Method for treating hypertension by periodic inhibition of aldosterone synthase - Patent Application 20070223333

Abstract

The present invention provides a method for treating hypertension in a hypertensive subject, comprising administering to the subject once or twice daily a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to inhibit CYP11β2 beta-hydroxylase by 50% or more for 40-60% of a 24-hour period, thereby treating hypertension in the hypertensive subject.

Description

[Technical field]

[0001] This application claims priority to U.S. Provisional Patent Application No. 63 / 400,301, filed August 23, 2022, and U.S. Provisional Patent Application No. 63 / 300,967, filed January 19, 2022, the contents of each of which are incorporated herein by reference.

[0002] Various publications are cited in this application, including those referenced within parentheses. The disclosures of all publications mentioned in this application are incorporated herein by reference in their entirety in order to provide further description of the art to which the invention pertains and in which the invention may be utilized.

[0003] FIELD OF THEINVENTION The present invention relates to a method for treating hypertension by inhibiting aldosterone synthase (CYP11β2 beta-hydroxylase). [Background technology]

[0004] Aldosterone is the major hydrocorticoid in humans, produced in the zona glomerulosa of the adrenal cortex by aldosterone synthase (CYP11β2 beta-hydroxylase). Aldosterone is a key component of the renin-angiotensin-aldosterone system (RAAS), which acts primarily as a regulator of electrolyte and fluid homeostasis.

[0005] Glucocorticoid receptor blockers (Glucocorticoid receptor antagonists, MRA), such as spironolactone and eplerenone, prevent aldosterone from binding to the Glucocorticoid receptor. Several clinical studies have demonstrated their efficacy in treating hypertension. Given the role that aldosterone plays in the RAAS, inhibition of aldosterone synthase indicates that it may be an alternative to Glucocorticoid receptor-blockers for treating hypertension. However, previous studies suggest that some of the actions of aldosterone may occur independently of stimulation of Glucocorticoid receptor / classical steroid receptor complex modulation (Grossmann, C. & Gekle, M., 2009;Good, DW, 2007;Mihailidou, AS & Funder, JW, 2005). In addition, the electrocorticoid receptor has similar affinity for the glucocorticoids cortisol and corticosterone, but is not selective for aldosterone.

[0006] Furthermore, plasma aldosterone (PA) levels follow a circadian rhythm, with PA typically reaching a peak upon waking in the morning and then gradually declining throughout the day (Williams, GH 1972). It is unclear to what extent different levels of PA throughout the day affect the blood pressure of hypertensive subjects, and it is also unclear whether inhibiting the synthesis of aldosterone during part of the day can effectively lower the blood pressure of hypertensive subjects. To effectively treat hypertension, a method is needed to inhibit the aldosterone synthesis enzyme in the right amount and at the right time. Summary of the Invention

[0007] The present invention provides a method for treating hypertension in a hypertensive subject, comprising administering to the subject once or twice daily a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to inhibit 50% or more of the activity of CYP11β2 beta-hydroxylase for 40-60% of a 24-hour period, thereby treating hypertension in the hypertensive subject.

[0008] The present invention provides a method for treating hypertension in a hypertensive subject comprising administering to the subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily for a period not shorter than 8 hours and not longer than 16 hours, in an amount sufficient to reduce the subject's serum aldosterone level by 50-90% compared to the subject's serum aldosterone level prior to drug administration.

[0009] The present invention provides a method for treating hypertension in a hypertensive subject, comprising administering to the subject once daily a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to inhibit CYP11β2 beta-hydroxylase activity by 50% or more between 1 and 16 hours, preferably between 3 and 8 hours.

[0010] The present invention also provides a method for treating hypertension in a hypertensive subject, comprising administering to the hypertensive subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily for at least 8 weeks in an amount sufficient to reduce the hypertensive subject's ambulatory systolic blood pressure by at least 10 mmHg compared to the hypertensive subject's ambulatory systolic blood pressure before administration of the CYP11β2 beta-hydroxylase inhibitor.

[0011] The present invention also provides a method for reducing systolic blood pressure in a hypertensive subject during sleep, comprising administering to the subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily in an amount sufficient to reduce the systolic blood pressure of the hypertensive subject during sleep. [Brief description of the drawings]

[0012] [Figure 1] Estimated times above the IC50 for various doses of Compound A·HBr are shown based on PKPD modeling from the SAD study.

[0013] [Diagram 2] The mean change from baseline in systolic blood pressure at week 4 is shown.

[0014] [Diagram 3] Changes from baseline in individual systolic blood pressures in the 100 mg QD and 25 mg BID cohorts are shown, with medians indicated by black bars to the left and right of each cohort.

[0015] [Figure 4] Box plots show the change from baseline in systolic blood pressure at week 4.

[0016] [Diagram 5] Median serum potassium over time is compared in placebo, 25 mg BID, and 100 mg QD cohorts.

[0017] [Figure 6] A graph of all available data for serum K+ levels in the placebo and 100 mg QD cohorts is shown.

[0018] [Figure 7] Individual responses for automated office-measured blood pressure (AOBP), serum K+, and estimated glomerular filtration rate (eGFR) in the 100 mg cohort are shown. Medians are indicated by black bars to the left and right of each cohort.

[0019] [Figure 8] Pharmacokinetic profiles (mean ± SE) from a single ascending dose study by treatment group are shown. SE = standard deviation.

[0020] [Figure 9]Pharmacokinetic profiles (mean ± SE, times are relative to the final dose) from a multiple ascending dose study by dose group and days are shown. SE = standard deviation

[0021] [Figure 10] Aldosterone time profiles for a single ascending dose study by treatment group are shown. Day -1 is the day before dosing, reflecting normal circadian rhythm. Day 1 is the day of dosing and represents the suppression of plasma aldosterone (mean ± SE) on that day. SE = standard deviation

[0022] [Figure 11] Aldosterone time profiles for a multiple ascending dose study by treatment group are shown. Day -1 is the day before dosing began and reflects normal circadian rhythm. Day 7 is the last day of dosing and represents the suppression of plasma aldosterone (mean ± SE). SE = standard deviation

[0023] [Figure 12] Percent change from baseline in aldosterone, time profile in a multiple ascending dose study by treatment group on day 7 is shown (mean ± SE). SE = standard deviation.

[0024] [Figure 13] Figure 1 shows percent change from baseline in aldosterone, time profile in a single ascending dose study by treatment group.

[0025] [Figure 14] Figure 1 shows the individual pharmacokinetics and time courses of aldosterone suppression and recovery in a single ascending dose study from Part 1.

[0026] [Figure 15] Effect of Compound A on aldosterone and cortisol in a single ascending dose study in Part 1; aldosterone AUC0-24 in a single ascending dose study in Part 1; AUC0-24: area under the curve from 0 to 24 hours; AUC0-72: area under the curve from 0 to 72 hours.

[0027] [Figure 16] The effect of Compound A on aldosterone and cortisol in a single ascending dose study in Part 1; cortisol AUC0-72 in a single ascending dose study in Part 1; AUC0-24: area under the curve from 0 to 24 hours; AUC0-72: area under the curve from 0 to 72 hours.

[0028] [Figure 17] 1 shows the effect of Compound A on plasma renin activity in a Part 2 multiple ascending dose study.

[0029] [Figure 18] 1 shows the effect of Compound A on 11-DOC in a Part 2 multiple ascending dose study.

[0030] [Figure 19] The effect of Compound A on renal sodium and potassium handling, urinary Na+ and log10(Na+ / K+) ratios are shown.

[0031] [Figure 20] FIG. 1 shows the effect of Compound A on renal sodium and potassium handling, serum K+.

[0032] [Figure 21]A study overview of Compound A HBr is shown. ABPM = ambulatory blood pressure monitoring; BP = blood pressure; BID = twice daily; EOT = end of treatment; FU = follow-up; PRA = plasma renin activity; QD = once daily; a = if screening results were available, an inclusion / exclusion assessment was performed. If the subject was not eligible based on the screening results, the subject did not proceed to visit 4. If screening results were not available, the subject proceeded to visit 4. If screening results were not available at visit 4, the subject should proceed to visit 5 to determine final eligibility. If eligible based on screening results, ABPM evaluation was initiated at visit 5. b = ABPM procedures were initiated at home approximately 24 hours prior to randomization (study day 1). Alternatively, sites were allowed to choose to visit the clinic on study day 0 (visit 5) to initiate ABPM procedures. Training for ABPM procedures was conducted either during the clinic visit or via telephone.

[0033] [Figure 22] Figure 1 shows waterfall plots of AOBP change in systolic blood pressure at week 8. The figure shows waterfall plots of the Full Analysis Set (FAS) and Safety Analysis Set for the placebo, 50 mg QD and 100 mg QD groups, and the analysis of Per Protocol ((Per Protocol) PP) for the 100 mg group. Also shown are the modeled and observed mean protocol adherence for each group.

[0034] [Figure 23] Figure 1 depicts a waterfall plot showing AOBP change in systolic blood pressure at week 8. The figure shows waterfall plots of the FAS analysis of 12.5 mg QD, 12.5 mg BID, and 25 mg BID with all subjects with measurements at week 8. Also shown are the modeled means and observed means of protocol adherence for each group.

