment of subjective response to therapeutic intervention, which will be administered continuously to participants in this study.

[0150] 10.3.2.1 Relevant subsets: The target population is participants with unilateral upper extremity lymphedema who are enrolled in this study.

[0151] 10.3.2.2 Measurement definition: This is an objective efficacy measure. Patients self-report symptomatology related to lymphedema, expressed on a visual analog scale (VAS). The outcome of each of these self-reported events is expressed as a linear dimension from -10 to +10 in centimeters (cm). A value of -10 represents the most severe expression of the symptom, while +10 represents the absence of the symptom. Changes are assessed at 12 and 36 weeks and calculated as 12 week score - enrollment score, or 36 score - 12 week score, respectively. Also, at 12 and 36 weeks, a specific VAS scale is given to evaluate the subjective perception of the change in the symptom area.

[0152] 10.3.2.3 Measurement Methods: VAS scoring will be completed prior to performance of efficacy assessments (volume measurements, skin caliper measurements, skin ultrasound).

[0153] 10.3.2.4 Measurement Time Points: Participants will complete VAS scores at enrollment, week 12 and at the end of the study (week 36).

[0154] 10.3.2.5 Response Review: Outcomes will be assessed by designated independent blinded assessors.

[0155] 10.3.3 Lymphoedematous Limb Volume Change: Change in volume of the limb affected by lymphedema

[0156] 10.3.3.1 Relevant subsets: The target population is participants with unilateral upper extremity lymphedema who are enrolled in this study.

[0157] 10.3.3.2 Measurement definition: Quantitative assessment of limb volume (mL) of the affected limb at week 12 will be compared to values ​​at enrollment, and limb volume (mL) of the affected limb at the end of the study (week 36) will be compared to values ​​at week 12. The differences in the means at weeks 12 and 36 will be compared.

[0158] 10.3.3.3 Measurement Method: Quantification of limb volume for affected and unaffected limbs is performed using limb circumference measurements at 4 cm intervals starting at the wrist. Limb volume is calculated using the truncated cone approximation {(volume = πh (R 2+ Rr + r 2 ) / 3), where h is the length along the axis of the limb, R is the radius of the inferior base, and r is the radius of the superior surface of the cut cone. For limb volume calculation, limb circumference is measured serially at enrollment, 12 weeks, and at the end of the study (36 weeks). For quantitative analysis, excess limb volume is defined as the difference between the measured volumes of the affected and unaffected arms, and changes in excess limb volume are calculated both as absolute values ​​and as percentage changes.

[0159] 10.3.3.4 Measurement Time Points: Limb circumference for calculation of limb volume will be measured at enrollment, week 12 and at the end of the study (week 36).

[0160] 10.3.3.5 Response Review: Outcomes will be assessed by designated independent blinded assessors.

[0161] 11. Regulatory considerations 11.1 Institutional review of the protocol The protocol, proposed informed consent, and all forms of participant information related to the study (e.g., advertisements used to recruit participants) will be reviewed and approved by the Stanford IRB and, where applicable, the Stanford Cancer Institute Scientific Review Committee (SRC). Any changes made to the protocol will be submitted as amendments and approved by the IRB prior to implementation. The protocol manager will disseminate protocol amendment information to all involved investigators.

[0162] 11.2 Data and Safety Monitoring Plan The DSMB will review study-related activities to determine whether the study was conducted in accordance with the protocol, local standard operating procedures, FDA regulations, and Good Clinical Practice (GCP). This may include reviewing the following types of documents related to the study: regulatory binders, case report forms, eligibility checklists, and source documentation. The DSMB will also periodically review serious adverse events and study-related protocol deviations to ensure the protection of human subjects. The results of the DSMB review will be communicated to the IRB and appropriate regulatory authorities at the time of continuing review or in an expedited manner, if necessary.

[0163] 11.3 Data Management Plan The Protocol Manager and his research team will create and maintain adequate and accurate participant case histories with observations and data directly related to the study. Study specific Case Report Forms (CRFs) will document the treatment outcomes for data analysis. Case Report Forms will be developed using Redcap or Oncore database systems and will be maintained by the Principal Investigator and his research team. CRFs (paper documents) will be kept in a secure locked place and will not be accessible to the public.

