Formulation for use in treating osteoarthritis

Abstract

To provide a formulation for suppressing the progress of osteoarthritis and the like.SOLUTION: An injectable liquid for local injection into a joint of a patient is provided, comprising a pharmaceutically acceptable, injectable carrier, and a therapeutically effective amount of a peptide comprising a specific sequence, wherein the injectable liquid affects morphological change of bone underlying articular cartilage in the patient, to suppress the progress of osteoarthritis.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] Field of the invention The present invention relates generally to methods for treating osteoarthritis by correcting the deformation of bones in joints, which is the pathology that underlies the development and progression of osteoarthritis. [Background technology]

[0002] background Osteoarthritis Osteoarthritis is the most common joint disease and the most widespread of all chronic diseases. In the United States, osteoarthritis (OA) is the second leading cause of work disability in people over age 50, after heart disease. Worldwide, osteoarthritis is the sixth leading cause of years lived with disability (Woolf 2003).

[0003] Approximately 80% of patients with osteoarthritis require treatment for the knee. The most common radiographic finding in the knee of affected individuals is loss of articular (hyaline) cartilage and deformation of the surrounding bone, often with the formation of osteophytes in the articular space. Lesions are commonly seen in both the femoro-tibial and patello-femoral joints. Patello-femoral osteoarthropathy, due to loss of cartilage in the patella and trochlear groove, accounts for the majority of patients with osteoarthritis of the knee, and is often accompanied by loss of cartilage in other parts of the knee (Davies 2002).

[0004] Pain is a common symptom in patients with knee osteoarthritis. Pain is usually treated with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). However, in addition to the first black box warning in 2005 and warnings and cautions in prescription labels for NSAIDs, the US Food and Drug Administration strengthened existing label warnings for non-aspirin NSAIDs, including over-the-counter drugs, in 2015 regarding an increased risk of heart attack or stroke (https: / / www.fda.gov / drugs / drug-safety-and-availability / fda-drug-safety-communication-fda-strengthens-warning-non-aspirin-nonsteroidal-anti-inflammatory). Intra-articular injections of corticosteroids and hyaluronic acid preparations are also used to relieve pain. Corticosteroid injections have been shown to accelerate knee cartilage degeneration (McAlindon 2017), and physicians often refrain from using this treatment. The American Academy of Orthopaedic Surgeons / American Association of Orthopaedic Surgeons does not recommend corticosteroid injections for the treatment of knee osteoarthritis.

[0005] Hyaluronic acid or "viscosupplementation" preparations are injected into the knee at 2 cc per week for three weeks, or at a single higher dose (6 cc: Chevalier 2010). Injections of hyaluronic acid remain in the joint for a short period of time, from a few hours to a few days. Joint pain may be relieved for weeks to months in some patients (Cohen 1998), but clinical trials have failed to demonstrate a clinically meaningful therapeutic effect. The American Academy of Orthopaedic Surgeons states that "the use of hyaluronic acid is not recommended in patients with symptomatic knee osteoarthritis" (American Academy of Orthopaedic Surgeons, Evidence-Based Guidelines for the Treatment of Knee Osteoarthritis, Second Edition, May 18, 2013: https: / / www.aaos.org / globalassets / quality-and-practice-resources / osteoarthritis-of-the-knee / osteoarthritis-of-the-knee-2nd-editiion-clinical-practice-guideline.pdf).

[0006] Articular cartilage degeneration and current treatments It is widely accepted that osteoarthritis involves the progressive degeneration of articular cartilage. Degeneration of articular cartilage in the knee, hip, and elbow progresses slowly with age. Joint degeneration can be accelerated by joint injury or by continued excessive stress on the joint caused by strenuous physical work or exercise (Sandmark 2000, Felson 1991).

[0007] Articular cartilage allows smooth, nearly frictionless movement of the joints. It cushions the impact of repeated loading and counteracts the shear forces acting on the joint. Articular cartilage is formed by chondrocytes embedded in an extracellular matrix consisting of collagen, non-collagenous proteins, water, and proteoglycans such as aggrecan. Proteoglycans are hydrophilic molecules that allow hydration of the cartilage surface, which increases the ability of articular cartilage to absorb biomechanical forces. Articular cartilage is a biologically unique tissue with properties that cannot be mimicked by any engineered material or by fibrous cartilage ("scab" cartilage) formed after cartilage injury or microfracture surgery.

[0008] Unfortunately, articular cartilage lost through injury or the continuing “wear and tear” that accompanies aging cannot be naturally regenerated (Buckwalter 2002).

[0009] To date, only surgery and symptomatic treatment (pain management) are accepted as treatments for patients suffering from knee osteoarthritis. Surgical treatment involves microfractures and deliberate damage to the subchondral bone to promote the formation of fibrous cartilage ("scab" cartilage). However, fibrous cartilage has less structural strength and stability than articular cartilage and degenerates more quickly. Another surgically invasive procedure aimed at repairing knee cartilage involves drilling holes in the bone beneath the cartilage and implanting plugs made of chondrocytes or their precursor cells obtained from a non-weight-bearing area of ​​the same patient's body or from a cadaver (autotransplantation of cartilage and bone, or allotransplantation, OATS). This procedure involves two surgeries and requires 6 weeks after surgery before the operated joint can be weight-bearing. It is not uncommon for the treatment to fail or for complications to require reoperation.

[0010] Autologous chondrocyte transplantation, in which healthy chondrocytes are harvested from the patient's own knee through arthroscopic surgery and then cultured and expanded, also requires two surgeries. The cultured chondrocytes are then transplanted into the patient. This requires surgery to open the knee. The patient's cartilage is incised (removed) down to the bone underneath, and a periosteum or artificial membrane enclosure is attached to the incision. The cultured chondrocytes are then injected into the membrane. Carticel, a company that has performed autologous chondrocyte transplants in over 150 patients, (登録商標) In a study of graft replacement therapy, 49% of patients required reoperation due to complications (Zaslav 2009). The main complications included detachment, graft failure, and poor graft survival (Niemeyer 2008).

[0011] The final treatment option for patients with severe knee osteoarthritis is joint replacement surgery, which is surgically invasive, expensive, and potentially morbid. Total knee replacement costs between $35,000 and $70,000, not counting the cost of postoperative rehabilitation (which takes at least six weeks) and lost productivity. Prosthetic joints have a limited lifespan and need to be replaced every 15 to 20 years. For this reason, total knee replacements are often reserved for older patients. However, the average age of patients undergoing total knee replacement continues to decline; in 2000 it was 68 years old, but in 2014 it was 65.9 years old (American Academy of Orthopaedic Surgeons, 2018). In 2014, over 680,000 total knee replacement surgeries were performed in the United States, and it is expected that 1.28 million total knee replacement surgeries (excluding revision surgeries) will be performed in 2030 (2018 American Academy of Orthopaedic Surgeons: https: / / aaos-annualmeeting-presskit.org / 2018 / research-news / sloan_tjr / ).

[0012] Drugs for the treatment of osteoarthritis (DMOAD) Understanding the limitations and potential complications of current treatments, considerable effort has been expended to develop therapies that attempt to slow knee joint degeneration by either promoting articular cartilage production or reducing cartilage degradation.

[0013] For example, several groups have attempted to develop inhibitors of matrix metalloproteinases, which have been thought to be the primary cause of cartilage degradation (Krsezki 2007). Another group has attempted to inhibit nitric oxide, which was thought to promote cartilage destruction (Hellio le Graverand 2013). Many drugs thought to inhibit cartilage degradation in knee osteoarthritis have been tested in controlled clinical trials, but so far none have been successful in slowing or halting cartilage loss.

[0014] Another approach to treating knee osteoarthritis is cartilage regeneration research. Various growth factors, including molecules of the TGFβ (Transforming Growth Factor β) family such as Bone Morphogenetic Protein-7 (BMP-7), have been tested for their effect on cartilage regeneration. None of the growth factors tested in clinical trials showed any effect (Guermazi 2017). Fibroblast Growth Factor-18 (FGF-18, also known as Sprifermin) produced a small but statistically significant increase in cartilage thickness at the femoro-tibial joint in subjects with knee osteoarthritis, but the treatment group did not improve subjects' knee function or pain compared to the placebo group (Hochberg 2017, Hochberg 2018).

[0015] Drugs in development that may regenerate articular cartilage or slow its degeneration are considered potential therapeutic drugs for the treatment of osteoarthritis (DMOADs).

[0016] The peptide with sequence ID No. 1, TPX-100, has demonstrated articular chondrogenic activity in a goat cartilage injury model and is a potential treatment for osteoarthritis (U.S. Patent Nos. 7,888,462 and 8,426,558). The peptide with sequence ID No. 1 was tested in a randomized, double-blind, placebo-controlled study in subjects with osteoarthritis of both knees. TPX-100-treated knees showed statistically significant and clinically meaningful improvements in knee function and other clinical outcomes compared to placebo-treated knees (McGuire 2017). The functional improvement in TPX-100-treated knees was significant and sustained through the end of the one-year study period. The improvement in knee function was accompanied by an increase or stabilization of cartilage thickness at the femoro-tibial joint as measured by MRI 12 months after treatment (McGuire 2018).

[0017] Questions about cartilage structure in the pathophysiology of osteoarthritis Degeneration of articular cartilage has been thought to be the primary pathological mechanism of knee osteoarthritis, but clinical observations have led some investigators to question whether cartilage degradation occurs as a consequence of changes in other parts of the joint.

[0018] For example, when articular cartilage is severely lost, the underlying bone is exposed. Because bone has a high density of pain-sensing nerve fibers, it is reasonable to expect that this "bone-on-bone" arthropathy would be accompanied by severe pain. However, it is not uncommon for subjects with knee osteoarthritis to have little or no pain, even though imaging shows complete loss of cartilage. Conversely, many osteoarthritis patients experience severe pain and reduced function, even though imaging shows little to no degeneration of the articular cartilage.