[0035] [Figure 24]Bar graphs depicting mean change from baseline in systolic blood pressure. Figure presents final analysis including both full analysis population (FAS, all evaluable subjects receiving at least one dose of Compound A HBr) and protocol adherence (PP, only subjects receiving >75% of study drug at the Week 8 visit). Part 2 data show mid-averages at the final visit, Weeks 5-6.

[0036] [Diagram 25] Figure 1 depicts a graph showing the dose response of Compound A HBr as the observed mean change in automated clinic blood pressure from baseline at week 8 in the QD dosing regimen. The BID protocol adherence cohort is shown on the far right of the graph.

[0037] [Figure 26] Graphs depicting change from baseline in systolic blood pressure at Week 8 for the pooled cohorts of 50 mg QD, 100 mg QD, 12.5 mg BID, and 25 mg BID, the pooled cohorts of lowest response quartile, the pooled cohorts of highest response quartile, and placebo.

[0038] [Figure 27] Figure 1 depicts a waterfall plot showing the change in systolic blood pressure from the placebo and 100 mg QD groups pooled from both Parts 1 and 2. Part 2 data from the interim snapshot, when all subjects were randomly selected, is shown, on average 5-6 weeks from the last visit, with a minimum of 2 weeks.

[0039] [Figure 28] Graph showing change in estimated glomerular filtration rate (eGFR) in different dose cohorts.

[0040] [Figure 29]1 depicts an exemplary graph of 24-hour ambulatory blood pressure measurements showing 24-hour ambulatory blood pressure (systolic blood pressure) versus baseline in subjects administered 100 mg QD of Compound A·HBr, demonstrating a reduction in mean 24-hour blood pressure and restoration of the normal nocturnal falling pattern.

[0041] [Diagram 30] 1 shows a graph showing the change in systolic blood pressure at week 8 compared to baseline, as measured using the full analysis set of ABPM. [Diagram 31] Waterfall plots showing mean 24-hour and mean overnight ABPM change compared to baseline at week 8. The 100 mg QD dose level provides superior 24-hour BP reduction. Nighttime BP reduction at the 100 mg QD dose level appears to be superior to 25 mg BID. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0042] How to Treat Hypertension The present invention provides a method for treating hypertension in a hypertensive subject, comprising administering to the subject once or twice daily a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to inhibit the activity of CYP11β2 beta-hydroxylase by 50% or more for 40-60% of a 24-hour period, thereby treating hypertension in the hypertensive subject.

[0043] In an embodiment of the invention, 50% or more of CYP11β2 beta-hydroxylase activity is inhibited during a 10-14 hour period within a 24 hour period.

[0044] The present invention provides a method for treating hypertension in a hypertensive subject comprising administering to the subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily for a period not shorter than 8 hours and not longer than 16 hours, in an amount sufficient to reduce the subject's serum aldosterone level by 50-90% compared to the subject's serum aldosterone level prior to drug administration.

[0045] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor reduces serum aldosterone levels in a subject by 60-80% compared to the subject's pre-drug serum aldosterone levels over a period not shorter than 8 hours and not longer than 16 hours.

[0046] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor restores serum aldosterone to or above the subject's pre-drug levels over a period of 16 and 24 hours after administration of the dose.

[0047] The present invention provides a method for treating hypertension in a hypertensive subject, comprising administering to the subject once daily a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to inhibit CYP11β2 beta-hydroxylase activity by 50% or more between 1 and 16 hours, preferably between 3 and 8 hours.

[0048] The present invention relates to a method for treating hypertension in a hypertensive subject, comprising administering to the subject (a) inhibiting 50% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 16 hours, preferably between 3 and 8 hours; (b) inhibiting 60% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 13 hours, preferably between 2 and 6 hours; (c) inhibiting 70% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 9 hours, preferably between 2 and 5 hours; (d) inhibiting 80% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 6 hours, preferably between 1 and 3 hours; and / or (e) inhibiting 90% or more of the activity of CYP11β2 beta-hydroxylase between 0 and 3 hours, preferably between 0 and 1 hour and administering once daily to a subject in need of treatment with a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to treat hypertension in the hypertensive subject.

[0049] The present invention relates to a method for treating hypertension in a hypertensive subject, comprising administering to the subject (a) inhibiting 50% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 20 hours, preferably between 4 and 11 hours; (b) inhibiting 60% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 17 hours, preferably between 3 and 9 hours; (c) inhibiting 70% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 15 hours, preferably between 2.5 and 7 hours; (d) inhibiting 80% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 10 hours, preferably between 2 and 5 hours; and / or (e) inhibiting 90% or more of the activity of CYP11β2 beta-hydroxylase between 1 and 5 hours, preferably between 0.5 and 2.5 hours; and administering once daily to a subject in need of treatment with a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to treat hypertension in the hypertensive subject.

[0050] In an embodiment of the invention, the hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof.

[0051] In an embodiment of the invention, the hypertensive subject is taking or has taken at least two of said hypertension medications.

[0052] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is administered to the subject once daily.

[0053] In an embodiment of the invention, a dose of a CYP11β2 beta-hydroxylase inhibitor is administered in the morning.

[0054] In an embodiment of the invention, a dose of a CYP11β2 beta-hydroxylase inhibitor is administered once daily in the morning.

[0055] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor is administered to a subject twice daily.

[0056] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is: (a) It is administered daily for at least 1 week; (b) administered daily for at least 2 weeks; (c) administered daily for at least 4 weeks; or (d) administered daily for at least 8 weeks.

[0057] In an embodiment of the present invention, the CYP11β2 beta-hydroxylase inhibitor is selective for inhibiting CYP11β2 beta-hydroxylase activity compared to inhibiting CYP11β1 beta-hydroxylase activity, and it is preferable that the inhibition constant (Ki) of CYP11β1 beta-hydroxylase divided by the Ki of CYP11β2 beta-hydroxylase is greater than 100.

[0058] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor is administered to a hypertensive subject in an amount less than the amount that would cause the subject's serum and / or plasma 11-deoxycortisterone (11-DOC) level to exceed 600 picomoles / L, preferably less than the amount that would cause the subject's serum and / or plasma 11-DOC level to exceed 400 picomoles / L.

[0059] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor is administered to a hypertensive subject in an amount less than that which causes 11-DOC to accumulate in the subject above 0.1 ng / ml.

[0060] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor is administered to a hypertensive subject in an amount that does not cause a clinically significant upregulation of the subject's adrenocortical hormone synthesis.

[0061] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is (a) does not cause a clinically meaningful decrease in the subject's serum and / or plasma cortisol levels compared to the subject's serum and / or plasma cortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor; (b) does not cause a clinically meaningful elevation of 11-DOC levels in the subject's serum and / or plasma compared to the subject's serum and / or plasma 11-DOC levels prior to administration of the CYP11β2 beta-hydroxylase inhibitor. The amount is administered to a hypertensive subject.

[0062] In an embodiment of the invention, no clinically meaningful increase is caused in the subject's serum and / or plasma 11-deoxycortisol levels compared to the subject's serum and / or plasma 11-deoxycortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor.

[0063] In an embodiment, the CYP11β2 beta-hydroxylase inhibitor is (a) in an amount that does not cause more than a 20% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor, preferably in an amount that does not cause more than a 10% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor; (b) in an amount that does not cause a greater than 20% increase in the subject's serum and / or plasma 11-DOC level compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor, preferably an amount that does not cause a greater than 10% increase in the subject's serum and / or plasma 11-DOC level compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (c) in an amount that does not cause a greater than 20% increase in the subject's serum and / or plasma 11-deoxycortisol level compared to the subject's serum and / or plasma 11-deoxycortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor, preferably in an amount that does not cause a greater than 10% increase in the subject's serum and / or plasma 11-deoxycortisol level compared to the subject's serum and / or plasma 11-deoxycortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor; Administered to hypertensive subjects.

[0064] In an embodiment of the present invention, the CYP11β2 beta-hydroxylase inhibitor is a compound described in U.S. Patent No. 10,029,993 (the contents of which are incorporated herein by reference).In an embodiment, the CYP11β2 beta-hydroxylase inhibitor is a compound described in U.S. Patent No. 10,329,263 (the contents of which are incorporated herein by reference).In an embodiment, the CYP11β2 beta-hydroxylase inhibitor is a 1,2,4-triazine compound or a pharma-ceutically acceptable salt thereof.

[0065] In an embodiment, the CYP11β2 beta-hydroxylase inhibitor has formula (A): [ka] or a pharma- ceutically acceptable salt thereof.

[0066] In an embodiment, the CYP11β2 beta-hydroxylase inhibitor is a pharma- ceutically acceptable salt of a compound of Formula (A).

[0067] In an embodiment, the CYP11β2 beta-hydroxylase inhibitor is the monohydrobromide salt of the compound of formula (A), i.e., Compound A·HBr.

[0068] In an embodiment, the CYP11β2 beta-hydroxylase inhibitor is the free base form of the compound of Formula (A).