[0164] 12. Statistical considerations statistical design This is designed as an open-label study insofar as all participants receive the designated 24-week exposure to active drug. Participants know that they will also receive a matching placebo during 12 of the 36 weeks of all enrollments, but are blinded to the fact that the placebo exposure will occur uniformly in each participant between weeks 0 and 12 of enrollment. This single-blind design allows for between-subject comparisons of placebo response versus response to active drug.

[0165] Key results The primary outcome will be the change in skinfold thickness as detected by ultrasound in the forearm of the affected limb. Changes measured from enrollment to 12 weeks will be statistically compared to changes measured from 12 weeks to 36 weeks.

[0166] Second result The secondary outcome will be the change in caliper skinfold thickness in the lymphedema-affected limb. Changes measured from enrollment to 12 weeks will be statistically compared to changes measured from 12 weeks to 36 weeks.

[0167] Key Analysis Analysis Population: The primary analysis will include participants who completed all required study visits. However, for participants who do not complete the study, their data will be censored and reviewed using the analysis population. Treatment summaries and adverse events data will also be provided separately for each treatment category. Analytical Plan: The final analysis will be undertaken after the last enrolled participant completes all planned study events. The primary analysis will use all enrolled subjects who complete the protocol by the end of the study.

[0168] In prospective clinical trials such as the proposed one, the main concern is loss to follow up. In such cases, if a participant is not followed up, the participant can be included in the analysis if at least one post-baseline value is recorded before being lost to follow up. The approach for loss to follow up relies on a flexible assumption about the missing data, that is, the missing value is lost randomly. However, in the current proposed situation, our previous experience with the clinical antagonism of 5-LO and LTB4 makes it clear that clinical response is not measurable before a total of 6 months of continuous treatment. For this reason, in the lost to follow up situation, interim data for analysis is not generated or available.

[0169] For this analysis, we perform two-sided paired t-test analyses of the mean change in skin thickness measured by ultrasound detected from enrollment to week 12 (single-blind placebo exposure) versus the mean change detected from week 12 to the end of the study (single-blind acevirstat exposure).

[0170] Second Analysis Analysis Population: The second analysis will include participants who completed all required study visits. However, for participants who do not complete the study, their data will be censored and reviewed using the analysis population. Treatment summaries and adverse events data will also be provided separately for each treatment category.

[0171] Analytical Plan: The final analysis will be undertaken after the last enrolled participant completes all planned study events. A secondary analysis will use all enrolled subjects who complete the protocol by the end of the study.

[0172] In prospective clinical trials such as the proposed one, the main concern is loss of follow-up. In such cases, if a participant is not followed up, the participant can be included in the analysis if at least one post-baseline value is recorded before being lost to follow-up. The approach for loss of follow-up relies on a flexible assumption about missing data, that is, missing values ​​are lost randomly. However, in the current proposed situation, our previous experience with the clinical antagonism of 5-LO and LTB4 makes it clear that clinical response is not measurable before a total of 6 months of continuous treatment. For this reason, in the situation of loss of follow-up, interim data for analysis is not generated or available.

[0173] For this analysis, we will perform two-tailed paired t-test analyses of the mean change in caliper skinfold thickness detected from enrollment to week 12 (single-blind placebo exposure) versus the mean change detected from week 12 to the end of the study (single-blind acevirstat exposure).

[0174] Sample size Accrual estimates: The principal investigator manages a national referral center for lymphatic disorders and will encounter approximately 600 new patients with clinically significant lymphedema on an annual basis. Some of these patients will be referred from the surgery and oncology breast clinics at Stanford, but most will come from urban and regional medical centers. With this pool of eligible patients, we expect to be able to recruit the 70 participants needed within one calendar year. Once the proposed study is approved and open for enrollment, we will facilitate enrollment through an IRB-approved marketing campaign for the study.