[0019] This discrepancy between clinical symptoms and cartilage thickness was demonstrated in a study of FGF-18 (also known as Sprifermin), a potential treatment for osteoarthritis and a chondrocyte growth factor. A clinical trial with over 500 subjects with knee osteoarthritis compared four dose groups of FGF-18 with a placebo group. Subjects received FGF-18 or placebo injections once a week for a total of three times (i.e., days 0, 7, and 14). The same injections of the investigational drug and placebo were repeated after 6, 12, and 18 months. Changes in the femoro-tibial joint spacing were measured by MRI, and clinical symptoms were measured using the Western Ontario and McMaster Universities Osteoarthritis Outcome Score (WOMAC), a widely accepted patient-reported measure. At 24 months after the start of treatment, the FGF-18-treated groups had a dose-dependent increase in cartilage thickness at the femoro-tibial joint compared to the placebo-treated group. At the two higher doses, the difference in articular cartilage thickness compared to the placebo-treated group reached statistical significance. However, no clinical improvement was observed in any of the FGF-18-treated groups compared to the placebo-treated group (Hochberg 2017). At 36 months after the start of treatment, no clinical differences were observed between the FGF-18-treated and placebo-treated groups (Hochberg 2018).

[0020] In 1999, the U.S. Food and Drug Administration (FDA) issued a draft guideline for treatment of osteoarthritis of the knee, which included radiographic joint space widening or delayed joint space narrowing as acceptable endpoints for approval of treatment. However, this draft guideline was updated in August 2018, in which the FDA stated that radiographic and other imaging findings are not recommended surrogate markers for the development of treatments for osteoarthritis. The latest guideline succinctly states:

[0021] “…there are multiple unresolved issues surrounding the development of such products, including the complex, multifactorial epidemiology of the disease, the lack of consistency between widely recognized structural changes and pathology / symptoms / function, the lack of a baseline definition of disease progression, and the associated lack of endpoints that can reliably assess a product’s ability to alter osteoarthritis progression.” (FDA 2018)

[0022] Thus, the current consensus is that there is no correlation between changes in cartilage thickness and clinical outcome. In particular, changes in cartilage thickness may not be sufficient to explain the osteoarthritis symptoms experienced by patients, and increasing cartilage thickness does not represent a clinical benefit to osteoarthritis treatment unless it is convincingly associated with clinical benefit to patients.

[0023] Pathological role of subchondral (perichondral) bone in knee osteoarthritis Studies are underway to determine the role of bone beneath the articular cartilage in the development and progression of osteoarthritis.

[0024] Clinical trials have examined whether osteoporosis drugs such as strontium ranelate (Reginster 2013), calcitonin (Karsdal 2015), and zoledronate (Laslett 2012) could be used to treat osteoarthritis. These drugs stimulate new bone formation or inhibit bone resorption. The high hopes for these drugs to be useful in osteoarthritis have been dampened by their lack of clinical efficacy in stabilizing or strengthening the subchondral bone and their strong adverse events. For example, strontium ranelate was found to increase the risk of myocardial infarction, leading the European Medicines Agency to restrict its use.

[0025] A recently proposed marker of osteoarthritis is the measurement of three-dimensional (3D) changes in perichondral bone morphology. In a large comparison of subjects enrolled in the National Institutes of Health Osteoarthritis Initiative (OAI) database, it was shown that all subjects with radiographic osteoarthritis had increased perichondral bone surface area in their knees compared to normal knees. Changes in bone surface area were shown to predict osteoarthritis symptoms and loss of joint function more reliably than cartilage thickness or joint space narrowing (Bowes 2015).

[0026] Analysis of perichondral bone morphology changes in subjects enrolled in the Osteoarthritis Initiative (OAI) revealed that the 3D perichondral bone morphology changes continuously and in the same direction as osteoarthritis progresses. The shape of the femur, tibia, and patella flatten even in the absence of obvious cartilage loss. The 3D perichondral bone morphology changes are measured by defining multiple anchor points ("principal components") on the bone surface. The movement of the location of these anchor points is measured using MRI images and algorithmic analysis using the Active Appearance Model (AAM). As osteoarthritis progresses, the bone morphology of the subjects, especially the perichondral bone surface of the femur, changes in the expected direction regardless of the subjects' demographic characteristics such as age, sex, and Body Mass Index (BMI). In non-osteoarthritic joints in the OAI database that were not radiographically diagnosed as osteoarthritis, i.e., had a Kellgren-Lawrence (KL) score of 0, the perichondral bone morphological changes over a 4-year period were found to be significantly slower than those in osteoarthritic joints as assessed by the KL score. The bone morphological changes were normalized by a "B score," which is the standard deviation from the extent of perichondral bone morphological changes in non-osteoarthritic knees (Neogi 2013; Hunter 2016).

[0027] Three-dimensional morphological changes in perichondral bone are a better predictor of osteoarthritis pain than semi-quantitative analysis of bone marrow lesions (Dube 2018).

[0028] The effect of bisphosphonate treatment was examined using changes in bone surface area and three-dimensional morphology in subjects enrolled in the OAI database who were treated for osteoporosis. There was a statistically significant reduction in the increase in medial tibial bone surface area in subjects treated with bisphosphonates compared to those not treated with bisphosphonates. However, there was no difference in the three-dimensional morphological changes of the bone between the two groups. No analysis of differences in symptoms of knee osteoarthritis, such as function or pain, was reported (Haj-Mirzaian 2018).

[0029] There are reports that high bone mass or bone mineral density increases the risk of knee osteoarthritis or joint replacement (Nevitt 2010, Hardcastle 2013). These reports, combined with the above data on bisphosphonates, mean that increased bone mass or strengthening of bones does not necessarily lead to improvement or reduced risk of osteoarthritis.

[0030] TPX-100 Peptide TPX-100 is a 23-residue synthetic peptide derived from human matrix extracellular phosphoglycoprotein or MEPE and has the amino acid sequence TDLQERGDNDISPFSGDGQPFKD (Sequence ID No. 1).

[0031] The active pharmaceutical ingredient of TPX-100 is manufactured as either an acetate or a sodium salt, and the final formulation is a lyophilized product with an amidated C-terminus. The TPX-100 injection (formulation) used in clinical trials was dissolved in water for injection.

[0032] TPX-100 tissue-compatible regenerates dentin, bone, and cartilage without causing mineralization or ossification of soft tissues. TPX-100 can be administered by standard subcutaneous or intra-articular injection.

[0033] In preclinical safety and efficacy studies, TPX-100 was first tested for its osteogenic activity. The TPX-100 peptide was found to be the "osteogenic active site" of human MEPE and was shown to increase the thickness of cultured mouse parietal bones (Hayashibara 2004). Subcutaneous injection of TPX-100 was then shown to promote fracture healing in a widely used rat long bone fracture model (also known as the Einhorn model) (Lazarov 2004). Furthermore, early studies of the TPX-100 peptide showed that it promoted dentin formation in a rat dentin injury model (Six 2007). TPX-100 was well tolerated in these in vivo bone and dentin formation studies. The safety of TPX-100 was also confirmed in subsequent GLP toxicity studies and in Phase I clinical trials in healthy subjects.

[0034] Based on these safety and bone and dentin formation data, TPX-100 was examined in two Phase II clinical trials for its alveolar bone and dentin formation activities, respectively. TPX-100 was shown to be safe in both studies. In one clinical trial examining dentin formation, TPX-100 administered to the site of a damaged human molar tooth was shown to form repair dentin (Lazarov 2006). In another clinical trial examining alveolar bone formation, no differences were found between the drug and placebo groups.

[0035] It is hereby noted that in the above non-clinical and clinical studies investigating the efficacy of TPX-100 on bone and dentin, there was no data or evidence to prove or suggest that TPX-100 affects the shape or other morphological characteristics of these hard tissues. TPX-100 was only shown to increase the hard tissues in flat, thin bone and dentin, and to heal experimental mid-section fractures of long bones in a rat model.

[0036] TPX-100 was subsequently shown to have cartilage regeneration activity in a standardized cartilage injury model in goats. Four weekly intra-articular doses of TPX-100 (125 mg and 250 mg) induced statistically significant, histologically confirmed regeneration of hyaline cartilage in a full-thickness knee cartilage injury model in pasture-controlled goats, compared with a sham control group, 6 months after surgical injury. TPX-100 was safe and well tolerated in pasture-controlled goats with fully weight-bearing knees (U.S. Patents 7,888,462 and 8,426,558).

[0037] A randomized, double-blind, placebo-controlled clinical trial of TPX-100 was conducted in patients with mild to severe osteoarthritis of both knees. TPX-100 was expected to improve key functions of the osteoarthritis-affected knees.

[0038] In this clinical trial, the study drug was administered by intra-articular injection once a week for three weeks for a total of four times (days 0, 7, 14, and 21). In this study, TPX-100 was safe and well tolerated.

[0039] TPX-100-treated knees (Index Knees) showed clinically meaningful and statistically significant improvements in the Knee injury and Osteoarthritis Outcome Score (KOOS) for Activities of Daily Living (ADL) and Sports and Recreation function. Knee-related quality of life (Knee-related QOL) and pain while ascending and descending stairs also showed clinically meaningful and statistically significant improvements. Additionally, Index Knees showed significant improvements in Western Ontario and McMaster Universities Osteoarthritis Score (WOMAC) function and total score compared to the control group. Improvements in TPX-100-treated knees were seen at 6 months, 12 months, or both after treatment. There were no measurable differences in MRI between index and control knees in overall knee cartilage thickness at 6 or 12 months from the start of treatment, however, knees that responded to TPX-100 treatment, i.e., knees that showed clinically meaningful functional improvement, showed a significant increase in cartilage thickness at the femoro-tibial joint at 12 months from the start of treatment (McGuire 2018).

[0040] As mentioned above, TPX-100 is derived from human MEPE. Several other orthologues of MEPE, and therefore orthologues of TPX-100, are known. Examples of TPX-100 orthologues are: TDLQERGDNDMSPFSGDGQPFKD (Macaca mulatta) (Sequence ID No. 2) PDLQERGDNDISPFSGDGQPFKD (Dog) (Sequence ID No. 3) PDLQGRGDNDLSPFSGDGPPFKD (Bovine) (Sequence ID No. 4) PDLLVRGDNDVPPFSGDGQHFMH (rat / mouse) (Sequence ID No. 5) The rat / mouse amino acid sequence has the lowest homology with the human type (15 / 23 identical, 65% homology). The rat type is known to enhance the uptake of tritiated thymidine by human osteoblastic mesenchymal stem cells (U.S. Patents 7,888,462 and 8,426,558), and these TPX-100 counterparts and their analogs should be expected to have the same biological function as TPX-100. These peptides share the common amino acid sequence DLXXRGDNDXXPFSGDGXXF (Sequence ID No. 6), where X can be any amino acid. Summary of the Invention

[0041] A new method for treating osteoarthritis is disclosed. This method includes any therapeutic intervention that can slow, halt, or reverse the pathological three-dimensional morphological changes in perichondral bone that accompany the onset and progression of osteoarthritis. The present invention is the first to demonstrate that pathological perichondral bone morphological changes can be treated, and that such treatment correlates significantly with dramatic improvements in many of the symptoms that cause disabling injuries to patients.