[0069] In one embodiment: (a) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (b) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (c) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or (d) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor is administered orally once daily.

[0070] In one embodiment: (a) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (b) 25 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (c) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; (d) 50 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or (e) 100 mg of a CYP11β2 beta-hydroxylase inhibitor is administered orally once daily.

[0071] In an embodiment, the CYP11β2 beta-hydroxylase inhibitor has formula (I): [ka] [In formula: 1) X and Y represent any of the following (i) to (iii): (i) X is N and Y is CH or CR Y or (ii) X is CH and Y is N; or (iii) X is CH and Y is CH; 2) R Y represents an alkyl group; 3) R A represents an optionally substituted cycloalkyl group, an optionally substituted cycloalkenyl group, an optionally substituted aryl group, or an optionally partially hydrogenated and substituted 6- to 10-membered monocyclic or bicyclic heteroaryl group; 4) R 1 represents a hydrogen atom or an alkyl group; 5) R 2 represents an optionally substituted alkyl group, an optionally substituted cycloalkyl group, an optionally substituted aliphatic heterocyclic group, or an optionally partially hydrogenated and optionally substituted heteroaryl group; and 6) R 3 represents a hydrogen atom or an alkyl group. or a pharma- ceutically acceptable salt thereof.

[0072] In an embodiment of the present invention: (a) the subject's systolic blood pressure measured in the office is reduced compared to the subject's systolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (b) the subject's 24-hour ambulatory systolic blood pressure is reduced as compared to the subject's ambulatory systolic blood pressure prior to administration of the CYP11β2 beta-hydroxylase inhibitor.

[0073] In an embodiment of the present invention: (a) the subject's systolic blood pressure measured in the office is reduced by at least 10 mmHg compared to the subject's systolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (b) the subject's ambulatory systolic blood pressure is reduced by at least 10 mmHg compared to the subject's ambulatory systolic blood pressure prior to administration of the CYP11β2 beta-hydroxylase inhibitor.

[0074] In an embodiment of the present invention: (a) the subject's diastolic blood pressure measured in the office is reduced compared to the subject's diastolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; (b) the subject's systolic and diastolic blood pressure measured in the office is reduced compared to the subject's systolic and diastolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; (c) the subject's ambulatory systolic and diastolic blood pressure is reduced compared to the subject's ambulatory systolic and diastolic blood pressure prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (d) the subject's systolic blood pressure falls below 130 mmHg and / or the subject's diastolic blood pressure falls below 80 mmHg.

[0075] In an embodiment of the present invention: (a) a reduction of at least 10 mmHg in the subject's ambulatory systolic blood pressure and a reduction of at least 5 mmHg in the subject's ambulatory diastolic blood pressure, respectively, compared to the subject's ambulatory systolic and diastolic blood pressure prior to administration of the CYP11β2 beta-hydroxylase inhibitor; (b) a reduction of at least 10 mmHg in the subject's systolic blood pressure measured in the office and a reduction of at least 5 mmHg in the subject's diastolic blood pressure measured in the office, respectively, compared to the subject's systolic and diastolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (c) the subject's systolic blood pressure falls below 130 mmHg and / or the subject's diastolic blood pressure falls below 80 mmHg.

[0076] In an embodiment of the invention, the hypertensive subject has a lower systolic blood pressure during sleep.

[0077] In an embodiment of the invention, the mean systolic blood pressure during sleep in a hypertensive subject is (a) a reduction of at least 10%, 10% to 40%, 10% to 30%, or 10% to 20% compared to the daytime mean systolic blood pressure in hypertensive subjects; (b) A reduction of at least 8 mmHg, at least 10 mmHg, 8 to 55 mmHg, 10 to 45 mmHg, or 10 to 25 mmHg compared to the mean systolic blood pressure during sleep before receiving the CYP11β2 beta-hydroxylase inhibitor.

[0078] In an embodiment of the invention, the duration of inhibition of CYP11β2 beta-hydroxylase activity is sufficient to maintain sodium status and fluid depletion in a hypertensive subject.

[0079] In an embodiment of the invention, the method does not result in persistent hypertension or a mild non-anion gap metabolic acidotic state in a hypertensive subject.

[0080] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor does not substantially accumulate in the hypertensive subject, and preferably, the lack of substantial accumulation of the CYP11β2 beta-hydroxylase inhibitor in the hypertensive subject allows the aldosterone levels of the hypertensive subject to return to pre-drug baseline within 24-48 hours of administration of the CYP11β2 beta-hydroxylase inhibitor, more preferably within 16-24 hours of administration of the CYP11β2 beta-hydroxylase inhibitor.

[0081] In an embodiment of the present invention, the potassium level of the hypertensive subject is generally maintained within a clinically normal range, preferably the potassium level of the hypertensive subject is slowly elevated compared to the potassium level of the hypertensive subject before administration of a CYP11β2 beta-hydroxylase inhibitor, more preferably the potassium level of the hypertensive subject is elevated by no more than 0.35 mmol / L, more preferably the potassium level of the hypertensive subject is maintained below a level of 5.5 mmol / L, more preferably the potassium level of the hypertensive subject is maintained between 3.5 mEq / l and 5.1 mEq / l.

[0082] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is (a) an amount that inhibits aldosterone production in a subject; (b) an amount that increases serum and / or plasma potassium levels in a subject; and / or (c) an amount that increases plasma renin activity (PRA) in a subject. is administered to hypertensive subjects.

[0083] In an embodiment of the present invention, (a) serum and / or plasma aldosterone AUC-24 is decreased in the subject by at least 25% compared to the aldosterone level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; (b) the serum and / or plasma potassium level in the subject is increased by at least 0.2 mmol / L compared to the serum and / or plasma potassium level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (c) the PRA in the subject is increased by at least 5 ng / ml / hour compared to the PRA in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor;

[0084] In an embodiment of the invention, the aldosterone levels in the hypertensive subject follow a substantially normal circadian rhythm.

[0085] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 1 ng / mL / hr.

[0086] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 0.6 ng / mL / hr.

[0087] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 4 ng / mL / hr.

[0088] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 3 ng / mL / hr.

[0089] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 2 ng / mL / hr.

[0090] In an embodiment of the invention, the hypertensive subject has a plasma aldosterone concentration of 6 ng / dL or greater, as measured by immunoassay.

[0091] In an embodiment of the invention, the hypertensive subject has a plasma aldosterone concentration of 1 ng / dL or greater, as measured by LC-MS.

[0092] In a preferred embodiment of the present invention, the hypertensive subject has a plasma renin activity of 1 ng / mL / hour or less and a plasma aldosterone concentration of 6 ng / dL or more as measured by immunoassay. In a preferred embodiment of the present invention, the hypertensive subject has a plasma renin activity of 1 ng / mL / hour or less and a plasma aldosterone concentration of 1 ng / dL or more as measured by LC-MS. In a further preferred embodiment, the hypertensive subject is taking or has taken a hypertensive drug selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof.

[0093] The present invention also provides a method for treating hypertension in a hypertensive subject, comprising administering to the hypertensive subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily in an amount sufficient to reduce the hypertensive subject's ambulatory systolic blood pressure by at least 10 mmHg compared to the hypertensive subject's ambulatory systolic blood pressure before administration of the CYP11β2 beta-hydroxylase inhibitor.

[0094] In an embodiment, the method reduces the ambulatory systolic blood pressure of the hypertensive subject by at least 10 mmHg compared to the ambulatory systolic blood pressure of the hypertensive subject before administration of a CYP11β2 beta-hydroxylase inhibitor for a period of at least 8 weeks.

[0095] The present invention also provides a method for reducing systolic blood pressure during sleep in a hypertensive subject, comprising administering to the subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily in an amount sufficient to reduce the hypertensive subject's systolic blood pressure during sleep.

[0096] In an embodiment of the invention, the mean systolic blood pressure during sleep in a hypertensive subject is (a) a reduction of at least 10%, 10% to 40%, 10% to 30%, or 10% to 20% compared to the daytime mean systolic blood pressure in hypertensive subjects; (b) a reduction of at least 8 mmHg, at least 10 mmHg, 8 to 55 mmHg, 10 to 45 mmHg, or 10 to 25 mmHg compared to the mean systolic blood pressure during sleep prior to receiving the CYP11β 2 beta-hydroxylase inhibitor.

[0097] In an embodiment of the present invention, the hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof. In an embodiment of the present invention, the hypertension subject is taking or has taken at least two of said hypertension medications.

[0098] In an embodiment of the invention, 50% or more of CYP11β2 beta-hydroxylase activity is inhibited for 40-60% of a 24 hour period.

[0099] In an embodiment of the invention, 50% or more of CYP11β2 beta-hydroxylase activity is inhibited for a period of 10 to 14 hours out of a 24 hour period.

[0100] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor reduces a subject's serum aldosterone level by 50-90% for a period not shorter than 8 hours and not longer than 16 hours compared to the subject's serum aldosterone level before administration of the drug.