[0175] Sample Size Justification: The null hypothesis for this study is that treatment of lymphedema of the arm with acevirstat for 24 weeks does not provide an improvement in skinfold thickness compared to placebo exposure. The alternative hypothesis is that acevirstat provides a statistically significant improvement compared to placebo. For the study, the primary and secondary endpoints represent matched pairs of continuous response variables. Previous data derived from our published placebo-controlled pilot study of ketoprofen treatment in lymphedema 19 , indicating that differences in matched pairs of such data are typically distributed with a standard deviation of 6. If the true difference in the mean response of matched pairs is 2.4, we would need to test 68 pairs of subjects to be able to reject the null hypothesis that this difference in response is 0 with a probability (power) of 0.9. The type I error probability associated with this test of this null hypothesis is 0.05.

[0176] Effect Size Justification: Previously demonstrated effect sizes of LTB4 / 5-LO antagonism in chronic lymphedema have been shown to provide meaningful subjective and functional gains in previously enrolled treatment responders. The current trial is designed to replicate or potentially increase the previously observed effect sizes.

[0177] Criteria for future trials: If the current pilot study statistically achieves its primary endpoint, we will proceed with a moderately accelerated, fully randomized, placebo-controlled trial of acevirstat in chronic lymphedema. Further prospective clinical investigations are planned to investigate the ability of effective prophylactic therapy with acevirstat in cohorts at high risk for lymphedema development and to formally investigate the ability of this therapy to reduce the prevalence of post-treatment soft tissue infections.

[0178] References [Table 7-1] [Table 7-2] [Table 7-3]

[0179] While the present invention has been particularly shown and described with respect to preferred embodiments thereof, it will be understood by those skilled in the art that various changes in form and details can be made therein without departing from the scope of the invention encompassed by the appended claims.

[0180] The patents and scientific literature referenced herein establish knowledge available to those skilled in the art. All U.S. patents and published or unpublished U.S. patent applications cited herein are incorporated by reference. All published foreign patents and patent applications cited herein are incorporated by reference. All other published references, documents, manuscripts and scientific literature cited herein are incorporated by reference. The relevant teachings of all patents, published applications and references cited herein are incorporated by reference in their entirety.

Claims

1. 1. A pharmaceutical composition comprising acebilstat for use in a method for treating acromyocyte lymphedema in a patient in need thereof, the method comprising administering to the patient an effective amount of acebilstat, wherein the treatment results in a reduction in skin thickening.

2. 10. The pharmaceutical composition of claim 1, wherein the reduction in skin thickening is measured by skin ultrasound.

3. 10. The pharmaceutical composition of claim 1, wherein the reduction in skin thickening is measured by skin calipers.

4. 10. The pharmaceutical composition of claim 1, wherein the patient is suffering from secondary or acquired acrolymphedema.

5. 5. The pharmaceutical composition of claim 4, wherein the patient has previously undergone surgery and / or radiation therapy for cancer.

6. The pharmaceutical composition according to claim 5, wherein the cancer is a solid tumor.

7. 7. The pharmaceutical composition of claim 6, wherein the patient is suffering from upper limb lymphedema associated with breast cancer treatment.

8. 2. The pharmaceutical composition of claim 1, wherein the effective amount of acebilstat is less than the amount that provides maximal inhibition of LTA4H.

9. 10. The pharmaceutical composition of claim 1, wherein acebilstat is administered orally.

10. 10. The pharmaceutical composition of claim 9, wherein the daily dose of acebilstat is 200 mg / day or less.

11. 11. The pharmaceutical composition of claim 10, wherein the daily dose of acebilstat is 100 mg / day or less.

12. 12. The pharmaceutical composition of claim 11, wherein the daily dose of acebilstat is 75 mg / day or less.

13. 13. The pharmaceutical composition of claim 12, wherein the daily dose of acebilstat is 50 mg / day or less.

14. 14. The pharmaceutical composition of any one of claims 1 and 12-13, wherein acebilstat is administered twice daily.

15. 14. The pharmaceutical composition of any one of claims 1 and 10 to 13, wherein acebilstat is administered once daily.

16. 10. The pharmaceutical composition of claim 1, wherein acebilstat is administered topically.

17. 2. The pharmaceutical composition of claim 1, wherein the reduction in skin thickness occurs within 24 weeks after the first administration of acebilstat.

18. 18. The pharmaceutical composition of claims 1 and 17, wherein the reduction in skin thickening is at least about a 10% reduction compared to baseline.

