Method and composition for treating corona virus, influenza, and acute respiratory distress syndrome

Abstract

To provide a method of treating Corona Virus, e.g., COVID 19, Influenza and ARDS.SOLUTION: A composition comprises a copper chelator including a tetrathiomolybdate salt, a 5-lipoxygenase inhibitor which is diethylcarbamazine (DEC), at least one additional active agent selected from the group consisting of baicalin, fluvoxamine, bufalin, sulforaphane, apigenin, indole-3-carbinol, beraprost, and the aldose reductase inhibitor AT-001 of Applied Therapeutics, and a pharmaceutically acceptable carrier for drug delivery.SELECTED DRAWING: None

Description

Technical Field

[0001] This application claims the benefit and priority of U.S. Patent Application No. 17 / 398,156, filed Aug. 10, 2021, and U.S. Provisional Patent Application No. 63 / 063,528, filed Aug. 10, 2020, which are incorporated herein by reference.

[0002] The present invention relates to methods and compositions for treating coronavirus (e.g., COVID-19, its analogs, progeny, and variants), influenza, and acute respiratory distress syndrome.

Background Art

[0003] Currently, there are no agreed-upon treatment guidelines for COVID-19 or potential future novel coronaviruses, and many current developments focus on antiviral activity and vaccine development under the idea that the spread of the virus can be stopped. One of the ongoing causes of death in COVID-19 coronavirus is acute respiratory distress syndrome (ARDS), an acute impairment of the lung's function as a gas exchanger. ARDS is not a disease but a syndrome with multiple causes and can be caused by sepsis, trauma, surgical complications, massive blood transfusion, and aspiration of gastric contents. ARDS can also be caused by viral infections (coronavirus, hantavirus, herpesvirus, influenza virus). Outside of the current COVID-19 coronavirus pandemic, ARDS affects 200,000 patients annually in the United States, with a mortality rate of 22 - 33%. Since there is no effective treatment for fully developed ARDS, if COVID-19 coronavirus causes ARDS and progresses until it damages organs other than the lungs, death will result. Current ARDS treatment consists of low-volume mechanical ventilation and conservative management of intravenous fluids. The best way to avoid the development of ARDS is to prevent the progression from sepsis or diffuse alveolar damage to life-threatening fully developed ARDS. In many patients who develop ARDS, renal failure and sometimes multiple organ failure may follow. Since the median time period until the development of ARDS is 2 - 7 days after hospitalization, there is a treatable time window for early intervention (i.e., drug administration to patients at risk of developing ARDS). In the case of COVID-19 coronavirus patients, the time window may be several days longer. COVID-19 infected patients are at high risk when they have fever, pulmonary infiltrates, high plasma levels of C-reactive protein (CRP), and comorbidities such as cardiovascular disease and chronic lung disease (25).

[0004] According to research, the COVID-19 coronavirus has three stages as shown in Figure 1: Stage 1 - initial infection, Stage 2 - pulmonary stage, and Stage 3 - hyperinflammatory stage. In the initial infection stage, patients exhibit mild symptoms including fever, dry cough, fatigue, muscle pain, headache, dyspnea, and gastrointestinal symptoms such as nausea, vomiting, or diarrhea (in approximately 50% of patients). In the pulmonary stage, patients experience dyspnea (shortness of breath) with hypoxemia, abnormal infiltrates on chest imaging, transaminitis, and a lower than normal procalcitonin. In the hyperinflammatory stage, patients experience ARDS, systemic inflammatory response syndrome (SIS), and multiple organ failure (kidney, heart, liver, CNS) due to thromboembolic phenomena. In this devastating stage, inflammatory markers (IL-1, IL-6, and IL-8) increase, leakage of troponin indicates myocardial damage, and an increase in NT-proBNP reflects myocardial dysfunction. This disease progresses in severity from Stage 1 to Stage 2 and Stage 3, and in Stage 3, many patients die (25).

[0005] COVID-19 does not necessarily cause a severe illness. In fact, only a small proportion of patients infected with the virus are estimated to require hospitalization. The mortality rate of hospitalized patients varies depending on the age and pre-existing conditions of the patients. For patients who progress to Stage 2 and Stage 3 of this disease, the likelihood of death is relatively high. The fatal organ symptoms of the COVID-19 disease are generally acute lung injury (with or without pulmonary hypertension (19)) that causes respiratory failure, and cardiovascular disorders that cause heart failure (References 1-5). Underlying both symptoms are inflammation caused by multiple cell-cell interactions and in-situ thrombosis, which is a result of endothelial cell inflammation.

[0006] In diseases caused by COVID-19, it is generally recognized that the elderly, patients with comorbidities, and immunocompromised patients are at risk of developing severe diseases, and death is due to respiratory failure, heart failure, and multiple organ failure. According to the study by Li et al. (3), the most common organ damage outside the lungs was heart damage. The exact mechanism of heart damage has not been fully elucidated, but an excessive immune-inflammatory response and cytokine storm are most likely the causes. Troponin leakage, which reflects myocardial tissue damage, is seen in up to 8% of critically ill patients. In children, Kawasaki-like inflammation of the vasculature has been recognized. Although alveolar type II cells and macrophages have been found to be infected with COVID-19, it is now known that endothelial cells are also infected. Signs of thrombosis are recognized to cause acute coronary syndrome. Myocarditis and fatal arrhythmias have also been reported (1, 2, 4).

[0007] The common feature of the cardiac and respiratory failure syndromes that progress from COVID-19 is that inflamed endothelial cells (the endothelium can be regarded as an organ, and the lungs have the most endothelial cells in the body) serve as the stage for multicellular aggregates that clog blood vessels and capillaries (these aggregates are formed not only by macrophages but also include platelets, neutrophils, and red blood cells). The pathologically important mechanism of "vascular inflammation" is defined as the formation of multicellular aggregates that adhere to inflamed endothelial cells.

[0008] Experimentally infected Japanese macaques with COVID-19 progressed to acute lung injury characterized by large perivascular lymphocyte clusters and alveoli filled with macrophages and neutrophils (6).

[0009] In one human study, bronchoalveolar lavage fluid (BALF) from COVID-19 infected patients with severe lung injury was examined and the presence of numerous bone marrow-derived inflammatory cells, such as bone marrow dendritic cells, mast cells, plasma cells, and T lymphocytes, was reported. The authors describe a highly pro-inflammatory macrophage microenvironment and the presence of both M1 and M2 macrophages expressing NF-kappaB and STAT1 and STAT2 (7). NF-kappaB is a master transcription factor responsible for the transcription of several genes encoding inflammatory mediators.

[0010] In other recent papers, the role of oxidative stress has been discussed (8, 9). For intravascular inflammation, the generation of reactive oxygen species is expected and its cytotoxic potential is recognized. At present, it has not been resolved whether COVID-19-related lung injury is a special form of ARDS, but it is certain that inflammation (including intravascular inflammation) is involved in organ damage and patient death and is similar or identical to ARDS. A recent report by Ackermann et al. (24) showed vascular damage and microthrombi.

[0011] Figure 3 shows an intravascular inflammatory environment. This Figure 3 shows cell-cell interactions within the pulmonary vasculature and possibly within the coronary arteries and may be applicable to intravascular events occurring in severe COVID-19 disease. There are several pathways by which sepsis can cause damage to the endothelium. Sepsis can increase the expression of endothelial selectins (P and E selectins), allowing activated leukocytes (neutrophils and monocytes) and platelet aggregates to adhere and increasing endothelial permeability. The potential role of neutrophil extracellular traps (NETs) and histone release is also included, as well as orf-medin 4, lipocalin 2, and CD24, and bacterial permeability-increasing protein. These are mainly neutrophil products. Some circulating factors in plasma are biomarkers of damage and also enhance damage such as Ang-2 and VEGF. Additionally, in the drawing, circulating factors that enhance inflammation such as IL-8 and IL-6, sTNFr-2 are shown. Markers of endothelial damage include vWF and sFLT-1, circulating VEGF receptors. Also shown in the drawing are the components of the activated protein C complex, namely protein C, protein S, factor V, and thrombomodulin, and sepsis disrupts the normal function of activated protein C, causing a procoagulant environment.

[0012] Coronavirus disease (COVID-19) can be fatal due to inflammatory organ damage. In the lungs, it causes diffuse alveolar damage (DAD) and thrombotic vascular occlusion, ARDS, and in the heart (the other organ attacked), it causes myocarditis and myocardial injury (3 - 5). There is a consensus that the inflammatory response caused by COVID-19 determines the outcome.

[0013] Influenza virus infections occur annually and cause a significant mortality worldwide. Vaccines are developed every year to fight new influenza virus strains. There is no effective treatment for immunocompromised patients, children, and the elderly who show a high mortality rate when infected.

[0014] The role of the immune system as a defender against inflammatory organ damage has been evaluated. There is also a consensus that cytokines play an important role in the occurrence of inflammatory reactions. Of particular interest are IL-1, IL-6, and IL-8, and the therapeutic blockade of their receptors is a strategy that is being actively investigated in COVID-19 infected patients.

[0015] These cytokines can be produced by several inflammatory cells, but also by endothelial cells and vascular smooth muscle cells. The center of the production of these cytokines and TNFα is the transcription factor NF-κB, and IL-1 can activate IL-6 production and cause a vicious cycle of enhanced cytokine production.

[0016] The activation of NF-κB by TNFα induction and miR-125b induction is copper-dependent, and copper chelation has been shown to inhibit the activation of NF-κB in various cell types, including endothelial cells that are likely to develop an inflammatory phenotype (one of the characteristics of NF-κB expression). Furthermore, the activation of Toll-like receptors (TLRs) causes upregulated expression of several copper transporters, particularly Ctr1, Ctr2, and ATP7A (15).

[0017] Currently, there is no COVID-19 therapeutic agent that can prevent the progression of the coronavirus and prevent the intravascular inflammatory and procoagulant mechanisms that cause lung injury and heart failure.

[0018] Currently, there is no influenza therapeutic agent that can prevent the progression of the influenza virus and prevent the intravascular inflammatory and procoagulant mechanisms that cause lung injury and heart failure.

Summary of the Invention

[0019] Broadly speaking, the present invention is based on the finding that lethal events due to coronavirus, influenza, or ARDS can be prevented by drugs that interfere with intravascular inflammation. See FIGS. 3, 6, and 13. Intravascular events link lung failure and heart failure. Briefly, the "diseased pulmonary circulation" releases numerous mediators that enter the next adjacent circulation, the coronary circulation. The "bad humor" released by the diseased pulmonary circulation spills into the systemic circulation and also reaches the central nervous system. The overall concept is that damaged lungs, particularly the pulmonary vasculature, emit signals of cell injury. These signals include chemotactic factors such as chemokines and leukotrienes, cell fragments, and free DNA.

[0020] Specifically, the present invention is based on an understanding of the diseased pulmonary circulation, and the pulmonary microvasculature is severely affected in COVID-19 lung injury (see FIG. 5, reference 24). It undergoes an intravascular inflammatory response (by endothelial cells EC that have been shown to be infected with COVID-19 virus particles) that produces mediators and multiple cell-cell interactions. FIG. 4 illustrates this concept of "bad lung humor". The lungs have the largest capillary network in the human body and thus the most endothelial cells (EC). ECs infected with COVID-19 become cells involved in inflammatory cell-cell interactions and produce harmful mediators that spill out of the "diseased pulmonary circulation". FIG. 5 shows how the airways cause damage to the heart and lungs.