[0101] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor reduces a subject's serum aldosterone level by 60-80% for a period not shorter than 8 hours and not longer than 16 hours compared to the subject's serum aldosterone level before administration of the drug.

[0102] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is capable of restoring a subject's serum aldosterone to or above the subject's serum aldosterone level prior to drug administration within a period of 16 hours and 24 hours after administration of the dose.

[0103] In an embodiment of the invention, 50% or more of CYP11β2 beta-hydroxylase activity is inhibited over a period of between 1 and 16 hours, or preferably over a period of between 3 and 8 hours, out of a 24 hour period.

[0104] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is administered to the subject once a day. In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is administered in the morning. In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is administered to the subject once or twice a day.

[0105] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is (a) It is administered daily for at least 1 week; (b) administered daily for at least 2 weeks; (c) administered daily for at least 4 weeks; or (d) administered daily for at least 8 weeks.

[0106] In an embodiment of the present invention, the ambulatory systolic blood pressure of the hypertensive subject is reduced by 10-55 mmHg, 10-50 mmHg, 10-45 mmHg, 10-40 mmHg, 10-35 mmHg, 10-30 mmHg, 10-25 mmHg, 10-20 mmHg, or 10-15 mmHg, compared to the ambulatory systolic blood pressure of the hypertensive subject before administration of a CYP11β2 beta-hydroxylase inhibitor for a period of at least 8 weeks. In an embodiment of the present invention, the ambulatory diastolic blood pressure of the hypertensive subject is reduced by 5-25 mmHg, 5-20 mmHg, or 5-15 mmHg, compared to the ambulatory diastolic blood pressure of the hypertensive subject before administration of a CYP11β2 beta-hydroxylase inhibitor for a period of at least 8 weeks.

[0107] In an embodiment of the invention, the duration of inhibition of CYP11β2 beta-hydroxylase activity is sufficient to maintain sodium status and fluid depletion in a hypertensive subject.

[0108] In an embodiment of the invention, the method does not result in a persistent state of hyperkalemia or mild non-anion gap metabolic acidosis in a hypertensive subject.

[0109] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor does not substantially accumulate in the hypertensive subject, and preferably, the lack of substantial accumulation of the CYP11β2 beta-hydroxylase inhibitor in the hypertensive subject allows the aldosterone levels of the hypertensive subject to return to pre-drug baseline within 24-48 hours of administration of the CYP11β2 beta-hydroxylase inhibitor, more preferably within 16-24 hours of administration of the CYP11β2 beta-hydroxylase inhibitor.

[0110] In an embodiment of the invention, the potassium level of the hypertensive subject is generally maintained within the clinically normal range, preferably the potassium level of the hypertensive subject is slowly elevated compared to the potassium level of the hypertensive subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor, more preferably the potassium level of the hypertensive subject is elevated by no more than 0.35 mmol / L, more preferably the potassium level of the hypertensive subject is maintained below a level of 5.5 mmol / L, more preferably the potassium level of the hypertensive subject is maintained between 3.5 mEq / l and 5.1 mEq / l.

[0111] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is (a) an amount that inhibits aldosterone production in a subject; (b) an amount that increases serum and / or plasma potassium levels in a subject; and / or (c) an amount that increases plasma renin activity (PRA) in a subject is administered to hypertensive subjects.

[0112] In an embodiment of the present invention: (a) serum and / or plasma aldosterone AUC-24 is decreased by at least 25% in the subject compared to the aldosterone level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; (b) the serum and / or plasma potassium level in the subject is increased by at least 0.2 mmol / L in the subject compared to the serum and / or plasma potassium level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (c) the PRA in the subject is increased by at least 5 ng / mL / hour compared to the PRA in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor;

[0113] In an embodiment of the invention, the aldosterone levels of the hypertensive subject follow a substantially normal circadian rhythm.

[0114] In an embodiment of the present invention, the CYP11β2 beta-hydroxylase inhibitor is selective for inhibiting CYP11β2 beta-hydroxylase activity compared to inhibiting CYP11β1 beta-hydroxylase activity, preferably having an inhibition constant (Ki) of CYP11β1 beta-hydroxylase divided by the Ki of CYP11β2 beta-hydroxylase that is greater than 100.

[0115] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor is administered to a hypertensive subject in an amount less than the amount that would cause the subject's serum and / or plasma 11-deoxycortisterone (11-DOC) level to exceed 600 picomoles / L, preferably less than the amount that would cause the subject's serum and / or plasma 11-DOC level to exceed 400 picomoles / L.

[0116] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor is administered to a hypertensive subject in an amount less than the amount that causes accumulation of 11-DOC above 0.1 ng / ml in the subject.

[0117] In an embodiment of the invention, a CYP11β2 beta-hydroxylase inhibitor is administered to a hypertensive subject in an amount that does not result in clinically significant upregulation of the subject's adrenocortical hormone synthesis.

[0118] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is (a) in an amount that does not cause a clinically meaningful decrease in the subject's serum and / or plasma cortisol levels compared to the subject's serum and / or plasma cortisol levels prior to administration of the CYP11β2 beta-hydroxylase inhibitor; (b) in an amount that does not result in a clinically meaningful increase in the serum and / or plasma level of 11-DOC in the subject compared to the serum and / or plasma level of 11-DOC in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (c) in an amount that does not produce a clinically meaningful increase in serum and / or plasma 11-deoxycortisol levels compared to the subject's levels prior to administration of the CYP11β2 beta-hydroxylase inhibitor. Administered to hypertensive subjects.

[0119] In an embodiment of the invention, the CYP11β2 beta-hydroxylase inhibitor is (a) in an amount that does not cause more than a 20% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor, preferably in an amount that does not cause more than a 10% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor; (b) in an amount that does not result in more than a 20% increase in the subject's serum and / or plasma 11-DOC level compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor, preferably in an amount that does not result in more than a 10% increase in the subject's serum and / or plasma 11-DOC level compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor; and / or (c) in an amount that does not result in more than a 20% increase in the subject's serum and / or plasma 11-deoxycortisol level compared to the subject's serum and / or plasma 11-deoxycortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor, preferably in an amount that does not result in more than a 10% increase in the subject's serum and / or plasma 11-deoxycortisol level compared to the subject's serum and / or plasma 11-deoxycortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor; Administered to hypertensive subjects.

[0120] In an embodiment, the CYP11β2 beta-hydroxylase inhibitor has formula (A): [ka] or a pharma- ceutically acceptable salt thereof.

[0121] In an embodiment, the compound is in the form of a pharma- ceutically acceptable salt of the compound of Formula (A).

[0122] In one embodiment: (a) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (b) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (c) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or (d) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor is administered orally once daily.

[0123] In one embodiment: (a) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (b) 25 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; (c) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; (d) 50 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or (e) 100 mg of a CYP11β2 beta-hydroxylase inhibitor is administered orally once daily.

[0124] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 1 ng / mL / hr.

[0125] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 0.6 ng / mL / hr.

[0126] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 4 ng / mL / hr.

[0127] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 3 ng / mL / hr.

[0128] In an embodiment of the invention, the hypertensive subject has a plasma renin activity of less than or equal to 2 ng / mL / hr.

[0129] In an embodiment of the invention, the hypertensive subject has a plasma aldosterone concentration of 6 ng / dL or greater, as measured by immunoassay.

[0130] In an embodiment of the invention, the hypertensive subject has a plasma aldosterone concentration of 1 ng / dL or greater, as measured by LC-MS.

[0131] In an embodiment of the invention, the hypertensive subject has secondary hypertension, preferably primary aldosteronism. In another embodiment of the invention, the hypertensive subject does not have primary aldosteronism, preferably the hypertensive subject has primary hypertension.

[0132] In a preferred embodiment of the present invention, the hypertensive subject has a plasma renin activity of 1 ng / mL / hour or less and a plasma aldosterone concentration of 6 ng / dL or more as measured by immunoassay. In a preferred embodiment of the present invention, the hypertensive subject has a plasma renin activity of 1 ng / mL / hour or less and a plasma aldosterone concentration of 1 ng / dL or more as measured by LC-MS. In a further preferred embodiment, the hypertensive subject is taking or has taken a hypertensive drug selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof.

[0133] Alternatively, in embodiments in which the hypertensive subject is not taking a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, or a calcium channel blocker, in one embodiment the hypertensive subject has a plasma renin activity of 0.6 ng / mL / hr or less and a plasma aldosterone concentration of 6 ng / dL or more as measured by immunoassay or 1 ng / dL or more as measured by LC-MS.

[0134] composition The invention also provides a pharmaceutical composition for use in any one of the methods described herein.

[0135] definition Unless otherwise specified, all technical and / or scientific terms used herein have the same meaning as commonly understood by those skilled in the art to which this invention belongs. Methods and materials similar or equivalent to those described herein can also be used to carry out or test embodiments of the present invention, but exemplary methods and / or materials are described below. In case of conflict, the patent specification of this application, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and are not necessarily limiting.