19. 19. The pharmaceutical composition of claim 18, wherein the reduction in skin thickening is at least about a 20% reduction compared to baseline.

20. The pharmaceutical composition of claim 1, wherein the method further comprises administering a second active agent, the second active agent being selected from the group consisting of COX-1 inhibitors, COX-2 inhibitors, coumarins, antihistamines, montelukast and related leukotriene modifiers, antifibrotic compounds, diuretics, statins, mTOR inhibitors and pirfenidone.

21. The pharmaceutical composition of claim 1, wherein the method further comprises administering a second active agent, the second active agent being selected from the group consisting of a prolymphangiogenic drug, an anti-TGF-β1 antibody, an anti-IFN-γ antibody, an anti-IL-4 antibody and an anti-IL-13 antibody.

22. 1. A pharmaceutical composition comprising a selective LTA4H inhibitor for use in a method for treating acromyocyte lymphoedema in a patient in need of such treatment, the method comprising administering to the patient an effective amount of a selective LTA4H inhibitor, wherein the treatment results in a reduction in skin thickening, and the selective LTA4H inhibitor is selective for epoxide hydrolases over aminopeptidases.

23. 23. The pharmaceutical composition of claim 22, wherein the LTA4H inhibitor is at least about 1.5-fold selective for the epoxide hydrolase activity of LTA4H over the aminopeptidase activity of LTA4H.

24. 23. The pharmaceutical composition of claim 22, wherein the LTA4H inhibitor is at least about 2-fold selective for the epoxide hydrolase activity of LTA4H over the aminopeptidase activity of LTA4H.

25. 25. The pharmaceutical composition of any one of claims 22 to 24, wherein the LTA4H inhibitor is at least about 1.5-fold selective for LTA4H over other aminopeptidases.

26. 23. The pharmaceutical composition of claim 22, wherein the selective LTA4H inhibitor is selected from the group consisting of acebilstat, cis-resveratrol, trans-resveratrol, the isoflavone daidzein, and 7,8,4'-trihydroxyisoflavone.

27. 27. The pharmaceutical composition of claim 26, wherein the selective LTA4H inhibitor is acebilstat.

28. 23. The pharmaceutical composition of claim 22, wherein the reduction in skin thickening is measured by skin ultrasound.

29. 23. The pharmaceutical composition of claim 22, wherein the reduction in skin thickening is measured by skin calipers.

30. 23. The pharmaceutical composition of claim 22, wherein the effective amount of the selective LTA4H inhibitor is less than the amount that provides maximal inhibition of LTA4H.

31. A pharmaceutical composition comprising acebilstat or another selective LTA4H inhibitor for use in a method for reducing skin thickening in a patient in need thereof, the method comprising administering to the patient an effective amount of acebilstat or another selective LTA4H inhibitor, wherein the treatment results in a reduction in skin thickening.

32. 32. The pharmaceutical composition of claim 31, wherein the patient is in need of improved skin softness.

33. 32. The pharmaceutical composition of claim 31, wherein the patient is suffering from scleroderma.

34. 32. The pharmaceutical composition of claim 31, wherein the reduction in skin thickening is measured by skin ultrasound.

35. 32. The pharmaceutical composition of claim 31, wherein the reduction in skin thickening is measured by skin calipers.

36. 32. The pharmaceutical composition of claim 31, wherein the effective amount of acebilstat is less than the amount that provides maximal inhibition of LTA4H.

37. 32. The pharmaceutical composition of claim 31, wherein acebilstat is administered orally.

38. 32. The pharmaceutical composition of claim 31, wherein the daily dose of acebilstat is 200 mg / day or less.

39. 39. The pharmaceutical composition of claim 38, wherein the daily dose of acebilstat is 100 mg / day or less.

40. 1. A pharmaceutical composition comprising acebilstat for use in a method of treating lymphedema in a patient in need thereof, comprising administering to the patient an effective amount of a combination of acebilstat and a second active agent, wherein the second active agent is selected from the group consisting of COX-1 inhibitors, COX-2 inhibitors, coumarins, antihistamines, montelukast and other leukotriene inhibitors, antifibrotic compounds, diuretics, statins, mTOR inhibitors, and pirfenidone.