[0021] The present invention is partially based on the finding that microvessels with inflammation and thrombotic occlusion (FIG. 6) are important elements in COVID-19 severe disease and ARDS, and thus signs of vascular disease are targets for treatment. Regarding the involvement of the enzyme 5-lipoxygenase (5-LO), please refer to FIGS. 11 and 12.

[0022] The inventor has adopted the following strategies. (1) Inhibition of chemotaxis of inflammatory cells to the lungs and heart (2) Reduction of vascular permeability and leakage (3) Reduction in the activity of the master inflammatory mediator transcription factor NF-κB (7, 8, 16, 18) (4) Reduction in the production and action of VEGF (5) Inhibition or delay of viral entry into cells

[0023] The specific hypothesis is that the combined use of a 5-lipoxygenase inhibitor (e.g., diethylcarbamazine (DEC) or zileuton), an antioxidant, tetrathiomolybdate (TTM) which is a copper chelating agent with anti-inflammatory properties, and a VEGF production inhibitor suppresses the intravascular inflammatory and procoagulant mechanisms that cause lung injury and heart failure. These two drugs act through different mechanisms of action. 5-Lipoxygenase inhibitors and antioxidants (e.g., DEC or zileuton) inhibit the formation of leukotriene B4, thereby inhibiting the chemotaxis of neutrophils and macrophages to the damaged lung and endothelial cell damage. TTM may have a multifaceted action including inhibition of viral entry into cells and inhibition of VEGF-induced vascular leakage (VEGF is an enhancer of vascular permeability). The present invention uses a combination of two drugs with different mechanisms of action (a 5-lipoxygenase inhibitor such as DEC or zileuton and TTM as the main driver) to prevent the progression of the disease and treat this disease. Since these drugs are highly safe, they can be used in combination with other therapies. Furthermore, the inventors of the present invention include other drugs that can be used in combination with these two core drugs as an invention. Other drugs include, for example, anti-inflammatory antidepressants, such as selective serotonin reuptake inhibitors (SSRI) (e.g., fluvoxamine and apigenin), indole-3-carbinol (i3c), bufalin, baicalin, curcumin, quercetin, Applied Therapeutics aldose reductase inhibitor AT-001 with antioxidant properties, available antiviral drugs or coronavirus antibody drugs. In addition, the treatment can be further enhanced by adding prostacyclin analogs such as iloprost and its PGI2 receptor agonists, selecpag, treprostinil, and beraprost.

[0024] The present invention pursues the strategic goal of protecting the lungs and cardiovascular system from organ damage by using two core drugs (as above) and other existing drugs. The two main drugs are TTM and DEC or Zileuton. The other drugs may include SSRIs (e.g., fluvoxamine, an antidepressant shown to reduce inflammation via stimulation of the sigma-1 receptor) and / or ivermectin, which has been shown to inhibit in vitro replication of the COVID-19 virus. Caly, L. et al. published that ivermectin inhibits SARS-CoV-2 replication in vitro (Antivir Res, April 3, 2020) and that curcumin reduces inflammation. Since these drugs are safe, they can be used in combination with other treatments (e.g., oxygen, nitrous oxide, steroids). These treatments alone cannot prevent the mechanisms of intravascular inflammation and procoagulation that cause lung injury and heart failure.

[0025] In the present invention, it has been found that coronavirus disease (COVID-19) and influenza can be fatal. Pulmonary inflammatory organ damage causes diffuse alveolar damage (DAD), thrombotic vascular occlusion and ARDS. In the heart, another organ under attack, myocarditis and coronary syndrome cause myocardial damage, and unknown mechanisms including cytokine-dependent mechanisms may directly damage the myocardium (3-5). Based on the findings and understanding of the inflammatory responses induced by COVID-19 and influenza, the inventors have determined that a combination of drugs, specifically the combination of TTM and DEC or diroton, addresses important biological functions that cause events such as a patient being placed on a ventilator, causing organ damage, or leading to death. The inventors' knowledge of the mechanisms of action of these drugs and the specific inhibitory activities they produce enables the inventors to combine TTM and / or DEC with other codrugs (e.g., the SSRI anti-inflammatory antidepressant fluvoxamine, sulforaphane, ivermectin, curcumin, and their variants). These drugs are designed to treat ARDS caused by medical conditions other than coronavirus (with the exception of ivermectin, which is likely not applicable to ARDS).

[0026] The role of the immune system as a defender against inflammatory organ damage is highly regarded. There is also a consensus that cytokines play an important role in the development of inflammatory responses. Of particular interest are IL-1 and IL-6. The therapeutic blockade of their receptors is a strategy being actively investigated in COVID-19 infected patients. Both cytokines are produced not only by some inflammatory cells but also by endothelial cells and vascular smooth muscle cells. At the center of the production of these cytokines and TNFα is the transcription factor NF-κB.

[0027] Activation of NF-κB by TNFα induction and miR-125b induction is copper-dependent (16, 18), and copper chelation has been shown to inhibit NF-κB activation in various cell types, including endothelial cells that are likely to develop an inflammatory phenotype, one characteristic of which is NF-κB expression. Also, Toll-like receptor (TLR) activation causes upregulated expression of several copper transporters, particularly Ctr1, Ctr2, and ATP7A (15).

[0028] The transcriptional activity of HIF-1α is also copper-dependent, resulting in the production of VEGF, which is called the "vascular permeability factor". VEGF plays a role as a vascular permeability (leakage) enhancing factor in ARDS.

[0029] In conclusion, copper chelation by TTM inhibits cytokine production and HIF-1α-dependent gene transcription in inflammation caused by COVID-19 and influenza. The latter is important due to tissue hypoxia in damaged organs.

[0030] In one embodiment of the present invention, the inventors use a 5-lipoxygenase inhibitor such as DEC or zileuton in combination with TTM as a mechanism of action for chemotaxis inhibition and vascular leakage inhibition in the treatment of subjects suffering from COVID-19, variants of COVID-19, other coronaviruses having the same mechanism of action as COVID-19, or influenza. Note that one of the most potent chemotactic mediators is leukotriene B4 (LTB4), which is a product of activated 5-lipoxygenase. LTB4 is produced by macrophages, eosinophils, neutrophils that cooperate with erythrocytes, and activated endothelial cells. The specific hypothesis here is that LTB4 is very important in the development of organ failure due to direct damage to endothelial cells that results in activation of chemotaxis and vascular leakage. In addition to being expected to inhibit the synthesis of LTB4, DEC or zileuton is expected to inhibit the synthesis of LTC4, a peptide leukotriene that causes vascular and bronchial spasms.

[0031] DEC has antioxidant properties and suppresses oxidative stress involved in the inflammation of COVID-19 (8,9) and influenza. DEC can inhibit the production of inflammatory mediators and the 5-lipoxygenase-dependent activation of NF-κB.

[0032] The inventors have also discovered that TTM treatment (i.e., treatment with a copper chelator that inhibits NF-κB activation in various cell types including endothelial cells that are likely to develop an inflammatory phenotype) can be further enhanced by combination with a copper chelator containing a TTM salt and at least one activator (e.g., diethylcarbamazine). The copper chelator containing the TTM ammonium salt and at least one activator can be administered separately, but can also be administered together in combination in a tablet. For example, the copper chelator containing the TTM ammonium salt can be administered orally, and the at least one activator can be administered intravenously or orally.

[0033] In one embodiment, the present invention further provides a composition comprising a copper chelator containing an effective amount of a TTM salt and a 5-lipoxygenase inhibitor, such as DEC or zileuton. Other activators other than the combination of TTM and DEC or TTM and zileuton may be the antiparasitic agent ivermectin, apigenin, indole-3-carbinol, bufalin, baicalin, curcumin (quercetin), an aldose reductase inhibitor, and the anti-inflammatory antidepressant fluvoxamine or sulforaphane, which have been shown to inhibit the entry of the COVID-19 coronavirus into cells in in vitro studies. Such a composition can be in an intravenous or oral form such as a tablet, microtablet, or capsule. The oral form can provide delayed release of the TTM salt after passing through the stomach. Such a composition can release the TTM salt, for example, after (1) the oral form of TTM has passed through the stomach and (2) at least one other activator has been released into the stomach, or after the other activator has passed through the stomach.

[0034] A summary of the mechanism of action achieved by TTM includes inhibition of chemotaxis, inhibition of vascular permeability, inhibition of inflammatory mediator production, inhibition of activation of the master transcription factor NF-κB, reduction of VEGF production, and a certain degree of inhibition of viral entry into cells. VEGF is a powerful factor that mobilizes progenitor cells from the bone marrow. The role of VEGF in ARDS has been recognized as a vascular permeability factor. VEGF is 50 times more effective than histamine in causing vascular leakage. Since the HIF-1α-dependent transcription of the VEGF gene is also copper-dependent, TTM reduces VEGF production.

[0035] The mechanism of action of DEC is inhibition of the enzyme 5-lipoxygenase, inhibition of oxidants, and inhibition of NF-κB-dependent gene transcription. Overall, due to such molecular mechanisms, DEC inhibits chemotaxis and maintains normal endothelial cell function.

[0036] The main mechanism of action of the anti-inflammatory drug sulforaphane is activation of the transcription factor Nrf2. This transcription factor is a switchboard that transcribes a number of antioxidant enzyme genes, and as a result, antioxidant enzymes such as superoxide dismutase and catalase are produced. Since inflammation is associated with oxidative stress, sulforaphane reduces the oxidative stress component of inflammation.

[0037] The main mechanism of the anti-inflammatory action of fluvoxamine, an antidepressant and anxiolytic drug, is stimulation of the endoplasmic reticulum Sigma-1 receptor, which limits the activation of inositol-requiring enzyme 1 [IRE1]-dependent inflammatory mediators.

[0038] Direct administration of two drugs, diethylcarbamazine and a prostacyclin analogue (e.g., beraprost), to the lungs by inhalation of a spray powder has the advantage of delivering a relatively high dose of the drug to the lungs because there is no outflow to the peripheral systemic circulation. The action of the drug is limited to the targets of the airways and lung tissue. The advantages are the delivery of a pulmonary vasodilator and an inhibitor of 5-lipoxygenase. Both drugs have a synergistic effect of inhibiting lung inflammation without toxicity or side effects.

Brief Description of the Drawings

[0039] The advantages of the embodiments of the present invention will become apparent from the following detailed description of the exemplary embodiments. Hereinafter, the present invention will be described in detail with reference to the drawings.

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Mode for Carrying Out the Invention

[0040] Aspects of the present invention are disclosed in the following description directed to specific embodiments of the present invention. Those skilled in the art will recognize that alternative embodiments can be devised without departing from the spirit or scope of the claims. Further, well-known elements of exemplary embodiments of the present invention are not described in detail or are omitted so as not to obscure the relevant details of the present invention. Further, to facilitate understanding of the description, some of the terms used herein are described below.

[0041] As used herein, the term "exemplary" means "serving as an example, instance, or illustration." The embodiments described herein are illustrative only and not limiting. It should be understood that the embodiments described are not necessarily to be construed as preferred or advantageous over other embodiments. Further, the terms "embodiments of the present invention," "embodiments," or "invention" do not require that all embodiments of the present invention include the features, advantages, or modes of operation discussed.