[0136] Unless otherwise specified, in the description, adjectives such as "substantially" and "about" modifying a condition or relationship characteristic of an embodiment of the present invention are understood to mean that the condition or characteristic is defined within a range that is acceptable for the operation of the embodiment for its intended use. In an embodiment, "about" means within a range of standard deviation using a measurement means generally accepted in the art. In an embodiment, "about" means a range covering ±10% of a particular value. In an embodiment, "about" includes a particular value. Unless otherwise specified, the term "or" in the specification and claims is considered to be an inclusive "or" rather than an exclusive "or" and indicates at least one of the items it conjugates, and any combination thereof.

[0137] As used above and elsewhere in this specification, the terms "a" and "an" refer to "one or more" of the listed components. It will be apparent to one of ordinary skill in the art that the use of the singular encompasses the plural unless specifically stated otherwise. Thus, the terms "a," "an," and "at least one" are used interchangeably in this application.

[0138] For the purpose of better understanding the teachings of the present invention, and not to limit the scope of the teachings in any way, unless otherwise indicated, all numbers and other numerical values ​​expressing quantities, percentages or proportions used in the specification and claims are to be understood as being modified in all instances by the word "about." Accordingly, unless indicated to the contrary, the numerical parameters set forth in the following specification and appended claims are approximations that may vary depending upon the desired properties sought to be obtained. At the very least, each numerical parameter should be construed in light of the number of reported significant digits and by applying ordinary rounding techniques.

[0139] In the specification and claims of this application, the verbs "comprise," "include," and "have," as well as their conjugations, are used to indicate that the object of the verb is not necessarily an exhaustive listing of compartments, elements, or parts of the subject of the verb. Other terms used herein are to be defined by their well-known meanings in the art.

[0140] "Hypertension" is also referred to as high blood pressure, blood pressure higher than normal. In 2017, the American College of Cardiology and the American Heart Association published guidelines for managing hypertension, defining hypertension as blood pressure equal to or greater than 130 mmHg systolic and 80 mmHg diastolic. Stage 1 hypertension is defined as blood pressure between 130-139 mmHg systolic and 80-89 mmHg diastolic, while stage 2 hypertension is defined as blood pressure greater than 140 mmHg systolic and greater than 90 mmHg diastolic. As used herein, "hypertension" encompasses both stage 1 and 2 hypertension, unless otherwise indicated. In one embodiment, the hypertensive subject has stage 1 hypertension. In another embodiment, the hypertensive subject has stage 2 hypertension. Hypertension includes hypertension that is multifactorial and does not have one clear cause (primary hypertension), and hypertension that has a direct cause (secondary hypertension). As used herein, "hypertension" includes both primary and secondary hypertension, unless otherwise indicated. In an embodiment, the hypertensive subject has primary hypertension. In another embodiment, the hypertensive subject has secondary hypertension. Primary aldosteronism (hyperaldosteronism) is the most common form of secondary hypertension and is a condition that occurs when the adrenal glands produce too much aldosterone. In an embodiment where the hypertensive subject has secondary hypertension, the subject has primary aldosteronism.

[0141] "CYP11β2", "Cyp11B2", or "CYP11β2 beta-hydroxylase" is a cytochrome P450 enzyme encoded by the CYP11B2 gene in humans, which catalyzes a series of reactions from 11-deoxycorticosterone (i.e., aldosterone precursor) to aldosterone. Thus, it is referred to in the art as "aldosterone synthase". Cyp11B2 is mainly expressed in the zona glomerulosa of the adrenal cortex, and the level of aldosterone in plasma is regulated by the enzymatic activity of Cyp11B2 present in the adrenal gland. Aldosterone is expressed in other tissues, such as cardiovascular, renal, adipose, and brain.

[0142] "CYP11β1", "Cyp11B1", or "CYP11β1 beta-hydroxylase" is a cytochrome P450 enzyme that is encoded by the CYP11B1 gene in humans and is involved in the biosynthesis of adrenal cortical steroids. It is also referred to in the art as "steroid 11β-hydroxylase".

[0143] An "inhibitor" refers to a compound (e.g., a compound described herein) that reduces activity when compared to a control, such as in the absence of the compound or a compound known to be inactive. Inhibitors can be small molecule inhibitors, antibody inhibitors, protein inhibitors, biomolecule inhibitors, natural ligands, and the like. An "inhibitor" can be, for example, in the form of a pharma- ceutically acceptable salt of a compound described herein.

[0144] As used herein, "compound A" refers to a compound having the formula (A): [ka] This refers to a disubstituted 1,2,4-triazine compound represented by the formula: 3-[4-[[trans-4-(acetamino)cyclohexyl]carbamoylmethyl]piperazin-1-yl]-5-(p-tolyl)-1,2,4-triazine.

[0145] "Compound A·HBr" refers to the hydrobromic acid (HBr) salt of Compound A. The weight and / or strength of "Compound A·HBr" and the "compounds" of the present invention refer to the weight of the free base of the HBr salt (i.e., Compound A), not the weight of the HBr salt.

[0146] Compound A and its pharma- ceutically acceptable salts may be prepared, for example, by the methods described in U.S. Pat. No. 10,029,993 and European Publication No. 3,549,935, the disclosures of which are incorporated herein by reference in their entireties.

[0147] As used herein (and as is well understood in the art), "treating" or "treatment" also broadly encompasses any approach to obtain beneficial or desired results in a subject's condition, including clinical results. Beneficial or desired clinical results may include, but are not limited to, alleviation or amelioration of one or more signs or symptoms, whether partial or total, detectable or undetectable, reduction in the extent of disease, stabilization of disease state (i.e., not worsening), prevention of disease spread or spread, delay or slowing of disease progression, amelioration or alleviation of disease state, reduction of disease recurrence, and remission. In other words, as used herein, "treatment" includes any cure, amelioration, or prevention of disease. Treatment may prevent the onset of disease; inhibit the spread of disease; alleviate the symptoms of disease; completely or partially eliminate the underlying cause of disease; shorten the duration of disease; or a combination of these.

[0148] As used herein, "treating" and "treatment" include prophylactic treatment. The treatment method includes administering a therapeutically effective amount of an active agent to a subject. The administration step may be a single administration or may include a series of administrations. The length of the treatment period depends on various factors, such as the severity of the symptoms, the age of the patient, the concentration of the active agent, the activity of the composition used in the treatment, or a combination thereof. It will also be understood that the effective dosage of the agent used for treatment or prevention may increase or decrease during the course of a particular treatment or prevention regimen. The change in dosage may be effected or revealed by standard diagnostic assays known in the art. In an embodiment, chronic administration may be required. For example, the composition is administered to the subject in an amount and for a period sufficient to treat the patient. In an embodiment, the treating or treatment is not a prophylactic treatment.

[0149] "Diuretics" refers to drugs for treating high blood pressure that increase urine production, thereby increasing the amount of water and salt excreted from the body. Diuretics can be carbonic anhydrase inhibitors, loop diuretics, potassium-sparing diuretics, thiazide diuretics, or any other diuretics known in the art. Exemplary carbonic anhydrase inhibitors include acetazolamide, brinzolamide, dorzolamide, dichlorphenamide, ethoxaolamide, zoniamide, indisulam, and methazolamide. Exemplary loop diuretics include bumatenide, ethacrynic acid, torsemide, and furosemide. Exemplary potassium-sparing diuretics include epererenone, triamterene, spironolactone, and amiloride. Exemplary thiazide diuretics include indapamide, hydrochlorothiazide, chlorthalidone, metolazone, methyclothiazide, chlorothiazide, methylclothiazide, metolazone, bendroflumethiazide, polythiazide, and hydroflumethiazide. Other diuretics include pamabrom and mannitol.

[0150] "Angiotensin-converting enzyme inhibitors" or "ACE inhibitors" refer to antihypertensive drugs that block the conversion of angiotensin I to angiotensin II, thereby dilating blood vessels and lowering blood pressure. Exemplary ACE inhibitors include benazepril, zofenopril, perindopril, trandolapril, captopril, enalapril, lisinopril, and ramipril.

[0151] "Angiotensin receptor blockers" or "angiotensin II inhibitors" refer to antihypertensive drugs that block the receptor from binding to angiotensin II, thereby dilating blood vessels and lowering blood pressure. Exemplary angiotensin receptor blockers include eprosartan, olmesartan, valsartan, candesartan, losartan, telmisartan, irbesartan, valsartan, and azilsartan medoxomil.

[0152] "Calcium channel blocker" refers to a hypertension drug that can block calcium from entering heart and arterial cells through calcium channels, thereby lowering blood pressure. Calcium channel blockers can be dihydropyridine calcium channel blockers, phenylalkylamine calcium channel blockers, benzothiazepine calcium channel blockers, non-selective calcium channel blockers, or any other calcium channel blockers known in the art. Dihydropyridine calcium channel blockers include amoxicillin, aranidipine, azelnidipine, barnidipine, benidipine, cilnidine, clevidipine, efonidipine, felodipine, isradipine, lacidipine, lercanidipine, manidipine, nicardipine, nifedipine, nilvadipine, nimodipine, nisoldipine, nitrendipine, and pranidipine. Phenylalkylamine calcium channel blockers include fendiline, gallipamil, and varapamil. Benzothiazepines include diltiazem. Nonselective calcium channel blockers include mibefradil, bepridil, flunarizine, fluspirilene, and fendiline. Other calcium channel blockers include gabapentin, pregabalin, and ziconotide.