[0042] One feature of the present invention is the treatment of pathological three-dimensional morphological changes in perichondral bone by administering (by local injection) to a patient (diagnosed with osteoarthritis) a therapeutically effective amount of a peptide formulation of Sequence ID No. 1.

[0043] Another feature of the present invention is a method for treating osteoarthritis by slowing, arresting or reversing the changes in perichondral bone morphology, comprising the steps of: analyzing the three-dimensional structure of a patient's joint with MRI to diagnose the perichondral bone morphology; administering a therapeutically effective amount of a peptide preparation of Sequence ID No. 1; and determining whether the perichondral bone morphology has changed significantly after 6 months, 12 months, 24 months, etc., compared to the morphology before treatment.

[0044] Other imaging techniques, such as computed tomography and ultrasound, may also be used to analyze bone morphology.

[0045] MRI is widely used to diagnose osteoarthritis pathology, such as loss of articular cartilage and the condition of the meniscus. Bone morphology before and after treatment can be analyzed using image sequences taken for cartilage diagnosis. Combining bone morphology and cartilage analysis may increase the sensitivity of treatment efficacy evaluation.

[0046] The peptides used in the present invention can be formulated as injections containing water or saline and injected locally by intra-articular or subcutaneous administration. Corresponding moieties of the peptide of SEQ ID No. 1 in other species and analogues thereof are known to exhibit activity similar to that of the peptide of SEQ ID No. 1. Any of these peptides can be formulated into an injectable preparation containing water for injection, saline, etc.

[0047] One feature of the present invention is that the method can involve injection of the formulation only once, only twice, three times, four times, five times, etc. Administration can be daily, once every three days, once a week, once every ten days, once a month, once every two months, once a quarter, once every six months, once a year, once a year, or any combination of these administration frequencies.

[0048] In one aspect of the invention, the method also includes assessing the patient's knee function and / or pain using a scale such as the KOOS and / or WOMAC, as well as other appropriate patient self-reported measures (Patient Reported Outcomes or PROs) and clinical assessments.

[0049] One feature of the present invention is that drug dosages ranging from 50 mg to 500 mg, 100 mg to 400 mg, 200 mg, etc., may be used, all milligram dosages being within ±20%, ±10%, ±5%.

[0050] Evaluating patients based on the match or non-match criteria described in this patent is also part of the present invention.

[0051] One of the features of the present invention is that it slows, stops, or reverses the aging of joints by correcting the morphological changes in bone surrounding cartilage that are inevitable with aging.

[0052] One aspect of the invention includes a method and / or use of such a substance to affect morphological changes in bone at the base of a joint in a patient, which patient may be any animal, including humans and dogs, comprising locally injecting into a joint of the patient an effective amount of an injectable formulation comprising any of the peptides of sequence ID No. 1, 2, 3, 4, 5, or 6. The injections may be intra-articular and repeated as needed, for example every other week for a period of 2, 3, 4 or more weeks, and may be continued in an amount ranging from 50 to 400 mg ± 20% of the peptide, for the purpose of affecting morphological changes in bone at the base of a joint in the patient, and the bone morphological changes to be treated may occur in a patient diagnosed with osteoarthritis.

[0053] One of the features of the present invention is that the dosage of the above-mentioned method and use can be adjusted according to several factors, such as the size, weight, sex, and physical condition of the patient. Furthermore, the dosage can be adjusted according to the type of patient, such as human or dog, and the joint to be treated. Larger patients and larger joints require higher dosages, while smaller patients and smaller joints require lower dosages. The basic concept of the present invention is not limited to a specific dosage range, and as will be appreciated by those skilled in the art, the dosage can be varied based on each of the above factors and taking into account other factors. The dosages given above are preferred dosage ranges for an average adult human knee. Those skilled in the art can extrapolate from the above dosages to dosages suitable for other joints and other animal species.

[0054] A feature of the invention is that the above method and / or use is directed to a human or canine patient, in which the amino acid sequence is that of SEQ ID No. 1. The injection may be intra-articular, and the changes in bone morphology may be due to osteoarthritis or due to ageing.

[0055] Another feature of the invention is that in the above methods and / or uses, administration and / or continuation of treatment may be determined, at least in part, by comparing images taken before and / or during treatment to determine whether the injection has affected bone morphology, and such measurement of bone morphology may be achieved using Active Appearance Model (AAM) software. [The present invention 1001] 1. A formulation for use in influencing morphological changes in bone at the base of an articular cartilage in a patient, comprising: An injectable liquid for local injection into a patient's joint, comprising a pharma- ceutically acceptable injectable carrier and a therapeutically effective amount of a pharma- ceutical active peptide that affects morphological changes in the patient's articular cartilage bed bone, thereby affecting morphological changes in the patient's articular cartilage bed bone. [The present invention 1002] The formulation of the present invention 1001, wherein the peptide is selected from the group consisting of peptides of SEQ ID No. 1, SEQ ID No. 2, SEQ ID No. 3, SEQ ID No. 4, SEQ ID No. 5, and SEQ ID No. 6. [The present invention 1003] The formulation of the present invention, wherein the peptide is a peptide of Sequence ID No. 1. [The present invention 1004] The formulation of any of claims 1001 to 1003, wherein a patient has been diagnosed with osteoarthritis, and the formulation inhibits the progression of osteoarthritis in the patient. [The present invention 1005] Obtaining initial images of the bone at the base of the articular cartilage before injection; Obtaining a second image of the bone at the base of the articular cartilage after injection; Comparing the first image with the second image; To determine the effect of the injections on bone morphological changes; and Based on the comparison, determine whether additional injections are needed. The formulation of any one of 1001 to 1004 of the present invention, further comprising: [The present invention 1006] The formulation of any of claims 1001-1005, wherein the peptide is a peptide of sequence ID NO. 1 and is administered in an amount within the range of about 50-400 mg ± 20%. [The present invention 1007] The formulation of any of claims 1001 to 1006, wherein said use is repeated injections over multiple weeks, and the peptide is injected in an amount within the range of 50 to 400 mg ± 20%. [The present invention 1008] 1. A formulation for use in slowing, arresting or reversing the natural aging of a joint, comprising: A peptide of Sequence ID No. 1 for use in retarding the increase in bone surface area and the changes in three-dimensional morphology that occur naturally in bone beneath an articular cartilage. [The present invention 1009] A formulation for use in a method comprising the steps of: (a) measuring bone morphology of a patient's joint; (b) locally injecting into a joint of a patient a therapeutically effective amount of a formulation comprising a pharma- ceutically acceptable injectable carrier and a peptide of Sequence ID No. 1; (c) re-measuring the bone morphology of the joint and comparing the measurements obtained with the measurements obtained prior to the local injection of step (b). [The present invention 1010] repeating steps (a), (b), and (c); A formulation for use according to the present invention 1009, further comprising: [The present invention 1011] A formulation for use according to the present invention 1009 or 1010, wherein the measuring and re-measuring steps are carried out using Active Appearance Model (AAM) software, the injection is an intra-articular injection, and the patient has been diagnosed with osteoarthritis (OA). [The present invention 1012] 1. A formulation for use in reducing the frequency of knee pain by influencing three-dimensional morphological changes in the bone at the base of the articular cartilage of the affected joint, the use of which comprises the following formulation: A therapeutically effective amount of a formulation comprising a pharma- ceutical acceptable injectable carrier and a pharma- ceutical active peptide that is characterized by influencing morphological changes in the bone at the base of the articular cartilage of the patient, thereby influencing morphological changes in the bone at the base of the articular cartilage of the patient, is locally injected into a joint of the patient. [The present invention 1013] The formulation for use of the present invention 1012, wherein the peptide is peptide of Sequence ID No. 1 for intra-articular injection and the bone is the patella. [The present invention 1014] The formulation of the present invention 1013, wherein the morphological changes are due to osteoarthritis. [The present invention 1015] The formulation of the present invention 1013, wherein the morphological changes are due to aging. [Brief description of the drawings]

[0056] The invention is best understood by reading the following detailed description in conjunction with the accompanying drawings, in which: It is emphasized that, as is normal practice in drawing figures, the various parts of the figures are not drawn to scale. Conversely, the scale used in the figures may be increased or decreased as circumstances require for clarity. The drawings included in this invention are as follows:

[0057] [Figure 1]This graph shows the results of a clinical trial conducted, measuring knee function from the start of the trial to 12 months later using the Activities of Daily Living ("KOOS ADL") scale included in the Knee injury and Osteoarthritic Outcome Score (KOOS). [Diagram 2] This graph shows the results of a clinical trial conducted, measuring the change in knee function from the start of the trial to 12 months later using the KOOS Sports and Recreation scale. [Diagram 3] A graph showing the results of a clinical trial conducted, measuring change from the start of the trial to 12 months later using the KOOS Knee-Related QOL scale. [Figure 4] The KOOS pain scale questions and scoring method are shown. [Diagram 5] This graph shows the results of a clinical trial, and specifically shows the change in "pain when going up or down stairs" on the KOOS pain scale from the start of the trial to 12 months later. [Figure 6] This graph shows the results of a clinical trial, showing the change in the frequency of knee pain, specifically in the KOOS pain scale, from the start of the trial to 12 months later. [Figure 7] A graph showing the results of a clinical trial conducted, illustrating the difference in the rate of change in pericartilage bone surface area between knees with and without osteoarthritic disease in four regions of the knee joint. [Figure 8] A graph showing the results of a clinical trial, showing the change in bone surface area around the medial femur cartilage from the start of the trial to 12 months later. [Figure 9] Graph showing the difference in the rate of change in surface area of ​​three regions of perichondral bone between the Index Knee (TPX-100 treated knee) and the Control Knee (sham treated knee). [Figure 10] This is a graph showing the results of a clinical trial, showing the change in femoral morphology score from the start of the trial to 12 months later. [Figure 11] is a graph showing the results of a clinical trial carried out comparing the frequency of pain in knees that responded to treatment with peptide having sequence ID No. 1 from the start of the trial to 12 months later in knees that did not respond to treatment. [Figure 12] Graph showing the results of a clinical trial carried out, showing the correlation between the change in three-dimensional patella morphology and the change in pain from the start of the trial until 12 months later, for knees that responded to treatment with peptide of sequence ID No. 1 and those that did not. [Figure 13] This is a graph showing the results of a clinical trial, illustrating the change in three-dimensional morphology of the femur from the start of the trial until 12 months later. [Figure 14] Graph showing the results of a clinical trial carried out, showing the change in frequency of knee pain in responders and non-responders to treatment with peptide of sequence ID No. 1 from the start of the trial until 12 months later. [Figure 15] A graph showing the results of a clinical trial carried out, showing that the changes in three-dimensional morphology of the patella in responders and non-responders to treatment with peptide of sequence ID No. 1 from the start of the trial until 12 months later correspond to the changes in frequency of knee pain. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0058] Detailed Description of the Invention Before describing the methods, uses, and formulations of the present invention, it should be understood that the invention is not limited to the particular articles described herein, but rather may vary, and the scope of the invention is limited only by the claims contained in this patent, and the terminology used is used to describe the particular articles and not for purposes of limitation.