[0042] Copper functions as an important cofactor for numerous proteins and enzymes involved in both physiological and pathological processes through its Fenton chemistry. The proteins are secreted, intracellular, or transmembrane. There are over 50 copper-binding proteins in various compartments of the cell (membrane, cytoplasm, nucleus, mitochondria). They function as copper transporters, chaperones, and enzymes. Theoretically, all of these copper-binding proteins may be affected to varying degrees by the copper chelator TTM.

[0043] The present invention is based on the discovery that high levels of extracellular and intracellular copper play a very important role in intravascular inflammation, particularly through the inhibition of the vascular permeability factor VEGF and the inhibition of NF-κB-dependent gene transcription.

[0044] The inventors understood that in order to prevent the progression to the state where patients infected with coronaviruses (e.g., COVID-19, variants of COVID-19, or coronaviruses having the same mechanism of action as COVID-19) need to be treated with a ventilator and death, it is necessary to select the administration of drugs that inhibit chemotaxis, vascular leakage, and endothelial cell damage and prevent the progression to hyperinflammation and ARDS. Such drugs need to intervene early enough to prevent the progression of the disease, treat the disease, and protect the lungs and cardiovascular system from the onset of organ damage. To achieve this, the inventors recognized that the mechanisms of action that these drugs must provide are as follows. (i) Inhibiting the chemotaxis of inflammatory cells to the lungs and heart (ii) Reducing the production and action of VEGF (iii) Decreasing vascular permeability and leakage (iv) Reducing the activity of the master inflammatory mediator transcription factor NF-κB activation in various cell types, including endothelial cells that may develop an inflammatory phenotype, one of the characteristics of which is NF-κB expression (v) Inhibiting or delaying the entry of the virus into cells (vi) Inhibiting the intravascular inflammatory and procoagulant mechanisms that lead to lung injury and heart failure by providing a treatment having anti-inflammatory properties and using antioxidants and inhibitors of VEGF production (vii) Addressing LTB4 (since LTB4 is very important in the development of organ failure due to direct damage to the endothelium resulting in chemotactic activation and vascular leakage, and in the synthesis of LTC4), and addressing the peptide leukotrienes that are vaso- and bronchospastic (viii) Inhibiting the formation of leukotriene B4 and inhibiting the chemotaxis of neutrophils and macrophages to the damaged lung and endothelial cell damage (ix) Addressing cytokines that play an important role in the development of the inflammatory response (particularly of interest are IL-1, IL-6, and IL-8) (x) Inhibiting the activity of the important hypoxia-inducible transcription factors HIF-1α and HIF-2α (xi) Stimulating the endoplasmic reticulum [ER] sigma-1 receptor that suppresses inflammation

[0045] When treating patients suffering from COVID-19 and variants of COVID-19 or other coronaviruses having the same mechanism of action as COVID-19, using a copper chelating agent containing a TTM salt provides some of the necessary mechanisms of action described above.

[0046] The proposed mechanisms of action of the copper chelating agent containing a TTM salt in patients suffering from COVID-19 and variants of COVID-19 or other coronaviruses having the same mechanism of action as COVID-19 include reduction of vascular cell inflammation, chemotaxis of inflammatory cells, and decreased transport from the bone marrow to the lung. VEGF is a powerful factor that mobilizes progenitor cells from the bone marrow and may be involved in the damage and repair processes. By inhibiting the transcription of the VEGF gene, TTM reduces the VEGF-dependent increase in vascular permeability and changes in angiogenesis that are sequelae of intravascular inflammation (Figure 16).

[0047] Based on studies and tests using TTM for other indications, the inventors have provided the mechanism of action required for treatment with a copper chelating agent containing a TTM salt, and hypothesized that 5-lipoxygenase inhibitors and antioxidants, such as diethylcarbamazine (DEC) or zileuton, provide other required mechanisms of action. Furthermore, the inventors have identified other drugs that can be administered to help create the necessary and desired mechanisms of action.

[0048] Copper chelation has also been shown to significantly reduce the viral replication rate in cultured studies of infected lung cells. TTM has the property of chelating copper from the body. Influenza virus not only replicates in airway and lung tissue cells, but also destroys these cells, and in severe cases, causes pneumonia and acute lung injury [ARDS]. Reducing and significantly suppressing this inflammatory response is a treatment goal that cannot be achieved with antibiotics or steroids, but can be achieved with TTM.

[0049] The blood vessels and capillaries in the lungs are involved in the inflammation caused by influenza, ultimately causing vascular leakage and edema, and impairing the gas exchange function of the lungs. TTM inhibits the replication of influenza A virus, and the drug diethylcarbamazine [DEC] inhibits the synthesis of leukotriene [LTC4], which mainly causes bronchial and vascular constriction, and the synthesis of LTB4, which causes damage to lung endothelial cells, thereby inhibiting the chemotaxis of inflammatory cells (neutrophils, macrophages, immune cells) to the lung blood vessels.

[0050] TTM is also effective in the treatment of influenza because it inhibits the action of the master transcription factor NF-κB. NF-κB is involved in the activation of genes encoding many cytokines (such as IL-1 and IL-6) and inflammatory mediators such as TNα. TTM also inhibits the transcription factor HIF-1α, which is involved in the transcription of the VEGF gene. VEGF is a potent vascular permeability enhancer and is known to play a characteristic role in ARDS.

[0051] In summary, the combination of TTM+DEC has an antiviral mechanism of action and suppresses intrapulmonary vascular inflammation at several cellular and molecular levels. Therefore, TTM+DEC has the advantage of being independent of the viral strain and is expected to be an effective treatment for influenza A disease.

[0052] In addition, the inventors have determined that copper levels affect vascular inflammation. This discovery is based on the identification of four copper-dependent mechanisms.

[0053] First, copper is involved in the stabilization of hypoxia-inducible factor 1-alpha (or HIF-1-α), a ubiquitous transcription factor protein. HIF-1-α is involved in the transcription of over 100 genes, including those encoding vascular endothelial growth factor (VEGF) and its kinase insert domain receptor (KDR). HIF-1-α induces the mobilization of bone marrow-derived vascular regulatory cells to regulate tumor angiogenesis and invasion (Hoffmann BR. Et al. Physiol Genomics, 2013(27))

[0054] Both VEGF and its receptor play important roles in causing an increase in vascular permeability.

[0055] Second, copper plays a role in inflammation. It has long been recognized that inflammatory and immune cells infiltrate the pulmonary vascular lesions in IPAH (Tuder et al., Am J Pathol, 1994 Feb; 144(2): 275-85.). These cells secrete mediators of inflammation, so-called cytokines, particularly interleukin IL-1 and IL-6 (Humbert et al., Am J Respir Crit Care Med., 1995 May; 151(5):1628-31). Since the TTM ammonium salt has an anti-inflammatory effect in addition to its anti-angiogenic effect, it has been shown that the TTM salt, a specific copper chelator, reduces cytokine secretion in several cell and organ systems.

[0056] Thirdly, copper is involved in changes in the genes of cytochrome P450. The lungs, particularly the pulmonary vascular endothelial cells (EC), are involved in drug metabolism and the processing of toxic substances. The toxins in tobacco smoke are known to highly upregulate the expression of certain drug-metabolizing genes, which are genes of the cytochrome P450 superfamily. There are 56 known cytochrome P450 genes encoding 56 isozymes. These enzymes metabolize 75% of all drugs in use, including all vasodilators previously used in the treatment of PAH. These enzymes are also involved in cell growth and differentiation, and the metabolism of cholesterol and estrogen, and the role of these enzymes in the etiology of cancer (particularly prostate cancer, breast cancer, and lung cancer) has been investigated over the years (Kwapiszewska G et al, Circulation Research, submitted 2019). However, copper has been shown to cause liver and kidney damage due to changes in cytochrome P450 enzyme activity, and copper chelation has been demonstrated to prevent liver and kidney damage by inhibiting changes in the cytochrome P450 genes.

[0057] Fourthly, copper plays a role in angiogenesis, which may be a sequela of intravascular inflammation. Similar to cancer, vascular cells can undergo phenotypic transformation, which may be copper-dependent. Therefore, copper chelators provide an anti-angiogenic effect and maintain the phenotype of normal vascular cells.

[0058] One of the inventors, Norbert F. Voelkel, has determined that these four copper-dependent mechanisms involved in cell growth and differentiation, angiogenesis, and inflammation can be modified by treatment with copper chelators containing TTM salts. Since any or each of the mechanisms contributing to these diseases can be modified, the use of copper chelators for the treatment of intravascular inflammation has been proposed by Norbert F. Voelkel.

[0059] As used herein, "abnormal handling of copper" due to abnormal cell growth means and includes that there are potentially multiple diverse reasons for errors in copper handling. Genetic or acquired mutations in genes encoding copper transporters or copper-binding proteins, or mutations in one or more genes encoding cytochrome P450 enzymes, may cause abnormal copper processing and abnormal cell metabolism.

[0060] The copper chelating agent contains a salt of TTM, which is a very effective copper chelating agent for the purposes of the present invention. The salt may be represented by Formula I: X(MoS4).

[0061] X is (2Li) +2 , (2K) +2 , (2Na) +2 , Mg +2 , Ca +2 or {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}.

[0062] R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently H, or a group selected from the group consisting of optionally substituted alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl and heterocycloalkylalkyl.

[0063] R 4 and R 8is absent, or each independently is H, or an optionally substituted group selected from the group consisting of alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl and heterocycloalkylalkyl.

[0064] R 4 When absent, R 1 and R 2 form an optionally substituted 5- or 6-membered aromatic ring together with N. Here, up to two carbon atoms in the ring may be substituted with heteroatoms selected from the group consisting of O, N, and S.

[0065] R 8 When absent, R 5 and R 6 form an optionally substituted 5- or 6-membered aromatic ring together with N. Here, up to two carbon atoms in the ring may be substituted with heteroatoms selected from the group consisting of O, NH and S.

[0066] Here, R 1 and R 2 、R 2 and R 3 、or R 3 and R 4 optionally form a cyclic structure that may be substituted together with N.

[0067] Here, R 5 and R 6 、R 6 and R 7 、or R 7 and R 8 optionally form a cyclic structure that may be substituted together with N.

[0068] Here, R 4 and R 8 may be bonded by a covalent bond.

[0069] Here, R 1 、R 2, R 3 , R 5 , R 6 and R 7 are each independently optionally substituted with one or more OH, oxo, alkyl, alkenyl, alkynyl, NH2, NHR 9 , N(R 9 )2, -C=N(OH) or OPO3H2, where R 9 is alkyl or -C(=O)(O)-alkyl.

[0070] Here, R 4 and R 8 are each independently optionally substituted with one or more OH, oxo, alkyl, alkenyl, alkynyl, NH2, NHR 9 , N(R 9 )2, -C=N(OH) or - + (R 10 )3, where R 10 is optionally substituted alkyl.

[0071] R 1 , R 2 , R 3 , R 4 , R 5 , R 6 , R 7 and R 8 one or more -CH2- groups in may be optionally substituted with a moiety selected from the group consisting of O, NH, S, S(O) and S(O)2.