[0153] The "normal circadian rhythm" of aldosterone levels follows a diurnal pattern, with a trough in the middle of the night and a peak before early morning awakening. In one embodiment, the aldosterone levels of hypertensive subjects follow a substantially normal circadian rhythm. In one such embodiment, the CYP11β2 beta-hydroxylase inhibitors of the present invention, when administered once a day in the morning after waking, suppress the abnormally high production of aldosterone during waking hours. In the evening, the suppression of aldosterone production begins to wane, and the normal increase in serum aldosterone returns to normal by dawn, as it would under normal circumstances. The circadian rhythm of aldosterone in healthy subjects and subjects with primary aldosteronism is described in Kem, David C. et al., "Circadian rhythm of plasma aldosterone concentration in patients with primary aldosteronism," The Journal of clinical investigation 52. 9 (1973): 2272-2277, the contents of which are specifically incorporated herein by reference.

[0154] The present invention provides a method for lowering systolic blood pressure in a hypertensive subject "during sleep." In this context, "during sleep" refers to a period of sleep in the hypertensive subject's normal sleep / wake cycle. In other words, "during sleep" refers to the subject's approximately 7 to 9 hours of sleep (typically at night) that occurs between the approximately 15 to 17 hours of wakefulness of the hypertensive subject's day, and does not refer to any short periods of sleep (i.e., naps) that may occur outside the sleep phase of the subject's normal sleep / wake cycle. The blood pressure of a non-hypertensive individual typically drops during sleep, with blood pressure values ​​being approximately 10% to 15% lower during sleep compared to wakefulness. In contrast, a hypertensive subject may experience a smaller drop in blood pressure or no drop in blood pressure at all during sleep. Thus, the method of the present invention helps a hypertensive subject restore the drop in blood pressure that a normal non-hypertensive subject experiences during sleep.

[0155] The "pre-drug level" of serum aldosterone of a subject refers to the serum aldosterone level of the subject at the same time of day when not treated with a CYP11β2 beta hydroxylase inhibitor.As described above, aldosterone levels follow a circadian pattern, with a trough at midnight and a peak before waking up in the early morning.Therefore, in an embodiment where administration of a CYP11β2 beta hydroxylase inhibitor reduces the serum aldosterone level of a subject at a relative rate to its "pre-drug level", the reduction in serum aldosterone is measured relative to the serum aldosterone level of the same subject at the same time of day when not administered with a CYP11β2 beta hydroxylase inhibitor.For example, the serum aldosterone level of a subject at 11 am when administered with a CYP11β2 beta hydroxylase inhibitor is measured relative to the serum aldosterone level of the same subject at 11 am before administration with a CYP11β2 beta hydroxylase inhibitor.

[0156] overview In the above-described embodiments, it is contemplated that each embodiment disclosed herein is applicable to each of the other disclosed embodiments.

[0157] As used herein, all headings are for organizational purposes only and are not intended to limit the disclosure in any way. The contents of each section apply equally to all sections. All combinations of the various sections disclosed herein are within the scope of the invention.

[0158] Additional objects, advantages, and novel features of the present invention will become apparent to those skilled in the art upon examination of the following examples, which are not intended to be limiting. Additionally, each of the various embodiments and aspects of the present invention as defined hereinabove and as claimed in the claims section below finds experimental support in the following examples.

[0159] It is understood that certain features of the invention that are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention that are, for brevity, described in the context of a single embodiment, may also be provided separately or in any suitable subcombination or as appropriate in any otherwise described embodiment of the invention. Certain features described in the context of various embodiments are not considered essential features of those embodiments, unless the embodiment does not operate without those factors.

[0160] In order to facilitate a more complete understanding of the present invention, the following examples are provided. The following examples set forth illustrative modes for making and practicing the invention. However, the scope of the invention is not limited to the specific embodiments disclosed in these examples, which are for illustrative purposes only.

[0161] Working Example Example 1 A randomized, double-blind, placebo-controlled study was conducted in which 116 patients were randomized and 87 received Compound A·HBr.

[0162] A single ascending dose (SAD) study was conducted with the following doses tested: (a) 5 mg (b) 10 mg (c) 20 mg (d) 50 mg (e) 100 mg (f) 200 mg (g) 400mg (h) 800 mg The experiment was carried out using

[0163] The IC50 for inhibition of CYP11β2 beta-hydroxylase by compound A·HBr and the time above the IC50 at each dose were estimated by subjecting data from the SAD study to PKPD modeling. Estimates of time above the IC50 and percentage of time above the IC50 over a 24-hour period for doses proposed for the Phase 2 proof-of-concept study were extrapolated and are shown in the table below and Figure 1. [Table 1]

[0164] Time above the IC50 correlated closely with duration of aldosterone suppression in SAD studies.

[0165] In a multiple ascending dose (MAD) study, little drug accumulation was observed at doses of 40 mg, 120 mg, and 360 mg QD.

[0166] Example 2 Study design A double-blind, randomized, placebo-controlled study of the safety and efficacy of Compound A·HBr was conducted in hypertensive subjects.

[0167] Hypertensive subjects were divided into six experimental groups: (a) Placebo group: A placebo tablet matching the size, color, and shape of the study drug was orally administered once daily in the morning; (b) 12.5 mg BID: A group in which one tablet containing 12.5 mg of compound A·HBr was orally administered once in the morning and once in the evening, 12 hours apart, every day; (c) 25 mg BID: A group in which one tablet containing 25 mg of compound A·HBr was orally administered once in the morning and once in the evening, 12 hours apart, every day; (d) 12.5 mg QD: one tablet containing 12.5 mg of compound A·HBr was orally administered once daily in the morning; (e) 50 mg QD: two tablets containing 25 mg of Compound A HBr administered orally once daily in the morning; and (f) 100 mg QD: A group in which one tablet containing 100 mg of compound A·HBr was orally administered once daily in the morning. were randomly assigned to one of the following:

[0168] Inclusion criteria Study subjects met the following inclusion criteria: (a) Subjects must be male, 18 years of age or older, and non-pregnant, non-lactating females; (b) written informed consent Health Insurance Portability and Accountability Act approval and local patient privacy documentation required for this study have been obtained; (c) SBP with Automated Office Blood Pressure (AOBP) > be 130mmHg; (d) history of antihypertensive treatment with two or more drugs; (e) PRAs < be 1.0ng / mL; (f) Serum aldosterone > 1 ng / dL; and (g) Morning serum cortisol in the normal range; if baseline serum cortisol is <18 mcg / dL, then perform a baseline Cortrosyn stimulation test at baseline fulfilled.

[0169] Exclusion criteria Subjects who met the inclusion criteria also met the following exclusion criteria: (a) Concomitant use of an epithelial sodium channel blocker or an electrolyte corticoid receptor antagonist; (b) being subject to hypokalemia; (c) being subject to hyperkalemia; (d) subjects had serum cortisol <3 mcg / dL; (e) subjects had a serum sodium of <135 mEq / L; (f) Estimated glomerular filtration rate < 60 mL / min / 1.73 m 2 being subject to; (g) Type 1 or uncontrolled (hemoglobin A1c > 9%) being subject to type 2 diabetes; (h) Body mass index >40 kg / m 2 being subject to; (i) Subjects with unstable angina; (j) SBP > 175mmHg or DBP > be subject to 100mmHg; (k) SBP by sitting to standing > At 20mmHg or DBP > Subjects with a decrease of 10 mmHg; (l) Subjects suspected of non-adherence to antihypertensive treatment in the opinion of the investigator; (m) The subject has, in the opinion of the Investigator, any significant medical disease or indication; (n) Subjects who, in the opinion of the Investigator, have any medical or psychiatric condition, acute or chronic; (o) Any of the following: (i) Topical corticoids; (ii) sympathomimetic decongestants; (iii) theophylline; (iv) phosphodiesterase type 5 inhibitors; (v) NSAIDs; (vi) intramuscular steroids; (vii) estrogen; (viii) Cytochrome; (ix) strong CYP3A and CYP3A4 inducers; Being a subject receiving treatment with (p) the subject has known hypersensitivity to Compound A HBr or any of the excipients; and (q) The subject is a night shift worker. were excluded based on

[0170] result Change from baseline in systolic blood pressure at week 4 After 4 weeks of treatment, Compound A HBr administered once daily demonstrated a dose-response with activity at 50 mg QD and further increasing at 100 mg QD. Placebo showed a small, non-significant decrease. Twice daily administration of 25 mg BID was as effective as 100 mg QD. See Figure 2.

[0171] A summary table of the cohort change from baseline in systolic blood pressure at week 4 is shown below: [Table 2]

[0172] Individual systolic blood pressure changes from baseline in the 100 mg QD and 25 mg BID cohorts are shown in Figure 3. These cohorts had high response rates and consistent magnitude of benefit.