[0059] Where any range of values ​​is given, each value within that range is understood to be disclosed to the nearest tenth of the lowest value in that range, unless specifically stated otherwise. Any stated value or smaller range within a stated range of values, and any other stated or included value within a stated range, is included in the invention. The upper and lower limits of such smaller ranges may each be independently included or excluded from the range, and each smaller range that includes or excludes such limits is also included in the invention, unless otherwise stated. When a stated range includes one or both of its upper and lower limits, ranges that include one or both of those limits are also intended to be included in the invention.

[0060] Unless otherwise defined, technical and scientific terms used in this patent have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. Methods and materials similar or equivalent to those described in this patent can be used in the practice or testing of the present invention, although other preferred methods and materials that may be used are also described. Publications mentioned in this patent are used as references to disclose and illustrate the methods and / or materials described therein. It is to be understood that the present invention replaces the content disclosed in the publications mentioned in this patent, unless otherwise stated.

[0061] Unless otherwise indicated, as used in this detailed description and the claims which follow, the singular forms "a," "an," and "the" include the plural forms, so for example, reference to "an injection" includes the administration of multiple such injections, reference to "a measurement" includes one or more measurements or equivalents thereof known to those skilled in the art, and so forth.

[0062] The publications listed in this patent are solely for their disclosure prior to the filing of this patent application. They are not intended to be an admission of antecedence of the present invention. Further, the publication dates listed may be different from the actual publication dates, which may need to be independently confirmed.

[0063] Cartilage structure in the pathophysiology of osteoarthritis As mentioned in the background section above, the pathogenesis of osteoarthritis has long been believed to be the degeneration of articular cartilage, which is believed to cause joint dysfunction and pain. Many candidate drugs for the treatment of osteoarthritis (DMOAD) have been tested in clinical trials with the aim of modifying articular cartilage structure. However, few drugs have been able to actually modify cartilage structure in human clinical trials. Even when clinical trials have shown a small increase in cartilage, there has never been a corresponding patient benefit, such as improved knee function or pain, compared to a placebo treatment.

[0064] Of the clinical data published to date, the only study in which a statistically significant clinical benefit was observed in parallel with increased cartilage thickness or stabilization in knee osteoarthritis was a randomized, placebo-controlled clinical trial of peptide sequence ID No. 1 (McGuire 2018).

[0065] Clinical efficacy and cartilage thickness in knee osteoarthritis The peptide of Sequence ID No. 1 (or TPX-100) is known to promote new cartilage formation (US Pat. Nos. 7,888,462 and 8,426,558).

[0066] Because of this activity, peptide having Sequence ID No. 1 was tested in a Phase II, randomized, double-blind, placebo-controlled clinical trial in patients with mild to severe knee osteoarthritis to determine its safety and efficacy in treating conditions involving cartilage damage (see Examples).

[0067] The expected clinical benefit of this peptide was to improve knee function: if the peptide repairs damaged cartilage, maintains normal functioning cartilage, or strengthens cartilage against age-related wear and tear, joint function would be improved.

[0068] Knee function, as measured by the KOOS ADL and WOMAC functional scales, demonstrated clinically meaningful and statistically significant (p = 0.008) improvements in the knee treated with peptide Sequence ID No. 1 ("Index Knee") compared to the placebo-treated knee ("Control Knee") at both 6 and 12 months post-treatment. See Figure 1.

[0069] The Index Knee demonstrated clinically meaningful and statistically significant improvements in KOOS sports and recreation function and knee-related quality of life measures compared with the Control Knee. See Figures 2 and 3.

[0070] Although the index knee showed only a statistically significant improvement (p<0.09) in the overall KOOS pain scale compared to the control knee 12 months after treatment, the index knee showed a statistically significant improvement (p<0.05) in pain frequency and pain when ascending and descending stairs compared to the control knee. See Figures 5 and 6.

[0071] The primary endpoint of this study was patellar cartilage thickness 6 months after treatment, but no statistically significant difference was observed between the index and control knees. Only 16% of the patellas in the study showed a change in cartilage thickness from baseline to measurement, limiting the number of samples available for this endpoint. However, it may be reasonable to attribute the strong clinical benefits seen in the TPX-100-treated group to cartilage repair, formation, and stabilization by the peptide.

[0072] In a post-hoc analysis of this study, a positive correlation was found between the change in cartilage thickness at the femoro-tibial joint and knee function measured by the KOOS ADL and WOMAC functional scales at 12 months after treatment in the index knee but not in the control knee (McGuire 2018). Among the many clinical trials of potential treatments for osteoarthritis, this is the first study to demonstrate that the increase in cartilage thickness was accompanied by clinical efficacy significantly superior to that of the placebo treatment group.

[0073] Following publication of these results, additional analysis was performed that confirmed that there was a statistically significant correlation between increased cartilage thickness and stabilization of the femoro-tibial joint and improved knee function at 12 months post-treatment in the index knee, but not in the control (placebo-treated) knee. See Table 1.

[0074] (Table 1) Correlation between increase / stabilization of femoral-tibial articular cartilage thickness and improvement of knee function at 6 and 12 months after treatment in the index knee TIFF2025028788000002.tif52148

[0075] These results confirm that peptide having sequence ID No. 1 improves clinical efficacy and increases / stabilizes cartilage thickness in the femoro-tibial joint in patients with knee osteoarthritis.

[0076] The clear improvement in multiple clinical symptoms observed in patients with mostly moderate to severe knee osteoarthritis following treatment with peptide having Sequence ID No. 1 may suggest that other biological activities besides cartilage formation and stabilization contribute to the efficacy of this peptide.

[0077] Analysis of perichondral bone surface area and morphology To address this question, we measured the surface area and three-dimensional morphology of the perichondral bone in the index and control knees.

[0078] It has been shown that perichondral bone undergoes predictable morphological changes with normal aging, and that these changes accelerate with the onset and progression of osteoarthritis. This pattern of perichondral bone morphological change is common to osteoarthritic knees; the perichondral bone flattens and loses its normal morphology, increasing the bone surface area. Such bone morphological changes begin in patients with advanced osteoarthritis many years before joint abnormalities are visible on radiographs (Reichenbach 2008).

[0079] Such 3D morphological changes can be quantified using Active Appearance Models (AAMs). AAMs allow the 3D form and appearance of an object of interest to be quantified using a number of anchor points ("principal points") on the object's surface. These principal points allow the computation of an object-specific 3D morphology. The use of AAMs to represent the morphology of the femur, tibia, and patella has been described in detail by Neogi et al. (Neogi, 2013).

[0080] Using this method, perichondral bone surface area and bone morphology were compared between knees with and without osteoarthritic disease in subjects enrolled in the National Institutes of Health Osteoarthritis Initiative (OAI). As detailed by Bowes et al. (Bowes 2015) and Hunter et al. (Hunter 2016), the percent change in surface area and bone morphology of the femur, tibia, patella, and trochlea (the front part of the femur that contacts the patella; this area is also called the patellofemoral joint bone or PF) were compared between knees with and without osteoarthritic disease over a 4-year period. All areas of bone surface area increased from baseline in subjects with or without osteoarthritis. Bone morphology scores also increased in all areas from baseline. These changes were unidirectional and did not reverse in nature.

[0081] Osteoarthritic knees showed greater increases in bone surface area in all regions compared to non-osteoarthritic knees (see Figure 7). Perichondral bone surface area in osteoarthritic knees typically showed statistically significant increases over the first year compared to non-osteoarthritic knees (Bowes 2015). Perichondral bone in osteoarthritic knees also showed statistically significant faster changes in bone morphology compared to non-osteoarthritic knees.

[0082] In clinical trials of TPX-100, where the drug was administered only four times at the beginning of the study period (days 0, 7, 14, and 21) and no additional treatment was administered thereafter, Imorphics used AAM analysis to measure the 3D perichondral bone morphology and surface area of ​​the knee joint, which showed a slower rate of change in the index knee (treated with TPX-100) compared to the control knee. The MRI images used to measure articular cartilage thickness were used to measure the perichondral bone surface area of ​​the lateral and medial femur, lateral and medial trochlear femur, lateral and medial tibia, and lateral and medial patella. Bone morphology scores of the femur, trochlear femur, tibia, and patella were also measured using the same MRI images.

[0083] In the same clinical trial, changes in perichondral bone surface area were compared between the index knee and the control knee in each of the eight regions.

[0084] In control knees (treated with a placebo), perichondral bone surface area continued to increase in all regions, similar to the natural changes seen in osteoarthritic knees in the Osteoarthritis Initiative database.

[0085] The increase in perichondral bone surface area of ​​the medial femur in the index knee showed a trend toward a decrease approaching statistical significance after 6 months compared to the control knee (p = 0.08). Figure 8 compares the change in medial femoral bone surface area between the index knee and the control knee at 6 and 12 months after treatment.

[0086] Figure 9 shows the change in perichondral bone surface area of ​​the index knee and control knee for the lateral femur, lateral patella, and medial patella, respectively. Although no significant differences were found between the two groups in these comparisons, the change in bone surface area in the index knee was almost zero in all these bone regions for the first 6 months after treatment.

[0087] When comparing the changes in three-dimensional bone morphology, the changes in the Index Knee were statistically significantly reduced compared to those in the Control Knee. This difference was statistically significant at both 6 and 12 months after treatment (p = 0.005 and 0.007, respectively). Notably, the average bone morphology change in the Index Knee during the first 6 months was 0.03, which was very close to the average rate of change in subjects without osteoarthritis in the OAI database. See Figure 10.