[0072] In an exemplary embodiment, X is of formula (II):

Chemical formula

[0073] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}. [N + (R 1 )(R 2 )(R 3 )(R 4 )] and [N + (R 5 )(R 6 )(R 7 )(R 8 )] are the same or different.

[0074] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently H or C1-C 10 alkyl. In other embodiments, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and R 1 , R 2 , R 3 , R 5 , R 6 and R 7is independently H, C1-C3 alkyl or C1-C6 alkyl. In a further embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 4 and R 8 are each independently H or C1-C6 alkyl.

[0075] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently H, methyl, ethyl or propyl. In a further embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and each of R 1 , R 2 , R 3 , R 4 , R 5 , R 6 , R 7 and R 8 is propyl, and the compound is tetrapropylammonium tetrathiomolybdate. In a further embodiment, X is {[N + (R1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 1 、R 2 、R 3 、R 4 、R 5 、R 6 、R 7 and R 8 are each methyl, and the compound is tetramethylammonium tetrathiomolybdate. In another embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 1 、R 2 、R 3 、R 4 、R 5 、R 6 、R 7 and R 8 are each ethyl, and the compound is tetraethylammonium tetrathiomolybdate.

[0076] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 1 、R 2 and R 3 are each independently H, methyl or ethyl, and R 4is H or an optionally substituted alkyl, alkenyl, cycloalkylalkyl, cycloalkyl, aryl, aralkyl, heterocycloalkyl or heteroaryl. In other embodiments, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, where R 5 , R 6 and R 7 are each independently H, methyl or ethyl, and R 8 is H or an optionally substituted alkyl, alkenyl, cycloalkylalkyl, cycloalkyl, aryl, aralkyl, heterocycloalkyl or heteroaryl. In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and any substituent of R 4 and / or R 8 is selected from alkyl, OH, NH2 and oxo. In other embodiments, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and one or more -CH2- groups of R 4 and / or R 8 are substituted with a moiety selected from O, NH, S, S(O) and S(O)2.

[0077] In one embodiment, X is {[N +(R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 1 、R 2 、R 3 、R 5 、R 6 and R 7 are each independently methyl, and R 4 and R 8 are each independently optionally substituted alkyl. In a further embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and each of R 1 、R 2 、R 3 、R 5 、R 6 and R 7 is methyl, and R 4 and R 8 are each optionally substituted ethyl. In a further embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 1 、R 2 、R 3 、R 5 、R 6 and R 7 are each independently methyl, and R 4 and R 8is ethyl which may be substituted, and the substituent is hydroxyl. In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} where R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently methyl, and R 4 and R 8 are each -CH2CH2-OH.

[0078] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} where R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently methyl, and R 4 and R 8 are each alkyl which may be substituted, and the compound is tetramethylammonium tetrathiomolybdate. In another embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} where R 1 , R 2 , R3 , R 5 , R 6 and R 7 are each independently ethyl, and R 4 and R 8 are each optionally substituted ethyl, and the compound is tetramethylammonium tetrathiomolybdate. In a further embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently methyl, and R 4 and R 8 are each optionally substituted ethyl, and the substituent is hydroxy, and the compound is tetramethylammonium tetrathiomolybdate. In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently methyl. R 4 and R 8 are each -CH2CH2-OH, and the compound is tetramethylammonium tetrathiomolybdate.

[0079] In an exemplary embodiment, the chelate compound is bis(2-methylimidazolyl)tetrathiotungstate.

[0080] In one embodiment, the copper chelating agent compound represented by formula (I) is

Chemical formula

[0081] Table 1 provides a non-limiting embodiment where X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}.

Table 1

[0082] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and each of [N + (R 1 )(R 2 )(R 3 )(R 4 )] and [N + (R 5 )(R 6 )(R 7 )(R 8 )] is independently

Chemical formula

[0083] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and at least one of [N + (R 1 )(R 2 )(R 3 )(R 4 )] and [N + (R 5 )(R 6 )(R 7 )(R 8 )] is

Chemical formula

[0084] In other embodiments, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and both [N + (R 1 )(R 2 )(R 3 )(R 4 )] and [N + (R 5 )(R 6 )(R 7 )(R 8 )] are

Chemical formula

[0085] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and R 1 , R 2 , R 3 and R 4 are each independently H or alkyl. In another embodiment, R 5 , R 6 , R 7 and R 8 are each independently H or alkyl.

[0086] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and R 4 and R 8 are joined by a covalent bond. For example, when both R 4 and R 8 are methyl, R 4 and R 8 are joined by a covalent bond and can form an ethylene bond between the two nitrogen atoms as shown below.

Chemical formula

[0087] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N +(R 5 )(R 6 )(R 7 )(R 8 )]} and R 4 and R 8 are both optionally substituted alkyls bonded by a covalent bond.

[0088] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and R 1 , R 2 , R 3 , R 5 , R 6 and R 7 are each independently H, methyl, ethyl or propyl, and R 4 and R 8 are bonded by a covalent bond. In one embodiment, R 4 and R 8 are each independently optionally substituted alkyls. In one embodiment, the substituents of R 4 and R 8 are N + (R 10 ) 3 . In another embodiment, one or more -CH2- groups of R 4 and R 8 are substituted in part by one selected from O, NH, S, S(O) and S(O)2.

[0089] In one embodiment, said X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and X is [Chemical formula] is one of the following.

[0090] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, where R 1 and R 2 are each independently H, methyl or ethyl, and R 3 and R 4 are each independently optionally substituted alkyl, aryl or aralkyl. In another embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, where R 5 and R 6 are each independently H, methyl, ethyl or propyl, and R 7 and R 8 are each independently optionally substituted alkyl, aryl or aralkyl. In one embodiment, the substituents of R 3 , R 4 , R 7 and R 8 are -OH.

[0091] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R7 )(R 8 )]} and [N + (R 1 )(R 2 )(R 3 )(R 4 )] and / or [N + (R 5 )(R 6 )(R 7 )(R 8 )] are each independently

Chemical formula

[0092] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, where R 1 and R 4 are each independently H, methyl, ethyl, or propyl, and R 2 and R 3 may form a cyclic structure optionally substituted with N.

[0093] In another embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, where R 5 and R 8 are each independently H, methyl, ethyl, or propyl, and R 6 and R 7 may be able to form a cyclic structure optionally substituted with N. In one embodiment, R 2 , R 3 , R6 and R 7 One or more -CH2- groups in may be partially substituted with one selected from O, NH, S, S(O) and S(O)2.

[0094] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, and [N + (R 1 )(R 2 )(R 3 )(R 4 )] and / or [N + (R 5 )(R 6 )(R 7 )(R 8 )] are each independently

Chemical formula

[0095] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]}, R 4 and / or R 8 do not exist, and R 1 and R 2 and / or R 5 and R 6 may form a 5- or 6-membered aromatic ring substituted with N, where up to two carbon atoms in the ring may be substituted with heteroatoms selected from O, N and S.

[0096] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} and [N + (R 1 )(R 2 )(R 3 )(R 4 )] and / or [N + (R 5 )(R 6 )(R 7 )(R 8 )]} are each independently

Chem.

[0097] In one embodiment, X is {[N + (R 1 )(R 2 )(R 3 )(R 4 )][N + (R 5 )(R 6 )(R 7 )(R 8 )]} where R 1 , R 2 , R 3 , R 4 , R 5 , R 6 , R 7 and R 8 are each H.

[0098] In an exemplary embodiment, the chelate compound is ammonium tetrathiomolybdate [NH4]2MoS4 (ATTM). ATTM may be combined with other copper chelating agents such as ammonium trithiomolybdate [NH4]2MoOS3.

[0099] In some exemplary embodiments, a copper chelating agent comprising a therapeutically effective amount of a TTM salt is administered to treat COVID-19, variants of COVID-19, other coronaviruses having a similar mechanism of action as COVID-19, other viruses, or ARDS in a patient. In one exemplary embodiment, the copper chelating agent comprises ammonium tetrathiomolybdate [NH4]2MoS4 (or ATTM). In some exemplary embodiments, the copper chelating agent may further comprise ammonium trithiomolybdate [NH4]2MoOS3. The amount of TTM salt delivered is individualized. In an exemplary embodiment, a therapeutically effective amount of the copper chelating agent delivers 90 to 180 mg of TTM per day. The amount of TTM is adjusted according to the level of ceruloplasmin in the plasma. Effective copper chelation is achieved when the plasma ceruloplasmin level approaches 50% of the normal level (i.e., 15 - 17 mg / dl).

[0100] The copper chelating agent can be administered in a composition comprising a pharmaceutically acceptable carrier and / or excipient. The composition can be administered in intravenous form or oral form (e.g., tablets, microtablets, or capsules). In some exemplary embodiments, the copper chelating agent may be an oral form composition comprising specific carriers, coatings, and / or excipients that provide delayed release of the copper chelating agent after passing through the stomach. Specifically, the carrier and / or excipient is selected to protect the copper chelating agent from degradation by gastric acid and to allow optimal intestinal uptake and absorption. For example, the oral form of the composition may include an enteric coating for tablets or capsules, or may include a delayed release formulation.

[0101] In some exemplary embodiments, a patient is treated by administering a copper chelating agent comprising a therapeutically effective amount of a TTM salt in combination with other antiviral compositions, antibodies, coronaviruses (e.g., COVID-19, variants of COVID-19, or other coronaviruses having a similar mechanism of action as COVID-19), or other treatments for influenza.

[0102] In another exemplary embodiment, in addition to TTM, a 5-lipoxygenase inhibitor (DEC or zileuton) is used in combination with TTM for disease prevention and treatment strategies for COVID-19, variants of COVID-19, or other coronaviruses having a similar mechanism of action as COVID-19, or influenza. DEC or zileuton are inhibitors of the 5-lipoxygenase enzyme (5-LO), which can cause inflammation and is likely to contribute to endothelial and lung damage (Figures 9, 10(a), 10(b)).

[0103] Therefore, the copper chelating agent containing TTM salt and the 5-LO inhibitor may have a synergistic effect in the prevention of intravascular inflammation. While TTM salt is expected to reduce vascular permeability and chemotaxis, inhibition of 5-LO is expected to reduce inflammation and inhibit neutrophil chemotaxis and NF-κB-dependent gene transcription. The 5-LO enzyme expressed in activated pulmonary vascular endothelial cells acts as an activator of gene expression in relation to pulmonary vascular diseases. 5-LO causes the production of leukotriene C4, which is the first established action of 5-LO. Leukotriene C4 increases pulmonary vasoconstriction by contracting the smooth muscle cells of the bronchial airway and pulmonary vessels. Therefore, inhibition of 5-LO also inhibits leukotriene C4 synthesis, thereby removing pulmonary vasoconstricting substances. The second action is the non-enzymatic function of binding to the 5-LO activating protein (FLAP) on the nuclear envelope. Fitzpatrick and Lepley showed in 1998 that 5-LO co-precipitates with a subunit of the transcription factor NF-κB when examining nuclear extracts. NF-κB controls the expression of genes encoding several LTB4 inflammatory mediators. Therefore, 5-LO can activate the transcription of a number of genes that control cell proliferation and genes encoding inflammatory mediators such as IL-1β, IL-6, and VEGF by binding to NF-κB in the cell nucleus. As a result of 5-LO inhibition treatment, vascular inflammation may be reduced, and the progression of the disease may be halted and the recovery of the disease promoted by the reprogramming of stem cells. LTB4 is another important chemotactic leukotriene that is a product of leukotriene A4 hydrolase downstream of 5-LO. Recently, the study of LTB4 in rats demonstrated that LTB4 causes apoptosis of pulmonary endothelial cells (Tian W. et al Sci Transl Med.2013 Aug 28;5(200):200ra117). Since effective inhibition of 5-LO also blocks LTB4 production, 5-LO inhibitors in the treatment of COVID-19-induced diseases and influenza are expected to also target the LTB4-dependent pathogenesis mechanism.