[0173] Figure 4 provides a box plot of the change in systolic blood pressure from baseline at week 4. Both dose levels, 100 mg QD and 25 mg BID, produced a significantly greater reduction in systolic blood pressure than that seen in the placebo group. Formal inter-cohort comparisons will be performed at the end of the study using a mixed-effects model. The results are summarized in the table below: [Table 3]

[0174] Serum K + Effect on In the 100 mg QD cohort, serum potassium (K + A median increase of 0.2 mmol / L was observed in median K (see Figure 5). In the 100 mg QD cohort, + No subjects had dose withholding or reduction associated with elevated serum K levels throughout the study.+ Most increases were isolated events. Serum K in the placebo and 100 mg QD cohorts + A graph showing all the data available for the values ​​is provided in FIG.

[0175] Individual responses in the 100mg cohort Figure 7 shows automated office-measured blood pressure (AOBP) and serum K in the 100 mg cohort. + , and all individual responses in estimated glomerular filtration rate (eGFR) are shown.

[0176] The decrease in BP is due to the increase in serum K + was associated with targeted, modest increases in serum K and a decrease in eGFR. + Changes in both GLBP and eGFR were monitorable and were reversible if Compound A HBr was held, dose adjusted, or discontinued.

[0177] Consideration The double-blind, randomized, placebo-controlled study described in Example 2 demonstrates that Compound A·HBr administered at a dose of 100 mg once daily and at a dose of 25 mg twice daily has the greatest effect on systolic blood pressure of all dosing regimens tested. See Figure 2. Based on subjecting the data from the SAD study summarized in Example 1 to PKPD modeling, these dosing regimens demonstrated, on average, an IC of approximately 12.5 to 13.5 hours per 24-hour period. 50 (Inhibition of CYP11β2 beta-hydroxylase) was determined to provide a time above that of

[0178] Without wishing to be limited to a particular theory, the inventors hypothesize that a method of inhibiting 50% or more of CYP11β2 beta-hydroxylase activity for 40-60% of a 24-hour period, i.e., for approximately 10-14 hours per day, can be used to safely and effectively treat hypertension in hypertensive subjects. The results described in Example 2 demonstrate that inhibiting this amount of CYP11β2 beta-hydroxylase activity can lower systolic blood pressure in hypertensive subjects without causing adverse increases in serum potassium or other adverse reactions that would require cessation of treatment.

[0179] Moreover, it is beneficial that the 100mg QD dosing regimen is effective in lowering blood pressure in hypertensive subjects. In the 100mg QD cohort of Example 2, the CYP11β2 beta hydroxylase inhibitor was administered once a day in the morning. The time above IC50 averaged about 13.5 hours (see Example 1), and the results of the 100mg QD dosing regimen demonstrate that inhibition of CYP11β2 beta hydroxylase for about half a day is effective in lowering blood pressure in hypertensive subjects. In addition, the results of the 25mg BID dosing regimen confirm that exposure to the CYP11β2 beta hydroxylase inhibitor above IC50 to produce aldosterone for about 12 hours is effective in achieving blood pressure reduction, regardless of whether the reduction is achieved by once a day or twice a day dosing.

[0180] Thus, the studies described herein demonstrate that blood pressure can be effectively lowered in hypertensive subjects by administering a CYP11β2 beta-hydroxylase inhibitor once or twice daily in an amount that inhibits 50% or more of CYP11β2 beta-hydroxylase activity for 40-60% of a 24-hour period.

[0181] Example 3 method In vitro studies Assays for hCYP11B2 and hCYP11B1 Inhibition The inhibitory effect of Compound A on human CYP11B1 (hCYP11B1) and human CYP11B2 (hCYP11B2) enzyme activities was evaluated by measuring the enzyme conversion rates of 11-deoxycortisol to cortisol for hCYP11B1 and 11-DOC to aldosterone for hCYP11B2. Osilodrostat, a potent inhibitor of both hCYP11B1 and hCYP11B2, was used as a positive control. The inhibition constants of Compound A (free base) and osilodrostat against hCYP11B2 were calculated based on the rate of aldosterone production from the substrate 11-DOC (pg / μg protein / hour) using mitochondrial fractions from V79 cells stably expressing hCYP11B2 as the enzyme source. Similarly, the inhibition constants of compound A and osilodrostat against hCYP11B1 were calculated based on the cortisol production rate (pmol / mg protein / hour) from the substrate 11-deoxycortisol using the mitochondrial fraction of V79 cells stably expressing hCYP11B1 as the enzyme source.

[0182] Pan-receptor screening Compound A was screened against 46 targets in receptor binding and enzyme inhibition studies at a concentration of 10 micromol / L to determine whether Compound A interacted with any off-target enzymes or receptors.

[0183] Effect on hERG current The effect of compound A on human ether-a-go-go-related gene (hERG) currents was assessed using the whole-cell patch clamp technique in human embryonic kidney (HEK293) cells stably expressing hERG channels. Cells were treated with compound A at concentrations of 1, 3, 10, and 30 micromol / L, positive control (E-4031) at a concentration of 0.1 micromol / L, or vehicle (0.3% v / v dimethyl sulfoxide) for 10 min.

[0184] Inhibitory effect on adrenal steroidogenesis Multiple concentrations of Compound A and aminoglutethimide (positive control) were evaluated in human adrenal cortex NCI-H295R cell cultures. The effect of Compound A on adrenal steroidogenesis was determined by measuring 12 steroid hormones in the medium after 3 days of incubation. The following steroids were measured: pregnenolone, 11-deoxycortisol, 17α-hydroxypregnenolone, 11-DOC, dehydroepiandrosterone, corticosterone, progesterone, cortisol, 17α-hydroxyprogesterone, androsterone, androstenedione, and testosterone.

[0185] In vivo animal studies All studies (except for the ACTH-treated cynomolgus monkey experiments and the cardiovascular study in halothane-anesthetized dogs) were performed in contract research laboratories accredited by the Association for Assessment and Accreditation of Laboratory Animal Care (AAALAC) International. The most complete and accurate studies were performed in AAALAC-accredited contract research laboratories according to Good Laboratory Practices (GLP) regulations.

[0186] The cardiovascular system in halothane-anesthetized dogs. The cardiovascular effects of Compound A were evaluated in halothane-anesthetized dogs. Compound A was administered as free base at doses of 0, 0.3, 1, and 3 mg / kg intravenously in ascending order in the same three male dogs at a rate of 0.1 mL / kg / min for 10 minutes, cumulatively with a 30 minute interval between initiation of infusion. Heart rate, systolic, diastolic, and mean blood pressure, cardiac output, total peripheral resistance, left ventricular end-diastolic pressure, maximum rate of rise of left ventricular pressure, and electrocardiogram parameters (PR interval, QRS duration, QT interval, and QTcV) were evaluated.

[0187] Cardiovascular system in telemetered monkeys The cardiovascular effects of Compound A were evaluated in telemetered, conscious monkeys. Single doses of 0, 10, 30, or 100 mg / kg Compound A were administered orally as the free base to four male monkeys in a Latin-square design with a 7-day interval between doses. Blood pressure, heart rate, and electrocardiogram parameters (PR interval, QRS duration, QT interval, and QTcB) were assessed up to 24 hours after each dose.

[0188] Sodium-deficient cynomolgus monkey experiment Experiments were performed in sodium-deficient cynomolgus monkeys with secondary hyperaldosteronism to evaluate the effect of Compound A on plasma aldosterone concentration (PAC). A low-sodium diet and three doses of 5 mg / kg frusemide were used in the study. Two animals each were assigned to six groups, consisting of a vehicle group and five Compound A (free base) groups (0.3, 1, 3, 10, and 30 mg / kg). Six crossovers were performed to ensure that all animals were assigned to each group. Hyperaldosteronism was induced once every three weeks. PAC was determined by radioimmunoassay and measured over a 24-hour period following administration of Compound A.

[0189] ACTH-treated cynomolgus monkey experiment An adrenocorticotropic hormone (ACTH)-treated cynomolgus monkey study was conducted to evaluate the effect of Compound A on plasma cortisol concentration (PCC). Compound A was administered as the free base at a dose 100-fold greater than that required to reduce PAC (oral, 0.3 mg / kg), followed immediately by ACTH (subcutaneous, 50 μg / kg). PAC was also assessed in the animals. PAC and PCC were determined by radioimmunoassay and measured over a 24-hour period following Compound A administration.

[0190] toxicity research The toxicity profile of Compound A was evaluated in several toxicity studies, including a 13-week repeated-dose oral study in Sprague-Dawley rats and cynomolgus monkeys, a standard population genotoxicity study, a preliminary embryo-fetal development study in rats and rabbits, and in vitro and in vivo phototoxicity studies. Rats and monkeys were selected for the general toxicity studies based on pharmacological and metabolic data indicating that these animals would have a metabolism similar to that of humans. The studies were conducted in accordance with GLP regulations.

[0191] Doses in the 13-week toxicity study were 0, 50, 150, 450 (female), and 600 (male) mg / kg / day in Sprague-Dawley rats. In cynomolgus monkeys (female and male), doses were 0, 10, 30, and 100 mg / kg / day. Hematoxylin and eosin stained sections (nominal thickness approximately 5 μm) were prepared from formalin-fixed, paraffin-embedded organs / tissues of all animals in the toxicity study.