[0088] Analysis of participants in the Osteoarthritis Initiative has shown that all knees undergo continuous changes in bone surface area and three-dimensional morphology with age. These changes are accelerated by knee osteoarthritis. If we could slow, halt, or reverse these bone changes, it would be a causal treatment for osteoarthritis.

[0089] As mentioned above, treatment of knees with mild to severe osteoarthritis with peptide of sequence ID No. 1 suppressed the changes in the three-dimensional morphology and surface area of ​​the femur compared to the placebo-treated group, indicating that the progression of osteoarthritis can be delayed, stopped, or even reversed by peptide of sequence ID No. 1. In this study, only one series of peptide of sequence ID No. 1 was administered (four times on days 0, 7, 14, and 21). If peptide of sequence ID No. 1 was administered in multiple series at regular intervals, such as several months, one year, or two years, the pathological changes in the three-dimensional structure and surface area of ​​bone in osteoarthritis should be kept normal for a long period of time.

[0090] These data suggest that peptide of Sequence ID No. 1 may slow, stop or even reverse the increase in perichondral bone surface area, thereby slowing, stopping or reversing the progression of osteoarthritis and slowing or completely reversing the loss of joint function that occurs with natural aging.

[0091] It is noteworthy that the effect of peptide of sequence ID No. 1 in increasing the pathological perichondral bone surface area and correcting the changes in three-dimensional bone morphology is observed within a relatively short period of 6 to 12 months after treatment.

[0092] It was surprising that the reduction in pathological perichondral bone morphological changes with peptide of Sequence ID No. 1 occurred in such a short period of time, resulting in a clear and statistically significant therapeutic effect, despite the relatively small sample size.

[0093] Because knee clinical outcomes as measured by KOOS Activities of Daily Living (KOOS ADL), KOOS Sports and Recreation Function, and KOOS Knee Quality of Life scales showed clinically meaningful and statistically significant improvements in the Index Knee at 6 months, 12 months, or both after treatment, and because progression of osteoarthritis as measured by perichondral bone changes was slowed, stopped, or reversed in the Index Knee compared to the Control Knee, it is believed that the peptide having Sequence ID No. 1 modifies the pathophysiology of osteoarthritis by modifying the perichondral bone structure.

[0094] To explore the possibility that peptide having Sequence ID No. 1 may have an effect of improving perichondral bone morphology, correlation analysis was performed using Pearson and Spearman statistical analysis methods.

[0095] Among all the regions of the knee joint, the femur is the bone with the largest cartilage periphery. Structural changes in the femur are believed to have a significant impact on the pathophysiology and progression of knee osteoarthritis. The peptide with sequence ID No. 1 significantly reduced the pathological three-dimensional bone morphological changes of the femur within 6 months of administration (Figure 10). Both Pearson and Spearman statistical analysis methods showed that there was a correlation between the reduction in pathological three-dimensional morphological changes of the femur and the increase / stabilization of the femoro-tibial joint cartilage thickness in the knee treated with peptide with sequence ID No. 1 (index knee). See Table 2. There was a statistically significant correlation between the increase / stabilization of the cartilage thickness of the femoro-tibial joint as a whole, the lateral side, the medial side, and the femoral condyle, and the reduction in pathological three-dimensional morphological changes of the femur. Even at 6 months after treatment, there was a trend toward a statistical correlation between the increase / stabilization of the cartilage thickness of the femoro-tibial joint as a whole, the medial side, and the femoral condyle, and the reduction in pathological three-dimensional morphological changes of the femur. These results indicate that the peptide with sequence ID No. 1 reduces the pathological three-dimensional morphological changes of the femur at a relatively early stage (within 6 months after treatment) and increases / stabilizes the thickness of the cartilage in the femoral-tibial joint. The reduction in the pathological three-dimensional morphological changes of the femur and the increase / stabilization of the cartilage in the femoral-tibial joint were statistically highly correlated at 12 months after treatment.

[0096] (Table 2) Correlation between the reduction in pathological three-dimensional morphological changes of the femur and the increase / stabilization of the thickness of the femoral-tibial articular cartilage at 6 and 12 months after treatment in the index knee. TIFF2025028788000003.tif64159

[0097] When the same analysis was performed in subjects with femoro-tibial osteoarthritis in both knees (excluding patients with only patello-femoral osteoarthritis from the analysis), despite the further limited sample size, a statistically significant correlation was found between the reduction in pathological three-dimensional morphological changes of the femur and the increase / stabilization of cartilage thickness in the entire femoro-tibial joint and in the medial and femoral condyles at 12 months after treatment. See Table 3.

[0098] These correlations were only observed in the index knee, and no correlations were observed in the control knee, regardless of the analysis used.

[0099] Table 3. Correlation between reduction in pathological three-dimensional morphological changes of the femur and increase / stabilization of femoro-tibial articular cartilage thickness at 6 and 12 months after treatment in the index knee of subjects with osteoarthritis of the femoro-tibial joint in both knees. TIFF2025028788000004.tif62170

[0100] The pathological three-dimensional morphological changes of the patella were also reduced by the peptide of sequence ID No. 1. At 12 months after treatment, a statistically significant correlation was found in both Pearson and Spearman analyses between the reduction in the pathological three-dimensional morphological changes of the patella in the knee treated with peptide of sequence ID No. 1 (index knee) and the reduction in the frequency of knee pain. See Table 4. In the treatment responder group, the frequency of pain was significantly reduced during the 12-month follow-up period. See Figure 11. In the treatment responder group, the pain frequency score before the start of treatment was 3, i.e., daily pain level. Over the course of 12 months, the score improved by about 1.5 points, and the frequency of knee pain became "about once every two weeks." In addition, the frequency of painkiller use by the trial participants was reduced by 62.5% throughout the clinical trial.

[0101] Furthermore, the pathological three-dimensional morphological changes in the patella in the treatment response group regarding the frequency of pain were almost zero throughout the 12 months, whereas the changes continued to increase in the non-response group. There was a statistically significant difference between the two groups in the three-dimensional morphological changes in the patella from before the start of treatment until 12 months after treatment. See Figure 12.

[0102] Taken together, these results suggest that peptide having sequence ID No. 1 may reduce or reverse the pathological three-dimensional morphological changes of the patella, thereby significantly reducing the frequency of knee pain and the use of analgesics.

[0103] (Table 4) Correlation between the reduction in pathological three-dimensional morphological changes of the patella in the index knee and the reduction in pain frequency 12 months after treatment. TIFF2025028788000005.tif23152

[0104] This correlation between the reduction in pathological three-dimensional morphological changes of the patella and the improvement in pain frequency was only seen in the index knee, not in the control knee.

[0105] The pathological three-dimensional morphological changes of the patella are not as clear as those of the femur. Although it has been frequently stated that the severity of knee pain is associated with patellar pathology (Joseph 2016), this invention has demonstrated for the first time that the pathological three-dimensional morphological changes of the patella are a specific pathophysiological mechanism of knee pain in osteoarthritis. In traditional symptomatic pain treatment, patients can determine whether their pain has decreased immediately after treatment. In essential treatment of diseases that delay, stop, or reverse this pathological three-dimensional morphological change of the bone, the decrease in pain occurs as a result of the effect on the bone structure, and therefore takes several months after treatment, as shown by the data of this clinical trial. Therefore, tracking the morphological changes of the bone after this treatment can provide patients and medical professionals with useful information such as whether the patient's current pain will be relieved, whether further deterioration will be prevented, and whether repeated treatment will be of further benefit. Treating and preventing knee pain by reducing the pathological three-dimensional morphological changes of the patella is one of the most important elements of this invention.

[0106] As described above, the peptide of sequence ID No. 1 administered to patients with knee osteoarthritis can delay or even reverse the pathological three-dimensional morphological changes of the bone surrounding the cartilage at multiple sites in the knee joint, thereby resulting in clinical effects such as improved knee function and reduced frequency of knee pain. The peptide of sequence ID No. 1 simultaneously exerts a therapeutic effect on the bone and cartilage structures surrounding the cartilage. Therefore, a therapeutic drug containing the peptide of sequence ID No. 1 as a single active ingredient can treat both bone and cartilage lesions surrounding the cartilage. Depending on the method of administration, the peptide of sequence ID No. 1 can not only treat osteoarthritis, but also delay, stop, or reverse pathological changes associated with aging of the joint, i.e., it can be used prophylactically against osteoarthritis to delay its onset. Since the basic mechanism of osteoarthritis is common to many joints, the use of peptide having Sequence ID No. 1 for the treatment and prevention of osteoarthritis is not limited to the knee joint, but also extends to the hip, ankle, knee, shoulder, neck, spine, wrist and finger joints. Furthermore, this method can also be used to repair, rebuild and stabilize joints in other types of arthritis, such as rheumatoid arthritis, after treating specific causes such as autoimmune reactions and inflammation.

[0107] A new treatment for osteoarthritis The above clinical trial results have established a new method for treating osteoarthritis.

[0108] This method includes any therapeutic intervention that delays, stops, or reverses pathological periarticular bone morphological changes. Although data from follow-up studies of osteoarthritis patients participating in the Osteoarthritis Initiative have shown that the pathological nature of periarticular bone morphological changes in the onset and progression of knee osteoarthritis has been demonstrated, the clinical trial results described in this patent are the first to demonstrate that such periarticular bone morphological changes that do not naturally revert due to osteoarthritis can be delayed, stopped, or even reversed. Most importantly, the delay, stop, or reversal of periarticular bone morphological changes correlated with clinically significant patient benefits, such as improved function and pain in the affected joint. The present invention has confirmed in controlled human clinical trials that it is possible to delay pathological periarticular bone morphological changes, which are associated with improvement in the clinical symptoms of knee osteoarthritis.

[0109] The key element of this method is to inject a patient with osteoarthritis with a formulation containing a therapeutically effective amount of peptide of sequence ID No. 1 to inhibit the rate of change in bone surface area and morphology in diseased joints. Because osteoarthritic joints exhibit increased rates of change in perichondral bone surface area and three-dimensional morphology compared to non-osteoarthritic joints, reducing this rate of change could slow, halt, or even reverse the progression of osteoarthritis. Because these perichondral bone structural changes have been shown to begin before measurable cartilage loss and continue as osteoarthritis progresses, this new method could be used across the entire range of osteoarthritis from incipient to severe.

[0110] In addition to peptide of SEQ ID No. 1, orthologous peptides from non-human species, including but not limited to primates, dogs, cattle, and mice, are expected to have similar activity on perichondral bone structural changes in joints in humans and other species, and are therefore included in the present invention, for example peptides of SEQ ID Nos. 2-5.