[0104] In some other exemplary embodiments, a patient suffering from coronavirus (e.g., COVID-19, variants of COVID-19, or other coronaviruses having a similar mechanism of action as COVID-19), ARDS or influenza can be treated by administering a therapeutically effective amount of a 5-LO inhibitor (e.g., DEC) in combination with other antiviral compositions or other coronavirus treatments.

[0105] In some exemplary embodiments, COVID-19, variants of COVID-19, other coronaviruses having a similar mechanism of action as COVID-19, ARDS or influenza in a patient can be treated by a combination of a copper chelating agent containing a therapeutically effective amount of TTM salt and at least one 5-LO inhibitor. In particular, the treatment for patients with severe COVID-19-induced organ damage and the treatment for preventing the progression of organ damage can be achieved by a combination of one of a therapeutically effective amount of 5-LO inhibitor diethylcarbamazine or zileuton and a copper chelating agent containing a therapeutically effective amount of TTM salt.

[0106] In some exemplary embodiments, COVID-19, variants of COVID-19, other coronaviruses having a similar mechanism of action as COVID-19, ARDS or influenza in a patient can be treated by a combination of a copper chelating agent containing a therapeutically effective amount of TTM salt and at least one 5-LO inhibitor. In particular, the treatment for patients with severe COVID-19-induced organ damage and the treatment for preventing the progression of organ damage can be achieved by a combination of one of a therapeutically effective amount of 5-LO inhibitor diethylcarbamazine or zileuton and a copper chelating agent containing a therapeutically effective amount of TTM salt.

[0107] Fulvoxamine is an approved antidepressant and anxiolytic drug that inhibits the production of inositol-requiring enzyme 1 (IRE1)-dependent inflammatory signals, particularly those following the activation of Toll-like receptors (TLRs). Knockout of the gene encoding the intracellular sigma-1 receptor showed increased expression of IL-6 (persisting even after addition of an inhibitor of NF-κB). This suggests that the anti-inflammatory effect of fulvoxamine is independent of NF-κB.

[0108] Sulforaphane activates the transcription factor Nrf2. This transcription factor is a switchboard that transcribes a number of antioxidant enzyme genes to produce antioxidant enzymes such as superoxide dismutase and catalase. Since inflammation is associated with oxidative stress, sulforaphane is a suitable codrug that reduces the oxidative stress component of inflammation.

[0109] Apigenin is also a suitable codrug because it affects or specifically inhibits NF-κB. Such NF-κB inhibitors can be considered for use in the treatment of accidental severe PAH either alone or in combination with a copper chelator containing TTM salt or a 5-LO inhibitor. In fact, pyrrolidine dithiocarbamate, one of the inhibitors of NF-κB, has been shown to reverse established vascular obstructive PAH in a preclinical rat model of Sugen / hypoxia-induced PAH (Farkas D. et al AJRCMB, Vol. 15, No. 3, September 1, 2014). These data indicate that NF-κB is involved in the remodeling of pulmonary vessels, and it can be predicted that by inhibiting NF-κB in the context of COVID-19-induced intravascular inflammation or influenza, the production of inflammatory mediators such as IL-1, IL-6, and TNF-α will be inhibited. Such an effect can prevent the progression from COVID-19 infection to organ damage. Apigenin has been shown to reduce inflammation, in particular. Therefore, a synergistic effect is expected between the drug actions of a 5-LO inhibitor (e.g., zileuton or DEC) and apigenin because 5-LO and the transcription factor NF-κB interact in the cell nucleus to initiate the expression of inflammatory and cell proliferation-promoting genes. Similarly, the combination of apigenin and a copper chelator containing TTM salt is expected to provide a combination of the anti-inflammatory effect of apigenin and the anti-angiogenic and anoikis-inducing effects of the copper chelator containing TTM salt. Accordingly, in some exemplary embodiments, a patient suffering from PAH is treated by administering a therapeutically effective amount of apigenin together with a copper chelator containing a therapeutically effective amount of TTM salt.

[0110] Indole-3-carbinol (I3C) is considered to be a suitable codrug because it is another NF-κB inhibitor. I3C is a plant-derived compound with a multifaceted action profile and has been demonstrated to have anti-inflammatory and antitumor growth effects. Specifically, I3C intervenes in signal transduction and controls cell proliferation by affecting several receptors and transcription factors. It inhibits the inflammatory switchboard NF-κB and is also a ligand for the aryl hydrocarbon receptor (AhR), which is involved in drug metabolism and has recently become a target for cancer treatment. Recently, it has been shown that I3C can upregulate the activity of the important tumor suppressor PTEN. Each of these pathways can explain the anti-inflammatory and antitumor effects of I3C. The level of PTEN has been shown to decrease in the lungs of animals with pulmonary hypertension, and several experimental studies have shown that pulmonary vascular remodeling can be regulated in a PTEN-dependent manner. Therefore, inflammation and uncontrolled vascular cell proliferation are characteristics of both PAH and cancer. Treatment of PAH patients with I3C alone or in combination with a copper chelator containing the TTM salt can reverse the occlusion of the pulmonary vascular lumen by inhibiting abnormal cell proliferation and inflammation. Such a mechanism of action may help prevent the progression from intravascular inflammation to COVID-19-induced organ damage. Some exemplary embodiments of the present invention include treating patients suffering from COVID-19 infection and susceptible to organ damage by administering a therapeutically effective amount of I3C together with a copper chelator containing a therapeutically effective amount of the TTM salt.

[0111] Bufalin is considered to be another codrug because it may also have anti-inflammatory effects through inhibition of NF-κB and inhibition of the expression of matrix metalloproteinases MMP2 and MMP9. Bufalin can also reduce the expression of integrin α2 / β5. Importantly, bufalin is a multi-target anti-cancer agent and is promising for cancer treatment. In several studies, bufalin has been shown to inhibit cancer epithelial-mesenchymal transition (EMT), which is one of the characteristics of cancer. This EMT inhibition occurs through down-regulation of TGFβ receptor expression in lung cancer cells. This is thought to be relevant to PAH treatment because in PAH there is also endothelial-mesenchymal transition (EnMT) that depends on TGFβ signaling. Bufalin is expected to inhibit EnMT in the diseased pulmonary vasculature. In particular, the "plugs" that occlude the vascular lumen in proliferative PAH are composed of cells with a changed phenotype (some of which have undergone EnMT). These cells are very likely to depend on abnormal matrix proteins and are also very likely to have undergone integrin conversion. Compounds such as bufalin may dissolve cell plugs by interrupting TGFβ signaling and induce anoikis by altering abnormal integrins. Bufalin has not yet been clinically tested. However, due to its multimodal action profile, bufalin is a candidate as a codrug with copper chelating agents containing TTM salts in COVID-induced diseases and influenza. Some exemplary embodiments of the present invention include treating a patient suffering from a COVID-19 induced disease by administering a therapeutically effective amount of bufalin together with a copper chelating agent containing a therapeutically effective amount of TTM salt.

[0112] Other potential codrugs include natural plant products, specifically baicalin, curcumin, and quercetin, which are useful for the treatment of inflammatory diseases. These compounds were identified as copper-processing modifiers in a Chinese publication that analyzed studies using plant extracts in various combinations to treat patients with copper-storage Wilson's disease (Xu M-B, Rong P-Q et al, Front in Pharmacol, 2019). The authors referred to experimental data showing that curcumin, baicalin, and quercetin can alter the handling of intracellular copper. However, each of these compounds has been shown to have other activities relevant to the treatment of COVID-19 and influenza-related inflammation and organ damage.

[0113] Among these three compounds, baicalin has received the most attention in recent years. Baicalin is an extract from a Chinese herb that has been used for centuries in China to treat many diseases. In particular, there are three findings most relevant to the treatment of intravascular inflammation. First, high doses of baicalin have been found to inhibit angiogenesis. This is because in ARDS, there is pulmonary thrombosis due to endothelial cell damage, and baicalin can inhibit intravascular inflammation and thrombosis. Second, baicalin has been shown to reduce silica-induced lung inflammation and fibrosis by inhibiting T helper 17 cells (TH17), and more broadly, to stimulate Tregs and have an anti-inflammatory effect. This is because baicalin can inhibit the inflammatory cell infiltration of the pulmonary vasculature. Third, baicalin has an anti-inflammatory effect and has been found to reduce monocrotaline-induced pulmonary hypertension via the bone morphogenetic protein signaling pathway. This is due to its beneficial effects in a model of inflammation-induced endothelial cell damage.

[0114] Results obtained in a recently published rat model of pulmonary arterial hypertension (PAH) demonstrate that pharmacological inhibition of HIF-2α may be a promising new therapeutic strategy for the treatment of severe vascular remodeling and right heart failure in PAH patients. In patients infected with COVID-19, both pulmonary hypertension and right heart failure have been reported. Thus, both the copper chelator containing TTM salt and baicalein inhibit HIF-1α, and the copper chelator containing TTM salt also inhibits HIF-2α.

[0115] Adding baicalein to the dosage of the copper chelator containing TTM salt can prevent endothelial cell death and intravascular inflammation. Thus, in some exemplary embodiments, patients suffering from infection with COVID-19, variants of COVID-19, other coronaviruses having a similar mechanism of action as COVID-19, patients at risk of developing ARDS or influenza can be treated by administering a therapeutically effective amount of the copper chelator containing TTM salt and a therapeutically effective amount of baicalein.

[0116] Curcumin is a diarylheptanoid extracted from turmeric and has long been thought to have anti-cancer effects. There is also a vast literature explaining the effects of curcumin in many models of cancer and inflammatory diseases. However, while these literatures focus on its antioxidant and anti-inflammatory properties, curcumin has also been shown to induce anti-hypertensive heme oxygenase 1 in the lung and has a protective effect against lung injury by inhibiting TGFβ1. It suppresses gastric cancer by inducing apoptosis of tumor cells. Therefore, curcumin can inhibit the inflammatory component of pulmonary vascular remodeling, and curcumin may also inhibit the proliferation of pulmonary vascular cells through inhibition of the signal transducer and activator of transcription 3 (STAT3) signaling pathway. Since inflammation is an important factor in vascular damage in severe PAH, curcumin may be a non-toxic partner of copper chelating agents containing TTM salts in the treatment or prevention of severe COVID-19-induced diseases. In fact, curcumin derivatives have been shown to be mild phosphodiesterase V inhibitors (acting like pulmonary vasodilators), suggesting that curcumin can be applied to the treatment of PAH. Therefore, in some exemplary embodiments, patients suffering from COVID-19, variants of COVID-19 or other coronavirus-induced infections having a similar mechanism of action as COVID-19, and / or patients at risk of developing ARDS or influenza can be treated by administering a copper chelating agent containing a therapeutically effective amount of TTM salt and a therapeutically effective amount of curcumin.

[0117] Quercetin is a plant flavonoid found in many plants and vegetables such as broccoli and onions, and its antioxidant effect has been well demonstrated. However, quercetin has also been shown to inhibit VEGF expression and VEGF receptor 2 signaling, thus inhibiting angiogenesis. It has also been shown to inhibit glycolysis in breast cancer cells (one of the characteristics of cancer), vascular remodeling in rodent models of PH, and endothelial-mesenchymal transition (EnMT). Furthermore, quercetin has been shown to improve wound healing by modifying integrin αv / β1. Therefore, quercetin can inhibit the intravascular disease component of Covid-19-induced diseases due to its antioxidant effect profile. Therefore, in some exemplary embodiments, patients suffering from severe COVID-19, variants of COVID-19 or other coronavirus-induced diseases having a similar mechanism of action as COVID-19, or patients at risk of developing ARDS or influenza can be treated by administering a copper chelate agent containing a therapeutically effective amount of the TTM salt and a therapeutically effective amount of quercetin.

[0118] The applied therapeutics aldose reductase inhibitor AT-001 is designed for diabetic cardiomyopathy, has antioxidant properties, and can cooperate with two drugs (5-lipoxygenase inhibitor + TTM) to relieve acute lung inflammation.

[0119] Beraprost is a stable prostacyclin analogue and is used orally for the treatment of severe pulmonary arterial hypertension. Beraprost is a vasodilator and further has anti-inflammatory and antifibrotic effects. Beraprost may be effective in protecting endothelial cells and strengthening endothelial cells for the treatment of ARDS.

[0120] The known and expected effects of the copper chelate agent containing the TTM salt (enumerated as "TTM") and the other active agents or codrugs discussed above are summarized in Table 2 below.

[0121]

Table 2

[0122] Regarding administration, some exemplary embodiments relate to administering both a copper chelating agent containing a TTM salt and one or more co-drugs in a single-dose form or composition. In other exemplary embodiments, the copper chelating agent containing the TTM salt and the co-drug are administered in separate compositions that can be administered via the same route. Alternatively, these separate compositions can be administered by different routes. For example, the copper chelating agent containing the TTM salt may be in oral form or intravenous form, and the co-drug may be in a composition in oral, intravenous or inhalation form.

[0123] In some exemplary embodiments, the TTM salt is administered at 90 - 180 mg per day, with or without a co-drug. This is adjusted to a target ceruloplasmin level of 50% of the normal value. For practical purposes, this target is 15 - 17 mg / dl plasma.

[0124] The composition may include a pharmaceutically acceptable carrier and / or excipient. The composition may include an intravenous form or an oral form (e.g., tablets, microtablets, or capsules). In a composition containing a copper chelating agent comprising a TTM salt, regardless of the presence or absence of a codrug, specific carriers and / or excipients can be added to provide a delayed release of the TTM salt after passing through the stomach. Specifically, the carrier and / or excipient is selected to (1) protect the TTM salt from destruction by gastric acid and enable optimal intestinal uptake and absorption, and (2) facilitate interaction with a co-drug that can be combined in the same pill. For example, an oral composition may include an enteric coating for tablets or capsules, or may include a delayed-release formulation. Such a composition can release the TTM salt, for example, (1) after the oral form of TTM has passed through the stomach and (2) after at least one other active agent has been released into the stomach, or after the other active agent has passed through the stomach. Alternatively, if the composition does not include an enteric coating, the release of the TTM salt can be delayed after gastric passage by co-administering a therapeutically effective amount of a proton pump inhibitor. The proton pump inhibitor can be included in the same oral form as the TTM salt, or in a composition administered separately.

[0125] In some embodiments, a single administration can administer at least one of a copper chelating agent comprising a TTM salt, DEC, or diroton, and optionally a proton pump inhibitor. As described above, a copper chelating agent comprising a TTM salt and one or more co-drugs can be administered in a single dosage form or composition, or in separate compositions. Also, as described above, these separate compositions can be administered by different routes. For example, a copper chelating agent comprising a TTM salt can be administered in an oral form or an intravenous form, and the co-drug can be administered in a composition in an oral, intravenous, or inhalable form. Thus, a single administration of at least one of a copper chelating agent comprising a TTM salt, DEC, or diroton, and optionally a proton pump inhibitor, can be administered in various forms by different routes. For example, (a) Oral administration comprising an oral form of a combination of a copper chelating agent containing a TTM salt and DEC or dilothion, all of which are contained in enteric-coated capsules or tablets. In the case of enteric-coated capsules, the copper chelating agent containing the TTM salt is separated from DEC or dilothion by the coating, or is separated from DEC or dilothion by being sealed in another compartment of the capsule. In the case of tablets, TTM and DEC or dilothion are separated by a barrier or coating. (b) A first oral form which is an oral form of a combination of a copper chelating agent containing a TTM salt that is separately sealed or separated from DEC or dilothion, and DEC or dilothion; a first oral form which is a capsule without an enteric coating; a second oral form which is a proton pump inhibitor that protects the TTM salt from gastric acid. (c) Oral administration comprising three separate oral forms that are packaged together as needed. The first oral form contains a copper chelating agent containing a TTM salt without an enteric coating, the second oral form contains DEC or dilothion, and the third oral form contains a proton pump inhibitor. (d) A first oral form containing a copper chelating agent containing a TTM salt without an enteric coating; and a second oral form containing a combination of DEC or dilothion and a proton pump inhibitor. (e) A first oral form containing a combination of a copper chelating agent containing a TTM salt without an enteric coating and a proton pump inhibitor, which are sealed to each other; and a second oral form containing DEC or dilothion. (f) A combination of administration routes in which a copper chelating agent containing a TTM salt is administered in an oral form, with or without an enteric coating, and DEC or dilothion is administered in an administration form or an intravenous form. (g) A combination of administration routes in which a copper chelating agent containing a TTM salt is administered in an intravenous form, and DEC or dilothion is administered in an oral, inhaled, or intravenous form. (h) A combination of administration routes in which a copper chelating agent containing a TTM salt is administered in an intravenous form, and DEC or Zilonton is administered in an inhaled form via an inhaler together with at least one of Beraprost or Fluvoxamine. For example, the inhaled form includes combinations of DEC and Beraprost, combinations of DEC, Beraprost, and Fluvoxamine, combinations of Zilonton and Beraprost, combinations of Zilonton, Beraprost, and Fluvoxamine, combinations that include Sulforaphane, include inhaled Beraprost, and may or may not include DEC or Zilonton. (i) A combination of administration routes in which a copper chelating agent containing a TTM salt is administered in an intravenous form, and DEC or Zilonton is administered in an inhaled form containing Fluvoxamine via an inhaler.

[0126] The composition of TTM and DEC of the present invention can be administered in various oral delivery dosage forms. The oral delivery dosage forms include, but are not limited to, active coatings (e.g., enteric coatings), hard shell capsules containing a combination of pellets including enteric coated pellets and pellets without them, multi-layer enteric coated tablets, ordinary multi-component tablets (which may or may not be enteric coated), enteric coated capsules, small intestine soluble coated capsules that release each active agent at different locations, mini tablets, granules, powders, granules, pellets, and / or hard capsules containing enteric capsules combined with mini tablets. All of these delivery dosage forms can be filled into hard capsules. Further forms may include hard shell capsules or enteric capsules containing melt extruded TTM and DEC processed or melt extruded by conventional methods, or dosage forms manufactured by 3D printing technology.

[0127] For example, in an exemplary embodiment, the dosage form can utilize an active coating (DEC in the coating) over an enteric coating of a tablet containing TTM. In this embodiment, the tablets of TTM are made of their respective components and enteric coated. Next, an active coating step is performed on the tablets (i.e., DEC is included in a soluble spray solution, included as a powder, or included by tablet-in-tablet compression). As a result, DEC is released immediately and TTM is protected from gastric acid. Also, in this embodiment, a top coat can be added so that the active coat does not come apart.

[0128] In another exemplary embodiment, the dosage form may be a MUPS (multi-unit pellet system; compressing enteric-coated pellets with TTM in a matrix containing DEC). In this embodiment, TTM is processed into micro-pellets with a smaller diameter than tablets, and each pellet is enteric coated, and the enteric coating separates TTM from DEC or other codrugs that can be added. Then, the TTM micro-pellets are compressed with a mixture of a suitable bulking agent, disintegrant, and other excipients, and one pill also contains DEC (or other codrugs). Such tablets can be coated with an appearance coat.

[0129] In another exemplary embodiment, the dosage form may be a hard shell capsule containing enteric-coated pellets of TTM and pellets / powder of DEC. In this embodiment, TTM is processed into micro-pellets with an enteric coating and then filled into a hard shell capsule together with DEC. In this embodiment, a binder may be added to bind DEC into a hard pill. This pill has no enteric coating of DEC, TTM is included within DEC, or included in the DEC and binder that made the pill.

[0130] In another exemplary embodiment, the dosage form may be an enteric-coated multilayer tablet (i.e., both drugs are released in the small intestine). In one embodiment, a three-layer tablet is made, where one layer contains DEC, the intermediate layer separates DEC and TTM, and TTM is contained in the third layer. The tablet is enteric-coated as a whole to protect TTM. In this embodiment, TTM in this layer is enteric, or TTM in this layer is an enteric-coated TTM microcapsule, and is made in a layer containing a binder which may or may not be an enteric coating. Such tablets can be coated with an appearance coat.

[0131] In another exemplary embodiment, the dosage form is a normal multi-component tablet (formulated with both TTM and DEC) and is also enteric-coated (i.e., both drugs are released in the small intestine). In this embodiment, both TTM and DEC are formulated using appropriate tableting excipients to form a single-layer compressed tablet, and then enteric-coated to protect TTM. Either TTM or DEC may be coated to avoid a formulation that is unstable due to chemical reactions.

[0132] In another exemplary embodiment, the dosage form may be an enteric-coated capsule containing TTM and DEC (i.e., both drugs are released in the small intestine). In this embodiment, both TTM and DEC are filled into the enteric-coated capsule in an appropriate form (powder, microtablet, pellet, granule, bead). Either TTM or DEC may be coated to avoid a formulation that is unstable due to chemical reactions.

[0133] In another exemplary embodiment, the dosage form may be an enteric-coated capsule containing TTM within a capsule containing DEC (DEC is released in the stomach and TTM is released in the small intestine). In this embodiment, TTM is filled into a smaller enteric-coated capsule, and this TTM-filled capsule is used together with DEC and filled into a capsule larger than a conventional capsule. The conventional capsule is a capsule that rapidly disintegrates in an acidic dissolution medium made of excipients such as gelatin and HPMC. In this embodiment, the relatively large capsule dissolves in the stomach to release DEC, and the relatively small enteric-coated TTM capsule passes through the stomach and releases TTM in the small intestine.

[0134] In another exemplary embodiment, the dosage form is TTM filled in an enteric-coated capsule, and further filled into a hard-shell capsule together with DEC powder, granules, pellets, mini-tablets, etc. In this embodiment, the hard-shell capsule dissolves in the stomach to release DEC, and the smaller enteric-coated TTM capsule passes through the stomach and releases TTM in the small intestine. The hard-shell capsule is made of HPMC and HPMCAS (HPMC acetate succinate) or other enteric polymers that impart resistance to disintegration in an acidic medium.