[0111] Peptides similar to the peptide of SEQ ID No. 1, including those having the common amino acid sequence of SEQ ID No. 6, and orthologues believed to have similar biological activity to the peptide of SEQ ID No. 1, are also included in the present invention.

[0112] Furthermore, because the knee joint is known to undergo changes in its perichondral bone surface area and three-dimensional morphology as part of aging, the method includes preventing, slowing, halting, etc., an inevitable process that increases the risk of osteoarthritis by reducing the rate of pathological perichondral bone surface area and morphology change.

[0113] As shown in the Examples, this new method is particularly effective in treating knee osteoarthritis.

[0114] A key element of the present invention is a novel method for reducing the incidence of knee pain by slowing, halting, or reversing the three-dimensional morphological changes of the patella.

[0115] Also included in the present invention are formulations comprising the peptide of SEQ ID No. 1 that treat osteoarthritis by slowing, arresting or reversing the pathological morphological changes in the perichondral bone.

[0116] Although this invention was derived from the results of clinical trials on patients with knee osteoarthritis, similar pathological morphological changes in the bones around the cartilage should occur in osteoarthritis of other joints, and therefore osteoarthritis of other joints, such as the hip joint, ankle, knee, shoulder, neck, spine, wrist, and fingers, should also be included.

[0117] Because perichondral bone is damaged in many joint diseases and because the peptide of Sequence ID No. 1 can slow, stop or reverse the pathological structural changes in perichondral bone, this new method can also be used in joint diseases other than osteoarthritis, including rheumatoid arthritis, arthritis due to injury and other joint diseases. EXAMPLES

[0118] The following examples are provided to fully disclose and describe to one of ordinary skill in the art how the present invention may be made and used, but are not intended to limit the inventor's understanding of the invention or to limit the examples to all experiments performed. While every effort has been made to ensure accuracy with respect to numbers (e.g., amounts, temperatures, etc.), experimental errors and deviations should be allowed for. Unless otherwise noted, percentages are weight percentages, molecular weights are average molecular weights, temperatures are in degrees Celsius, and pressures during experiments are approximately atmospheric.

[0119] Example 1 A Randomized, Double-Blind, Placebo-Controlled Study of TPX-100 in Patients with Knee Osteoarthritis Clinical trial methodology Overview of the study A randomized, double-blind, placebo-controlled, multi-center study was designed to evaluate the safety, tolerability, pharmacokinetics, and efficacy of TPX-100 administered four times every other week in subjects with osteoarthritis of the patellofemoral joints of both knees. The study was conducted under an IND granted by the Center for Drug Evaluation and Research (CDER) of the FDA in compliance with GCP and ICH guidelines. The study was conducted at 18 orthopedic, rheumatology, and family medicine specialty practices in the United States.

[0120] The study was divided into Phase A and Phase B. Phase A was to evaluate the safety of intra-articular administration of different doses of TPX-100 (20, 50, 100, and 200 mg per injection, in that order) in subjects with knee osteoarthritis and to select the dose to be used in Phase B. Phase B was to evaluate the safety and efficacy of the selected doses of TPX-100.

[0121] Participants in Phase A were randomly assigned to receive 20, 50, 100, or 200 mg of TPX-100 (index knee) in one knee and an identical placebo (control knee) in the other knee. All participants, clinical sites, clinical investigators, and MRI imaging centers were blinded to which knee received which treatment. A Safety Review Committee (SRC) assessed the safety of each dose group. The next higher dose group was initiated if deemed safe by the SRC. The doses and initiation of treatment in Phase B were determined once dosing and safety evaluations were completed for all dose groups in Phase A.

[0122] Phase A consisted of dose-specific study arms receiving 20, 50, 100, and 200 mg of TPX-100 or placebo intra-articular injections once a week for four doses, in that order. Six subjects participated in each of the 20, 50, and 100 mg dose-specific study arms, and nine subjects participated in the 200 mg group.

[0123] Following safety review and approval by the Safety Evaluation Committee, 200 mg was selected as the dose for Phase B. No dose-limiting toxicities were observed at this dose or the three lower doses tested in Phase A. Eighty-seven subjects participated in Phase B (200 mg dose). Based on the statistical analysis plan, these subjects were combined with the nine subjects who participated in Phase A at the 200 mg dose. For efficacy, data from 93 subjects who were randomly assigned to receive 200 mg of TPX-100 in the index knee and an identical placebo in the contralateral knee once weekly for a total of four doses were analyzed.

[0124] In both Phases A and B, subjects received four weekly intra-articular injections of the active drug in the index knee that was randomly assigned to the active drug and the placebo in the contralateral (control) knee. No other treatments were administered, either active or placebo. All subjects returned to their respective study sites for safety and efficacy evaluations 3, 6, and 12 months after the first injection.

[0125] Subject Selection After accepting participation in the study, subjects underwent a clinical and biochemical screening evaluation in which their preliminary suitability for study participation was assessed. The screening included the following tests: Medical history, including past treatments · Intensive physical examination Vital signs including resting blood pressure, heart rate, respiratory rate, and temperature Weight, height, and body mass index (BMI) · Knee x-ray (if not taken within the past 3 months) Biochemistry tests including full range of hematology, blood coagulation and metabolic tests Records of medications being used

[0126] Subjects who met all clinical and biochemical criteria for inclusion in the study underwent standardized MRI scans of both knees.

[0127] Eligibility and non-eligibility criteria for clinical trial participation The eligibility and ineligibility criteria for subject selection to participate in either Phase A or B were as follows:

[0128] Eligibility criteria for clinical trial participation 1. Between 25 and 75 years old 2. Both knees have mild to moderate osteoarthritis of the patella-femoral joint, with no damage to the meniscus or ligaments (cruciate ligament and collateral ligament). Clinically, the patient was first assessed using the Clinical Trial Eligibility Questionnaire and by the clinical trial physician (which may be supported by knee imaging diagnostics), and the image analysis center confirmed that the MRI images of both knees met ICRS criteria 1 to 3 or ICRS 4, with cartilage damage measuring 1 cm or less. No meniscus damage (stage II degeneration as seen on MRI is acceptable) - Clinically determined stability of the cruciate and anterior ligaments 3. Be able to read, understand, sign and date the consent form to participate in the clinical trial 4. Agree to use acetaminophen as the primary analgesic (pain relieving drug) during the study. The maximum daily dose of acetaminophen will be 4 grams (4,000 mg). 5. During the investigational drug injection period (30 days from the start of the clinical trial), I agree to use a combination of hydrocodone and acetaminophen or hydrocodone alone for severe pain. 6. Agree to refrain from using nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen during the first 30 days of the study period. 7. Female subjects of childbearing potential who are sexually active (non-abstinent) must agree to and continue to use two highly effective methods of contraception (oral contraceptives, implants, injectables or intrauterine devices, condoms with spermicide, or sexual abstinence) during their participation in the study.

[0129] Ineligibility criteria for clinical trial participation 1. Contraindications to MRI include: metallic fragments, clips, or devices in the brain, eye, or spinal cord; magnetically programmed implants; weight over 300 pounds; moderate to severe claustrophobia; and previous failure to tolerate MRI. 2. Exceeds ICRS standard 3, except for ICRS standard 4, where the size of the cartilage damage is confirmed to be 1 cm or less by the MRI image analysis center. 3. MRI shows inflammatory or hypertrophic synovial inflammation or significant cartilage calcification 4. Those who have had knee surgery, except for surgery aimed only at dissection of the joint 5. Planning a knee replacement or other knee surgery within the next 12 months 6. History of rheumatoid arthritis, psoriatic arthritis, or other autoimmune or infectious arthritis 7. Joint effusion greater than 2+ on the following clinical scale: Zero = no wave when knee is moved down; Trace = small wave on inside of knee when knee is moved down; 1+ = larger bulge on inside of knee when knee is moved down; 2+ = spontaneous return of effusion on inside of knee when knee is moved up (without moving down); 3+ = too much effusion to move effusion on inside of knee 8. Have used viscosupplementation therapy (e.g., Synvisc) in either knee within 3 months prior to eligibility for the study. (登録商標) or other hyaluronic acid preparations) 9. Received intra-articular injection of corticosteroids within 2 months prior to eligibility for clinical trial participation 10. Received any steroid treatment (excluding steroid inhalation for treating respiratory symptoms) within one month before the eligibility to participate in the clinical trial 11. Known hypersensitivity to TPX-100 12. Known hypersensitivity to acetaminophen or hydrocodone 13. Have undergone arthroscopic surgery on either knee within 3 months prior to eligibility for the study 14. History of septic arthritis, gout or pseudo-gout in either knee within 1 year prior to eligibility for clinical trial 15. Clinical signs of acute meniscal injury (e.g., fixed or new meniscal lesions that may be symptomatic of a meniscal tear) 16. X-ray shows patellar cartilage calcification 17. Skin symptoms, redness or sensitivity at the injection site on either knee 18. Have bleeding problems, platelet or coagulation disorders that would adversely affect intra-articular injections 19. You have a systemic infection. 20. Currently or within the past 2 years prior to eligibility for participation in the study, undergoing treatment for malignant neoplasms other than basal cell carcinoma or squamous cell carcinoma of the skin, unless specifically permitted in writing by the medical officer of the study sponsor. 21. Females of childbearing potential who are currently pregnant, breastfeeding, or who do not agree to plan pregnancy or continue to use an effective method of contraception during the study. 22. Have participated in a clinical trial of any other osteoarthritis drug, excluding painkillers, within one year prior to the eligibility for clinical trials 23. Currently using paclitaxel (antimitotic drug) and / or natalizumab (anti-integrin drug) 24. History of severe liver disease or consumption of more than 3 alcoholic drinks per day (1 alcoholic drink is: 12 ounces of beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces or 1 shot of 80 proof spirits such as gin, rum, vodka, or whiskey)

[0130] Random treatment assignment Once all inclusion or exclusion criteria were met, MRIs of both knees were obtained and the final criterion for each knee was assessed at the imaging center to determine whether it met ICRS criteria (gICRS). Subjects were enrolled in the study if the cartilage at the patellofemoral joint in both knees met gICRS criteria 1-3 or 4 and the size of the cartilage lesion was 1 cm or less. At the randomization center, each subject was assigned to either "right knee treated with active medication" or "left knee treated with active medication." The knee treated with active medication received TPX-100, and the contralateral knee received an identical placebo.