[0135] In another exemplary embodiment, the dosage form may be in the form of mini-tablets of a combination of TTM and DEC, or separately prepared by granulating or blending with suitable excipients and compressing these mini-tablets with a rotary tablet press. Next, such mini-tablets can be coated with an enteric polymer. Next, these mini-tablets are filled into a hard-shell capsule. In this embodiment, TTM may or may not be coated with an enteric polymer, and DEC may or may not be coated with an enteric polymer.

[0136] In another exemplary embodiment, the dosage form may be TTM and / or DEC granulated with a suitable enteric polymer. Such granules are then compressed into monolithic or multilayer tablets. The presentation may include monolithic or multilayer tablets containing enteric granules of TTM, non-enteric granules of DEC, and possible combinations (i.e., enteric TTM + enteric DEC, non-enteric TTM, enteric DEC, non-enteric TTM + non-enteric DEC). In other embodiments, the layers of TTM and DEC granules can be separated by an inert layer. Such tablets can be coated with an appearance coating.

[0137] Any of the above capsule formulations are filled into hard shell capsules and further coated with an enteric polymer.

[0138] In another exemplary embodiment of the dosage form, TTM can be melt extruded with an enteric polymer, and then the extrudate can be filled into hard shell capsules or enteric capsules together with similarly processed DEC or conventionally processed DEC. Alternatively, such extrudates can also be formed into single tablets by melt extrusion techniques. In this embodiment, the tablet first dissolves in the stomach to release DEC, and further, TTM formulated with the extruded enteric polymer passes through the stomach and is released in the small intestine.

[0139] In another exemplary embodiment of the dosage form, the desired release profile and separation between DEC and TTM can also be achieved by various 3D printing techniques currently under development.

[0140] In other exemplary embodiments, the two-part pills consisting of enteric-coated capsules contain 15 - 100 mg of TTM with or without a bulking agent. Such a bulking agent ensures that the TTM capsule does not disintegrate when the amount of TTM is not sufficient to fill the capsule. Such capsules are inserted into larger capsules that are also filled with DEC and dissolve in the stomach. The DEC in the outer pill contains DEC in the range of 50 mg to 350 mg.

[0141] In another exemplary embodiment, any of the above exemplary embodiments regarding the dosage forms of TTM and DEC or any of the above oral forms can be taken together with one or more of the following as part of a single dose, an additional oral form, or an additional component to one oral form. That is, selective serotonin reuptake inhibitors (SSRI), such as fluvoxamine, sulforaphane, apigenin, indole-3-carbinol (i3c), bufalin, Applied Therapeutics aldose reductase inhibitor AT-001, baicalin, curcumin, and quercetin. Alternatively, regarding baicalin, curcumin, and quercetin, in an intensive care unit setting, these drugs can be administered as a slurry via the gastrointestinal tract to achieve higher bioavailability.

[0142] In another exemplary embodiment, a single dose can administer at least one of a copper chelate containing a TTM salt, DEC or diroton, ivermectin or without ivermectin, and, optionally, a proton pump inhibitor. Such a single dose may include, for example, a first oral form containing DEC or diroton and ivermectin, and a second oral form containing a copper chelate containing a TTM salt having an enteric coating. This single dose can also be taken together with one or more of the following as combined with the first or second oral form or as an additional oral form. That is, fluvoxamine, sulforaphane, apigenin, indole-3-carbinol (i3c), bufalin, Applied Therapeutics aldose reductase inhibitor AT-001, baicalin, curcumin, and quercetin. Alternatively, regarding baicalin, curcumin, and quercetin, in an intensive care unit setting, these drugs can be administered as a slurry via the gastrointestinal tract to achieve higher bioavailability.

[0143] In another exemplary embodiment, any of the above combinations of TTM and DEC, TTM and Zerit, other active agents for administration in various forms by different routes, with or without ivermectin, selective serotonin reuptake inhibitors (SSRI) (e.g., fluvoxamine, sulforaphane, apigenin, indole-3-carbinol (i3c), bufalin, Applied Therapeutics aldose reductase inhibitor AT-001, baicalin, curcumin, and quercetin) can also be co-administered via various mechanisms of action with current and potential drugs targeting coronaviruses such as COVID-19. For example, AT-527 (an antiviral therapeutic drug manufactured by Atea Pharmceutical), Silmitasertib (Taiwan-based Senhwa Biosciences), Gil remdesivir (Gilead Science Inc.), Gilitinib (Japan-based Astellas Pharma), abemaciclib (Eli Lily), larimetinib, dasatinib (Bristol-Meyers Squibb), Favipiravir (or "FABIFLU"; India), Avifavir (Russia) (related to Favipiravir and developed by Japan's Fujifilm Toyama Chemical), and PF-07321332, a protease inhibitor that provides antiviral activity against Covid-19 (an antiviral agent manufactured by Pfizer).

[0144] In another exemplary embodiment, any of the above combinations of TTM and DEC, TTM and Zerit, other active agents for administration in various forms by different routes, with or without ivermectin, selective serotonin reuptake inhibitors (SSRI) (e.g., fluvoxamine, sulforaphane, apigenin, indole-3-carbinol (i3c), bufalin, Applied Therapeutics aldose reductase inhibitor AT-001, baicalin, curcumin, and quercetin) can also be administered in combination with drugs containing coronaviruses, or in the case of another virus, antibodies and other antiviral drugs.

[0145] In another embodiment, the treatment of coronavirus (e.g., COVID-19, variants of COVID-19, other coronaviruses having a similar mechanism of action as COVID-19), ARDS or influenza in a patient is carried out by administering to the patient a therapeutically effective amount of diethylcarbamazine (DEC) or diroton together with a therapeutically effective amount of at least one or two other active agents selected from selective serotonin reuptake inhibitors (SSRI), fluvoxamine, sulforaphane, apigenin, indole-3-carbinol, baicalin, bufalin, quercetin, curcumin, nutraceutical NRF2 activators, inhibitors of NF-κB, prostacyclin analogs, Applied Therapeutics aldose reductase inhibitor AT-001. Here, the coronavirus is COVID-19, a variant of COVID-19, other coronaviruses having a similar mechanism of action as COVID-19 or ARDS. Any of the above combinations of TTM and DEC, TTM and diroton, and other active agents for administration in various forms by different routes.

[0146] The foregoing description and the accompanying drawings illustrate the principles, preferred embodiments, and modes of operation of the present invention. However, the present invention should not be construed as being limited to the specific embodiments described above. Additional variations of the above-described embodiments will be understood by those skilled in the art.

[0147] Accordingly, the above-described embodiments should be regarded as illustrative rather than restrictive. Therefore, it should be understood that changes can be made to these embodiments by those skilled in the art without departing from the scope of the invention as defined by the claims.

[0148] References (1) Kang Y,ChenTet al. Cardiovascular manifestations and treatment considerations in Covid-19.Heart, April 2020. (2) Guzik T et al. Covid-19 and the cardiovascular system. Cardiovasc. Res. April 2020. (3) Li X et al.Clinical characterization of 25 death cases with COVID-19;A retrospective review of medicalrecords in a single center, Wuhan,China,Int J Infect Dis. May 2020. (4) Zhao M et al. Advances in the relationship between corona virus infection and cardiovascular diseases. Biomed Pharmacother, May 2020. (5) Tan W, Aboulhosen J.The cardiovascular burden of corona virus disease 2019 (COVID-19) with a focus on congenital heart disease.Int.J. Cardiol,June 2020. (6) Munster VJ et al. Respiratory disease in rhesus macaques inoculated wit SARS-CoV-2.Nature, May 2020. (7) Ligo M.et al. Single cell landscape of bronchoalveolar immune cells in patients with Covid-19.Nature Medicine, May 2020. (8) Delgado-Roche L. Oxidative Stress as key player in SARS-CoV infection. Arch Med Res. April 2020. (9) Sansome C., et al. Antioxidants as potential vectors controlling viral diseases, Antioxidants, May 2020. (10) Hu Z, Yu F, Gong P, Qiu Y, Zhou W, Cui Y, Li J, Chen H. Subneurotoxic copper(II)-induced NF-κB-dependent microglial activation is associated with mitochondrial ROS. Toxicol Appl Pharmacol. 2014 Apr 15;276(2):95-103. (11) Khan G, Merajver S.Copper chelation in cancer therapy using tetrathiomolybdate: an evolving paradigm. Expert Opin Investig Drugs. 2009 Apr;18(4):541-8. (12) McElwee MK, Song MO, Freedman JH. Copper activation of NF-kappaB signaling in HepG2 cells. J Mol Biol. 2009 Nov 13;393(5):1013-21. (13) Yang P, Gu H, Zhao Z, Wang W, Cao B, Lai C, Yang X, Zhang L, Duan Y, Zhang S, Chen W, Zhen W, Cai M, Penninger JM, Jiang C, Wang x. Angiotensin-converting enzyme 2 (ACE2) mediates influenza H7N9 virus-induced acute lung injury. Sci Rep. 2014 Nov 13;4:7027. (14) Geng Y-J. et al Pathophysiological characteristics and therapeutic approaches for Pulmonary Injury and Cardiovascular complications of Corona Virus Disease 2019 Cardiovasc. Pathol. April 17, 2020. (15) Ribeiro E.L et al. Diethylcarbamazine attenuates the development of carrageenan-induced lung injury in mice. Mediators of Inflammation, 2014 (16) Ackermann M et al. Pulmonary vascular endothelialitis, thrombosis and angiogenesis in COVID-19, NEJM, May, 2020. (17) Tan L. et al .Validation of predictors of disease severity and outcomes in COVID-19 patients:a descriptive and retrospective study. Med May 10, 2020. (18) The Global Phosphorylation Landscape of SARS-CoV-2 Infection Mehdi Bouhaddou, Danish Memon, Bjoern Meyer, Kris M. White, Veronica V. Rezelj, Miguel C. Marrero, Benjamin J. Polacco, James E. Melnyk, Svenja Ulferts, Robyn M. Kaake, Jyoti Batra, Alicia L. Richards, Erica Stevenson, David E. Gordon, Ajda Rojc, Kirsten Obernier, Jacqueline M. Fabius, Margaret Soucheray, Lisa Miorin, Elena Moreno, Cassandra Koh, Quang Dinh Tran, Alexandra Hardy, Remy Robinot, Thomas Vallet, Benjamin E. Nilsson-Payant, Claudia Hernandez-Armenta, Alistair Dunham, Sebastian Weigang, Julian Knerr, Maya Modak, Diego Quintero, Yuan Zhou, Aurelien Dugourd, Alberto Valdeolivas, Trupti Patil, Qiongyu Li, Ruth Huttenhain, Merve Cakir, Monita Muralidharan, Minkyu Kim, Gwendolyn Jang, Beril Tutuncuoglu, Joseph Hiatt, Jeffrey Z. Guo, Jiewei Xu, Sophia Bouhaddou, Christopher J.P. Mathy, Anna Gaulton, Emma J. Manners, Eloy Felix, Ying Shi, Marissa Goff, Jean K. Lim, Timothy McBride, Michael C.O'Neal, Yiming Cai, Jason C.J. Chang, David J. Broadhurst, Saker Klippsten, Emmie De wit, Andrew R. Leach, Tanja Kortemme, Brian Shoichet, Melanie Ott, Julio Saez-Rodriguez, Benjamin R. tenOever, Dyche Mullins, Elizabeth R. Fischer, Georg Kochs, Robert Grosse, Adolfo Garcia-Sastre, Marco Vignuzzi, Jeffery R. Johnson, Kevan M. Shokat, Danielle L. Swaney, Pedro Beltrao, Nevan J. Krogan PII: S0092-8674(20)30811-4 DOI: https: / / doi.org / 10.1016 / j.cell.2020.06.034 Reference: CELL 11493. (19) Hoffmann BR, Wagner JR, Prisco AR, Janiak A, Greene AS. Vascular endothelial growth factor-A signaling in bone marrow-derived endothelial progenitor cells exposed to hypoxic stress.Physiol Genomics. 2013 Nov 1;45(21):1021-34.