[0131] Subjects enrolled in the study were randomly assigned to treatment groups within the same subjects, with one knee receiving an active drug injection and the other receiving an identical placebo injection. By pairing the two knees of the same subject as a comparison set, we were able to eliminate confounding factors between subjects (e.g., activity level, genetic epigenetic factors, pain tolerance) and increase the statistical power to detect treatment effects, if any.

[0132] Subjects assigned to Phase A were excluded from enrollment in Phase B.

[0133] Administration On the first day of treatment, randomized subjects underwent a physical examination and assessment of vital signs. In addition, subjects completed the KOOS questionnaire, including the WOMAC, which assesses knee-specific activities of daily living, sports and recreational function, knee-related quality of life, and other symptoms such as stiffness and knee pain. The KOOS has been widely used in long-term clinical trials of knee osteoarthritis. After completing these assessments, subjects received one injection in each knee with the injection formulation specified for that knee. One knee received TPX-100 and the other knee received a placebo injection, with neither the subject, the clinical site, nor the investigator knowing which knee received which injection. Subjects were observed during and for several hours after the injection for any adverse events. Vital signs were also observed after the injection.

[0134] On days 7, 14, and 21 after the first dose, subjects received the second, third, and fourth (final) doses of study drug, respectively. Safety and adverse events were assessed as for the first dose.

[0135] Follow-up evaluation after completion of treatment Subjects visited each study site for treatment outcome assessments 3, 6, and 12 months after the first dose. In addition, study sites called subjects 9 months after the first dose to verify their health. At 3, 6, and 12 months after treatment, subjects underwent self-reported clinical outcome assessments at each study site, including physical examinations, vital signs, blood tests, and the KOOS. Adverse events and concomitant medications were also recorded. MRIs of both knees were also obtained at 6 and 12 months.

[0136] Drug efficacy analysis Analysis was performed on all KOOS scale scores, WOMAC overall and individual scale scores, patellofemoral and femoro-tibial articular cartilage thickness by MRI, and pericartilaginous bone surface area and three-dimensional bone morphology by MRI.

[0137] The MRI images were sent to a center for analysis of the cartilage and surrounding bone. The MRI analysts were blinded to which knees had received which treatment.

[0138] The surface area and three-dimensional morphology of the perichondral bone were analyzed using AAM software developed by iMorphics (www.imorphics.com) specifically for the assessment of these parameters in osteoarthritic knees.

[0139] Statistical analysis was performed using two-tailed paired t-tests with 95% confidence limits. The items analyzed were the change in scores on each scale of the KOOS from the start of treatment to 6 and 12 months, the change in cartilage thickness, the change in perichondral bone surface area, and the change in three-dimensional bone morphology ("B score") between knees treated with the therapeutic drug (Index Knee) and knees treated with the placebo (Control Knee).

[0140] When examining correlations between two variables (eg, knee function vs. cartilage thickness), Pearson and Spearman correlation analyses were used.

[0141] result According to the statistical analysis plan, 93 subjects who received 200 mg of TPX-100 in one knee and placebo in the other knee and had at least one follow-up MRI were included in the efficacy analysis.

[0142] Approximately 47% of all knees had gICRS 4 (most severe) knee osteoarthritis, all of which involved the femoro-tibial joint. Another 40% had gICRS 3 (second most severe) knee osteoarthritis of the patello-femoral and / or femoro-tibial joints, and the remaining 20% ​​had gICRS 2 (moderate) knee osteoarthritis of both or one knee at the patello-femoral and / or femoro-tibial joints. No subjects had gICRS 1 (mild) knee osteoarthritis. The mean body mass index (BMI) of all subjects was over 30, which was in the obese range and comparable to the mean BMI of osteoarthritis patients in the United States. The mean age of the subjects was 58.1 years and 58% were female, which is also in line with the figures for osteoarthritis patients in the United States. Most subjects had severe osteoarthritis of both knees.

[0143] Treatment with TPX-100 was safe and well tolerated. There were no serious adverse events associated with TPX-100 treatment. Treatment-related adverse events were mild to moderate, transient, and consistent with those experienced by most participants at the start of the study.

[0144] The Index Knee (treated with TPX-100) demonstrated clinically meaningful and statistically significant improvements compared to the Control Knee (treated with placebo) on multiple patient self-reported measures, including the majority of the KOOS scales.

[0145] The KOOS ADL (function in daily living) scale consists of 17 questions about knee function that is important for various activities of daily living. The KOOS ADL scale results showed clinically meaningful and statistically significant (p < 0.05) improvements in the index knee compared to the control knee at both 6 and 12 months after treatment compared to baseline. See Figure 1. As expected, the WOMAC knee function scale, which has the same questions as the KOOS ADL, also showed a similar clear improvement in the index knee compared to the control knee.

[0146] The KOOS sports and recreation function scale consists of five questions about sports activities such as jumping, running, squatting, etc. KOOS sports and recreation function showed clinically meaningful and statistically significant improvement in the Index Knee compared to the Control Knee at 6 months after treatment. See Figure 2.

[0147] The KOOS knee-related quality of life scale consists of four questions that address subjects' general knee-related problems and self-perception of their confidence in each knee. At 12 months after treatment, the KOOS knee-related quality of life scale showed a clinically meaningful and statistically significant improvement in the index knee compared to the control knee. See Figure 3.

[0148] The KOOS pain scale consists of nine questions regarding 1) frequency of pain and 2) pain intensity during different activities. See Figure 4. KOOS pain measures showed a trend toward clinically meaningful and statistically significant improvement (p<0.09) in the index knee compared to the control knee at 12 months after treatment. WOMAC pain scale showed clinically meaningful improvement, although it did not reach statistical significance in the index knee compared to the control knee at 12 months after treatment.

[0149] One of the questions that make up the KOOS pain (and WOMAC pain) scale is "pain when ascending or descending stairs." This pain during daily activities is the most common pain reported by patients with knee osteoarthritis, and after 12 months of treatment, the index knee showed a statistically significant (p<0.05) improvement compared to the control knee. See Figure 5.

[0150] One of the questions on the KOOS pain scale (Question 1) asks, "How often do you feel pain in each knee?" This is the only question regarding pain frequency. This question is unique to the KOOS pain scale and is not included in the WOMAC pain measure. Pain frequency showed a statistically significant (p<0.05) reduction in the index knee compared to the control knee at 12 months post-treatment. See Figure 6.

[0151] Patellofemoral joint cartilage thickness, measured by MRI from the start of treatment through 6 months, was the primary outcome of the study. There were no measurable differences between the index and control knees at either 6 or 12 months. The majority of knees (84%) did not show measurable changes in patellofemoral joint cartilage thickness over the 12-month study period. Only 16% of knees showed measurable changes, either increases or decreases, severely limiting the number of samples that could be analyzed and therefore reducing the power to detect treatment effects.

[0152] Similarly, there were no measurable differences in femoro-tibial joint cartilage thickness between the index and control knees from the start of treatment through either 6 or 12 months. However, for knees with improved function as measured by KOOS ADL and WOMAC function, increased femoro-tibial joint cartilage thickness or stabilization correlated with improved knee function at 12 months in the index knee; no such correlation was seen in the control knee. See Table 1.

[0153] Changes in perichondral bone surface area and three-dimensional morphology measured by MRI were also compared between the index knee and control knee. Eight subjects had MRI images of insufficient quality for analysis and were excluded from bone surface area and morphology analysis. Thus, the size of each group was 85.

[0154] On the medial side of the femur, the pathological increase in bone surface area 6 months after treatment was smaller in the index knee than in the control knee, and showed a tendency close to statistical significance (p=0.08). See Figure 8.

[0155] In the lateral femur and medial patella, the pathological increase in bone surface area in the index knee was nearly zero over 6 months after treatment and showed a slower increase over 12 months compared to the control knee. See Figure 9.

[0156] These data demonstrate that treatment of knee osteoarthritis with peptide of Sequence ID No. 1 slows, stops, or even reverses the increase in perichondral bone surface area that occurs during the development and progression of osteoarthritis.

[0157] The three-dimensional morphological changes in the perichondral bone of the femur, quantified by the bone morphology (B) score, showed a statistically significant (p<0.05) decrease in the index knee compared to the control knee at both 6 and 12 months after treatment. See Figure 10.

[0158] Although the difference did not reach statistical significance, the Index Knee also showed slower changes in the three-dimensional morphology of the perichondral bone of the tibia and patella than the Control Knee. These data also indicate that treatment of knee osteoarthritis with peptide of sequence ID No. 1 slows, stops, or reverses the pathological changes in the perichondral bone structure that are the cause of knee osteoarthritis progression.

[0159] As shown in Table 1, the increase / stabilization of the cartilage thickness of the femoro-tibial joint was statistically significantly correlated with the improvement of KOOS daily function / WOMAC function in the index knee, but no such correlation was observed in the control. Further analysis showed that the three-dimensional morphological changes of the bone surrounding the femoral cartilage were significantly correlated with the increase / stabilization of the femoro-tibial articular cartilage thickness in the index knee, but no such correlation was observed in the control knee. See Tables 2 and 3. These results suggest that treatment of osteoarthritic knees with peptide of sequence ID No. 1 simultaneously delayed the pathological morphological changes of the bone surrounding the femoral cartilage, increased / stabilized the femoro-tibial articular cartilage thickness, and improved knee function.

[0160] In the literature on symptomatic knee osteoarthritis, patellofemoral joint pathology has been identified as the most clearly associated with knee pain. Delayed patellar morphological changes were significantly correlated with decreased frequency of pain in the index knee, but not in the control knee. See Table 4.

[0161] Additionally, knees that responded to TPX-100 treatment showed a dramatic improvement in pain frequency, decreasing on average from daily pain to approximately twice a month over the 12 months following treatment (see Figure 11). Knees that showed a dramatic improvement in pain frequency did not experience any change in the three-dimensional patellar morphology over the 12-month period (see Figure 12). Notably, overall pain medication use decreased by 62.5% over the 12-month period.

[0162] The results of the above clinical trials in patients with mild to severe knee osteoarthritis showed that the Sequence ID No. 1 peptide delayed, stopped, or even reversed the pathological structural changes of the perichondral bone in multiple regions of the knee joint, resulting in clinical benefits including improved knee function and pain.