Claims

1. 1. A method of treating coronavirus or influenza in a patient, comprising: administering to said patient a therapeutically effective amount of a copper chelator comprising tetrathiomolybdate and at least one codrug; The method, wherein the coronavirus is COVID-19, a mutant of COVID-19, another coronavirus, a variant with a similar mechanism of action as COVID-19, or acute respiratory distress syndrome (ARDS).

2. The copper chelating agent is X(MoS ４ ) tetrathiomolybdate represented by the formula Here, X is (2Li) ＋２ , (2K) ＋２ , (2Na) ＋２ , Mg ＋２ , Ca ＋２ or {[N ＋ (R １ ) (R ２ ) (R ３ ) (R ４ ) ] [N ＋ (R ５ ) (R ６ ) (R ７ ) (R ８ ) ]}, R １ , R ２ , R ３ , R ５ , R ６ and R ７ are each independently H or a group selected from the group consisting of optionally substituted alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl, and heterocycloalkylalkyl; R ４ and R ８ 2. The method of claim 1, wherein each is absent or independently represents H or a group selected from the group consisting of optionally substituted alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl, and heterocycloalkylalkyl.

3. The copper chelating agent is [NH ４ ] ２ MoS ４ The method of claim 2 , comprising:

4. 10. The method of claim 1, wherein the copper chelator comprising tetrathiomolybdate is administered orally, as is the codrug.

5. 5. The method of claim 4, wherein the copper chelator comprising tetrathiomolybdate is orally administered in a delayed release formulation that releases the copper chelator comprising tetrathiomolybdate after the oral form has passed through the stomach.

6. 10. The method of claim 1, wherein the copper chelator comprising tetrathiomolybdate is administered intravenously and a codrug is administered orally or by inhalation.

7. a copper chelating agent comprising tetrathiomolybdate; a 5-lipoxygenase inhibitor selected from diethylcarbamazine (DEC) and zileuton; At least one other active agent may be selected from the group consisting of selective serotonin reuptake inhibitors (SSRIs), baicalin, fluvoxamine, bufalin, sulforaphane, quercetin, curcumin, NF-κB inhibitors, apigenin, indole-3-carbinol, nutrigenomic NRF2 activators, inhibitors of NF-κB, prostacyclin analogs; a pharma- ceutically acceptable carrier for drug delivery; A composition comprising:

8. The copper chelating agent is X(MoS ４ ) tetrathiomolybdate represented by the formula Here, X is (2Li) ＋２ , (2K) ＋２ , (2Na) ＋２ , Mg ＋２ , Ca ＋２ or {[N ＋ (R １ ) (R ２ ) (R ３ ) (R ４ ) ] [N ＋ (R ５ ) (R ６ ) (R ７ ) (R ８ ) ]}, R １ , R ２ , R ３ , R ５ , R ６ and R ７ are each independently H or a group selected from the group consisting of optionally substituted alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl, and heterocycloalkylalkyl; R ４ and R ８ 8. The composition of claim 7, wherein is absent, H, or a radical selected from the group consisting of optionally substituted alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl, and heterocycloalkylalkyl.

9. The copper chelating agent is [NH ４ ] ２ MoS ４ The composition of claim 8 comprising:

10. The composition of claim 7 , wherein the composition is in intravenous or oral form.

11. 8. The composition of claim 7, wherein the oral form is a delayed release formulation that releases the copper chelator comprising tetrathiomolybdate after (a) the oral form of tetrathiomolybdate has passed through the stomach and (b) at least one other active agent has been released into the stomach or after the active agent has passed through the stomach.

12. 1. A method of treating coronavirus or influenza in a patient, comprising: administering to the patient a therapeutically effective amount of a copper chelator comprising tetrathiomolybdate and a therapeutically effective amount of at least one or two other active agents; the other active agent is selected from the group consisting of selective serotonin reuptake inhibitors (SSRIs), diethylcarbamazine (DEC), zileuton, fluvoxamine, sulforaphane, apigenin, indole-3-carbinol, baicalin, bufalin, quercetin, curcumin, nutrigenomic NRF2 activators, NF-κB inhibitors, prostacyclin analogs, and Applied Therapeutics' aldose reductase inhibitor AT-001; The method, wherein the coronavirus is COVID-19, a variant of COVID-19, another coronavirus with a similar mechanism of action as COVID-19, or ARDS.

13. 13. The method of claim 12, wherein the coronavirus is COVID-19, a variant of COVID-19, another coronavirus with a similar mechanism of action as COVID-19, or ARDS.

14. The copper chelating agent is X(MoS ４ ) tetrathiomolybdate represented by the formula Here, X is (2Li) ＋２ , (2K) ＋２ , (2Na) ＋２ , Mg ＋２ , Ca ＋２ or {[N ＋ (R １ ) (R ２ ) (R ３ ) (R ４ ) ] [N ＋ (R ５ ) (R ６ ) (R ７ ) (R ８ ) ]}, R １ , R ２ , R ３ , R ５ , R ６ and R ７ are each independently H or a group selected from the group consisting of optionally substituted alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl, and heterocycloalkylalkyl; R ４ and R ８ 13. The method of claim 12, wherein is absent, H, or a radical selected from the group consisting of optionally substituted alkyl, alkenyl, alkynyl, aryl, heteroaryl, cycloalkyl, heterocycloalkyl, aralkyl, alkylaralkyl, heteroaralkyl, cycloalkylalkyl, and heterocycloalkylalkyl.

15. The copper chelating agent is [NH ４ ] ２ MoS ４ The method of claim 12, comprising:

16. 13. The method of claim 12, wherein the copper chelator comprising tetrathiomolybdate and the at least one other active agent are administered separately.

17. 13. The method of claim 12, wherein the copper chelator comprising tetrathiomolybdate is administered orally and the at least one other active agent is administered intravenously or by inhalation.

18. Copper chelators, including tetrathiomolybdate (TTM), (a) Oral administration of a combination oral form of a copper chelator including a TTM salt and DEC or zileuton, all contained in an enteric coated capsule or tablet, where in the case of an enteric coated capsule, the copper chelator including a TTM salt is separated from the DEC or zileuton by a coating or by being sealed in a separate compartment of the capsule, and in the case of a tablet, the TTM and DEC or zileuton are separated by a barrier or coating; (b) oral administration of a first oral form that is a combination oral form of a copper chelator with a TTM salt sealed separately or separated from the DEC or zileuton, the first oral form being a capsule without an enteric coating, and a second oral form of a proton pump inhibitor that is required to protect the TTM salt from stomach acid; (c) an oral administration of three separate oral forms, optionally packaged together, a first oral form comprising a copper chelator comprising a TTM salt without an enteric coating, a second oral form comprising DEC or zileuton, and a third oral form comprising a proton pump inhibitor; (d) oral administration of a first oral form comprising a copper chelator comprising a TTM salt without an enteric coating, and a second oral form comprising a combination of DEC or zileuton and a proton pump inhibitor; (e) oral administration of a first oral form comprising a combination of a copper chelator comprising a TTM salt and a proton pump inhibitor, the first oral form being sealed together and free of an enteric coating, and a second oral form comprising DEC or zileuton; (f) a combination of routes of administration in which a copper chelator, including a TTM salt with or without an enteric coating, is administered in oral form and DEC or zileuton is administered in inhaled or intravenous form; (g) a combination of routes of administration in which a copper chelator, including a TTM salt, is administered in intravenous form and DEC or zileuton is administered in oral, inhaled or intravenous form; (h) a combination of routes of administration in which a copper chelator comprising a TTM salt is administered in an intravenous form and DEC or zileuton is administered in an inhaled form comprising at least one of beraprost, fluvoxamine, or sulforaphane; (i) a combination of routes of administration in which a copper chelator including a TTM salt is administered in an intravenous form and DEC or zileuton is administered via an inhaler in an inhaled form including fluvoxamine or sulforaphane; 13. The method of claim 12, wherein the compound is administered in combination with DEC or zileuton in a manner selected from the group consisting of:

19. The copper chelator, including tetrathiomolybdate (TTM), is administered in one or more oral forms along with DEC or zileuton, and one or more additional active agents are added to or combined with the one or more oral forms; 20. The method of claim 18, wherein the additional active agent is fluvoxamine, sulforaphane, selective serotonin reuptake inhibitors (SSRIs), apigenin, indole-3-carbinol (i3c), bufalin, Applied Therapeutics aldose reductase inhibitor AT-001, baicalin, curcumin and quercetin, nutrigenomic NRF2 activators, inhibitors of NF-κB, and prostacyclin analogs.

20. 13. The method of claim 12, wherein the copper chelator comprising tetrathiomolybdate (TTM) is administered in a first oral form comprising DEC or zileuton, and ivermectin, together with DEC or zileuton, and ivermectin, and a second oral form comprising the copper chelator comprising a TTM salt having an enteric coating.

21. 13. The method of claim 12, wherein the copper chelator comprising tetrathiomolybdate (TTM) is administered in a first oral form comprising DEC or zileuton or sulforaphane, and fluvoxamine or sulforaphane, and a second oral form comprising the copper chelator comprising a TTM salt having an enteric coating, together with DEC or zileuton or sulforaphane, and fluvoxamine or sulforaphane.

22. 13. The method of claim 12, further comprising administering in combination with a therapeutically effective amount of a copper chelator comprising tetrathiomolybdate, or a therapeutically effective amount of DEC and other anti-viral compositions, antibody therapies, or other coronavirus therapies.

23. 13. The method of claim 12, further comprising administering together a therapeutically effective amount of a copper chelator comprising tetrathiomolybdate, a therapeutically effective amount of at least one other active agent, a drug that targets coronavirus via an antiviral mechanism, an antiviral protein, a coronavirus antibody, or an investigational nucleotide analog with broad-spectrum antiviral activity, wherein such treatment targets the virus.

24. 1. A method of treating coronavirus or influenza in a patient, comprising: administering to said patient a therapeutically effective amount of diethylcarbamazine (DEC) or zileuton together with a therapeutically effective amount of at least one or two other active agents; the other active agent is selected from the group consisting of selective serotonin reuptake inhibitors (SSRIs), fluvoxamine, sulforaphane, apigenin, indole-3-carbinol, baicalin, bufalin, quercetin, curcumin, nutrigenomic NRF2 activators, inhibitors of NF-κB, prostacyclin analogs, and Applied Therapeutics aldose reductase inhibitor AT-001; The method, wherein the coronavirus is COVID-19, a variant of COVID-19, another coronavirus with a similar mechanism of action as COVID-19, or ARDS.

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