[0163] Example 2 A randomized, double-blind, placebo-controlled study of TPX-100 in patients with knee osteoarthritis - stricter criteria for selection of MRI images for data analysis the purpose After the data analysis of Example 1 was completed, several additional MRI images used were questioned as to whether they were technically of sufficient quality to analyze the morphological changes of bone around the cartilage over time. In order to ensure the quality of the overall analysis results, the MRI images used in Example 1 were subjected to a more rigorous quality inspection again. As a result, 79 subjects passed again. The MRI images of the knees of these subjects were reanalyzed for morphological changes of bone around the cartilage, and the correlation between these and the thickness of the cartilage of the femoral-tibial joint and pain was reanalyzed by the method described in Example 1.

[0164] result The efficacy of the drug was analyzed according to the statistical analysis plan for 79 subjects who passed the MRI image quality inspection again.

[0165] Approximately 34% of all knees had gICRS 4 (most severe) knee osteoarthritis, all of which involved the femoro-tibial joint. Another 44% had gICRS 3 knee osteoarthritis at the patello-femoral and / or femoro-tibial joints, and the remaining 22% had gICRS 2 osteoarthritis at the patello-femoral and / or femoro-tibial joints. The patient demographics were similar to those in Example 1, with a mean body mass index of 30.9, mean age of 58.1, and 62% of all subjects being female.

[0166] All patient self-reported measures of knee function and quality of life (PROs) - KOOS ADL, WOMAC Function, KOOS Knee-Related Quality of Life - showed statistically significant (p<0.05) improvements in the Index Knee compared with the Control Knee at 6 months, 12 months, or both after treatment.

[0167] The KOOS pain scale showed similar results to Example 1: 12 months after treatment, the index knee showed improvement approaching statistical significance (p<0.09) compared to the control knee.

[0168] Of the nine questions included in the KOOS pain scale, the frequency of pain, pain when bending the knee fully, and pain when ascending and descending stairs showed statistically significant (p<0.05) improvements in the index knee compared to the control knee 12 months after treatment.

[0169] Regarding the three-dimensional morphological changes of the bone around the cartilage, as quantified by the bone morphological score, the Index Knee showed a statistically significant delay in the morphological changes of the femur compared to the Control Knee at both 6 and 12 months after treatment. See Figure 13.

[0170] As shown in Table 5, a statistically significant correlation was observed between the reduction in three-dimensional morphological changes in the bone surrounding the femoral cartilage and the increase / stabilization of the thickness of the femoro-tibial articular cartilage in the Index Knee, but no such correlation was observed in the Control Knee.

[0171] Table 5. Correlation between the reduction in pathological three-dimensional morphological changes in the femur and the increase / stabilization of the thickness of the femoral-tibial articular cartilage in the index knee 6 and 12 months after treatment. TIFF2025028788000006.tif60170

[0172] In the index knee, delayed patellar morphological changes were statistically significantly correlated with reduced frequency of pain, but in the control knee, no such correlation was observed (see Table 6).

[0173] Table 6. Correlation between the reduction in pathological three-dimensional morphological changes of the patella and the reduction in the frequency of pain in the index knee 12 months after treatment. TIFF2025028788000007.tif25156

[0174] Additionally, knees that responded to TPX-100 treatment showed a significant improvement in pain frequency, decreasing from an average of daily pain to approximately twice a month over the course of 12 months (see Figure 14). This significant improvement in pain frequency was accompanied by a complete cessation of three-dimensional bone morphological changes in the patella (see Figure 15).

[0175] In this Example 2, the quality control of the MRI images was more strictly performed, but the results were almost similar to those of Example 1. The above data indicate that peptide having Sequence ID No. 1 reduces, stops, or even reverses the pathological structural changes of the perichondral bone at multiple sites in the knee joint, resulting in important clinical benefits for patients, including improved knee function and pain.

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[0177] The above description merely describes the essence of the present invention. Those skilled in the art will be able to come up with various applications that constitute the essence of the present invention or include the spirit and scope of the present invention, even if they are not explicitly written or shown in this patent. Furthermore, the terms related to the embodiments and conditions used in this patent are primarily intended to help the reader understand the essence of the present invention and the concepts that the inventors have considered in carrying out the present invention, and the present invention is not limited to those specifically described embodiments and conditions. Furthermore, all descriptions that describe the principles, aspects, and embodiments of the present invention and their specific examples are intended to include structural and functional equivalents thereof in the present invention. In addition, the equivalents include those currently known to be similar and those developed in the future, that is, those that will be developed to perform the same function regardless of their structure. In other words, the scope of the present invention is not limited to only the examples described herein. Rather, the scope and spirit of the present invention are embodied by the appended claims.

[0178] Sequence information SEQUENCE LISTING <110> ORTHOTROPHIX, INC. <120> FORMULATION FOR USE IN TREATING OSTEOARTHRITIS <150> US 62 / 838,712 <151> 2019-04-25 <150> US 62 / 811,366 <151> 2019-02-27 <150> US 62 / 787,881 <151> 2019-01-03 <150> US 62 / 775,056 <151> 2018-12-04 <160> 6 <170> PatentIn version 3.5 <210> 1 <211> 23 <212> PRT <213> Artificial sequence <220> <223> synthetic sequence <400> 1 Thr Asp Leu Gln Glu Arg Gly Asp Asn Asp Ile Ser Pro Phe Ser Gly 1 5 10 15 Asp Gly Gln Pro Phe Lys Asp 20 <210> 2 <211> 23 <212> PRT <213> Artificial sequence <220> <223> synthetic sequence <400> 2 Thr Asp Leu Gln Glu Arg Gly Asp Asn Asp Met Ser Pro Phe Ser Gly 1 5 10 15 Asp Gly Gln Pro Phe Lys Asp 20 <210> 3 <211> 23 <212> PRT <213> Artificial sequence <220> <223> synthetic sequence <400> 3 Pro Asp Leu Gln Glu Arg Gly Asp Asn Asp Ile Ser Pro Phe Ser Gly 1 5 10 15 Asp Gly Gln Pro Phe Lys Asp 20 <210> 4 <211> 23 <212> PRT <213> Artificial sequence <220> <223> synthetic sequence <400> 4 Pro Asp Leu Gln Gly Arg Gly Asp Asn Asp Leu Ser Pro Phe Ser Gly 1 5 10 15 Asp Gly Pro Pro Phe Lys Asp 20 <210> 5 <211> 23 <212> PRT <213> Artificial sequence <220> <223> synthetic sequence <400> 5 Pro Asp Leu Leu Val Arg Gly Asp Asn Asp Val Pro Pro Phe Ser Gly 1 5 10 15 Asp Gly Gln His Phe Met His 20 <210> 6 <211> 20 <212> PRT <213> Artificial sequence <220> <223> synthetic sequence <220> <221> misc_feature <222> (3)..(4) <223> Xaa can be any naturally occurring amino acid <220> <221> misc_feature <222> (10)..(11) <223> Xaa can be any naturally occurring amino acid <220> <221> misc_feature <222> (18)..(19) <223> Xaa can be any naturally occurring amino acid <400> 6 Asp Leu Xaa Xaa Arg Gly Asp Asn Asp Xaa Xaa Pro Phe Ser Gly Asp 1 5 10 15 Gly Xaa Xaa Phe 20

Claims

1. 1. A formulation for use in influencing morphological changes in bone at the base of an articular cartilage in a patient, comprising: An injectable liquid for local injection into a patient's joint, comprising a pharma- ceutically acceptable injectable carrier and a therapeutically effective amount of a pharma- ceutical active peptide that affects morphological changes in the patient's articular cartilage bed bone, thereby affecting morphological changes in the patient's articular cartilage bed bone.

2. 2. The formulation of claim 1, wherein the peptide is selected from the group consisting of peptides having SEQ ID No. 1, SEQ ID No. 2, SEQ ID No. 3, SEQ ID No. 4, SEQ ID No. 5, and SEQ ID No.

6.

3. 2. The formulation of claim 1, wherein the peptide is a peptide of sequence ID No.

1.

4. 4. The formulation of any one of claims 1 to 3, wherein the patient has been diagnosed with osteoarthritis and the formulation reduces the progression of osteoarthritis in the patient.

5. Obtaining an initial image of the bone at the base of the articular cartilage before injection; Obtaining a second image of the bone at the base of the articular cartilage after injection; Comparing the first image with the second image; To determine the effect of the injections on bone morphology; and Based on the comparison, determine whether additional injections are needed. The formulation according to any one of claims 1 to 4, further comprising:

6. The formulation of any one of claims 1 to 5, wherein the peptide is a peptide of sequence ID NO. 1 and is administered in an amount ranging from about 50 to 400 mg ± 20%.

7. The formulation according to any one of claims 1 to 6, wherein said use is repeated injections over a period of several weeks, and the peptide is injected in an amount within the range of 50 to 400 mg ± 20%.

8. 1. A formulation for use in slowing, arresting or reversing the natural aging of a joint, comprising: A peptide of Sequence ID No. 1 for use in retarding the increase in bone surface area and the changes in three-dimensional morphology that occur naturally in bone beneath an articular cartilage.

9. A formulation for use in a method comprising the steps of: (a) measuring bone morphology of a patient's joint; (b) locally injecting into a joint of a patient a therapeutically effective amount of a formulation comprising a pharma- ceutically acceptable injectable carrier and a peptide of Sequence ID No. 1; (c) re-measuring the bone morphology of the joint and comparing the measurements obtained with the measurements obtained prior to the local injection of step (b).

10. repeating steps (a), (b), and (c); 10. The formulation for use according to claim 9, further comprising:

11. 11. The formulation for use according to claim 9 or 10, wherein the measuring and re-measuring steps are performed using Active Appearance Model (AAM) software, the injection is an intra-articular injection, and the patient has been diagnosed with osteoarthritis (OA).

12. 1. A formulation for use in reducing the frequency of knee pain by influencing three-dimensional morphological changes in the bone at the base of the articular cartilage of the affected joint, the use of which comprises the formulation: A therapeutically effective amount of a formulation comprising a pharma- ceutical acceptable injectable carrier and a pharma- ceutical active peptide that is characterized by influencing morphological changes in the bone at the base of the articular cartilage of the patient, thereby influencing morphological changes in the bone at the base of the articular cartilage of the patient, is locally injected into a joint of the patient.

13. 13. The formulation for use according to claim 12, wherein the peptide is peptide of Sequence ID No. 1 for intra-articular injection and the bone is the patella.

14. 14. The formulation of claim 13, wherein the morphological changes are due to osteoarthritis.

15. The formulation of claim 13, wherein the morphological changes are due to aging.

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