[0192] clinical research A four-part, phase 1, randomized, double-blind, placebo-controlled, first-in-human study was conducted to measure the safety, tolerability, PK, and PD of single ascending dose (SAD; part 1) and multiple ascending dose (MAD; part 2) of Compound A·HBr in healthy participants. The study also evaluated whether there were any gender (part 3) and age-related effects (part 4) on the PK of single doses of Compound A·HBr. The study was approved by the local independent ethical committee; the BEBO Foundation, Assen, The Netherlands; and the Central Committee for Research Involving Human Subjects, The Hague, The Netherlands, and was conducted in accordance with the provisions of the Declaration of Helsinki. Written informed consent was obtained from each study participant before any protocol-related procedures were performed.

[0193] In part 1, Compound A·HBr or placebo was administered to 64 healthy Caucasian males in eight cohorts of eight participants in each cohort, ages 18 to 55 years (inclusive). In each cohort, six participants were randomly assigned to receive a single dose of Compound A·HBr and two participants were randomly assigned to receive a matching placebo. Every cohort included two watchdog participants, one of whom received Compound A·HBr and one of whom received a matching placebo. The remaining six participants, five of whom received Compound A·HBr and one of whom received a placebo, were administered at least 24 hours after the watchdog participants. Cohort doses were 5, 10, 20, 50, 100, 200, 400, and 800 mg. Doses were administered in ascending order per cohort, with a minimum of 10 days between successive dose levels. Participants received a single dose of Compound A·HBr or placebo in the fasted state.

[0194] In part 2, Compound A HBr or placebo was administered to 36 healthy Caucasian men in three cohorts of 12 participants per cohort, aged 19 to 54 years (inclusive). In each cohort, nine participants were randomly assigned to receive repeated doses of Compound A HBr and three participants were randomly assigned to receive matching placebo. Participants received daily doses in the fed state on days 1 through 7. Doses were administered in ascending order per cohort. Progression to the next dose level and dose selection were based on available data from part 1 and from the preceding dose cohorts in part 2 (minimum 10 participants in the preceding dose cohorts [Compound A HBr n >The safety, tolerability, and PD data from [7] (up to 48 hours after the last dose) and available PK data (up to 24 hours after the last dose) were based on the available doses of Compound A HBr. Final dose levels of Compound A HBr for part 2 were 40, 120, and 360 mg. ACTH challenge studies were performed on days 2 and 6 to evaluate the selectivity of Compound A HBr for aldosterone synthesis. Plasma concentrations of aldosterone and 11-deoxycortisol, and serum concentrations of cortisol and 11-DOC were measured before and 30 and 60 minutes after ACTH administration on days 2 and 6.

[0195] Part 3 of the study evaluated sex-related effects on the safety, tolerability, and PK of Compound A HBr. In one cohort of eight healthy Caucasian women aged 20-35 years (inclusive), six participants were randomly assigned to receive a single dose of 100 mg Compound A HBr and two participants were randomly assigned to receive a matching placebo. Compound A HBr or placebo was administered in the fasting state. Results were compared to those of the same dose cohort in part 1.

[0196] Part 4 of the study evaluated age-related effects on the safety, tolerability, and PK of Compound A HBr. In one cohort of eight healthy Caucasian men aged 68-80 years, six participants were randomly assigned to receive a single 100 mg dose of Compound A HBr and two participants were randomly assigned to receive a matching placebo. Compound A HBr or placebo was administered in the fasting state. Results were compared to those of the same dose cohort in part 1.

[0197] Statistical, pharmacokinetic, and pharmacodynamic analyses Safety measures (adverse events [AEs], laboratory safety, vital signs, electrocardiograms, physical examinations) were summarized and / or listed.

[0198] Pharmacokinetics Plasma PK parameters were derived using noncompartmental analysis using Win Nonlin® (Version 6.3). Dose proportionality was assessed using the AUC 0-∞ , AUC 0-last , and C max For part 2 (MAD), we use AUC 0-last , AUC 0-∞ , AUC 0-τ , and C max Dose proportionality was assessed using a power model with: After logarithmic transformation of the parameters, a linear model (ln(Y) = α + β x ln(X), where Y is the pharmacokinetic parameter and X is the dose) was used to fit the power model. Dose proportionality was concluded when the 95% confidence limit (CI) of the slope (β) included the value 1.

[0199] AUC 0-last , AUC 0-∞ , and C max were used to explore sex- and age-related effects (parts 3 and 4, respectively). Linear models were used to estimate log-transformed AUC and C with sex or age as fixed effects. max Least squares mean (LSM) differences and corresponding 90% CIs were back transformed to compare the mean and mean differences between women and men, and > Estimates of the geometric mean proportions of participants aged 65 and <65 years and their CIs were obtained. Results were considered statistically significant if the 90% CI did not include 1.

[0200] Pharmacodynamics Plasma concentrations of aldosterone, 11-deoxycortisol, and ACTH; renin activity; renin concentration; and serum concentrations of cortisol and 11-DOC were measured during all parts of the study. Excretion of aldosterone, cortisol, sodium, and potassium, and urinary log 10 (10xNa + / K + ) percentages were listed for each collection interval.

[0201] PD parameters were derived by noncompartmental analysis using WinNonlin® Professional (version 6.3). Where possible, AUCs for plasma aldosterone and serum cortisol were calculated. 0-24 was measured.

[0202] Log-transformed changes from baseline at 24 h (day 1, pre-dose) and log-transformed changes from baseline at 22 h on day 1 (baseline on day -1, 22 h) in plasma aldosterone and serum cortisol were analyzed using linear models with treatment group (each Compound A HBr dose and pooled placebo) as a fixed effect and corresponding day 1 pre-dose as a covariate. LSM differences between each Compound A HBr dose compared to placebo were obtained from the models with 90% CIs and then back-transformed (exponentiated) to obtain estimates of adjusted geometric means and ratios with 90% CIs. Log-transformed changes from baseline at 0–24 h post-dose (time-matched) in plasma aldosterone and serum cortisol were analyzed using linear mixed models with repeated measures treatment group (each active Compound A HBr dose and pooled placebo) as a fixed effect and corresponding time-matched values ​​on day -1 as unstructured covariates. The predose time point on day 1 was used as the 24-h time point on day -1. LSM differences between each dose of Compound A HBr compared to placebo were obtained from the model along with their 90% CIs and then back-transformed to obtain estimates of adjusted geometric means and proportions with 90% CIs. Calculated AUC parameters were analyzed using a linear model. Log-transformed parameters of interest were analyzed using a linear model with fixed effects of treatment group (each dose of Compound A HBr and pooled placebo) and log-transformed AUC on day -1. 0-24 was variable dependently with α as a covariate. LSM differences and 90% CIs between each Compound A HBr dose compared with placebo were calculated and then back transformed to obtain estimates of adjusted geometric means and 90% CI ratios.

[0203] Analysis method Analytical methods for measuring Compound A in human plasma (dipotassium ethylenediaminetetraacetate [K2-EDTA]) and human urine using solid-phase extraction and high-performance liquid chromatography with mass spectrometry detection were validated over a concentration range of 0.1000 ng / mL (lower limit of quantification) to 100.0 ng / mL prior to initiating clinical trials. A quantitative analytical method for measuring 11-DOC in human ethylenediaminetetraacetate (EDTA) plasma samples using ultra-high-performance liquid chromatography with tandem mass spectrometry detection was validated over a concentration range of 0.0400 ng / mL (lower limit of quantification) to 32.2 ng / mL. Validated quantitative measurement methods were used for all other analyses.

[0204] result In vitro hCYP11B2 and hCYP11B1 inhibition Evaluating the pharmacological profile of compound A demonstrated that compound A inhibited hCYP11B2 and hCYP11B1 with inhibition constant values ​​of 1.27 nmol / L and 475 nmol / L, respectively. In comparison, the control compound osilodrostat inhibited hCYP11B2 and hCYP11B1 with inhibition constant values ​​of 0.151 nmol / L and 0.546 nmol / L, respectively. Compound A showed a very high selectivity for hCYP11B2 compared to osilodrostat (Table 2). These results indicate that compound A inhibits CYP11B2 with 374-fold higher selectivity compared to CYP11B1. Table 2: hCYP11B2 and hCYP11B1 Inhibition [Table 4]

[0205] Preclinical Pharmacology Screening Compound A did not substantially inhibit the activity of any of the 46 primary molecular target receptors or enzymes at a concentration of 10 micromol / L. The half maximal inhibitory concentration (IC50) of Compound A against any of these off-target receptors or enzymes was >10 micromol / L, indicating a low risk of off-target pharmacological effects.

[0206] Compound A inhibited hERG currents by 27% at 30 micromol / L, indicating an hERGIC50 of >30 micromol / L. No cardiovascular effects were observed in halothane-anesthetized dogs after intravenous infusion of Compound A as the free base up to 3 mg / kg under non-GLP conditions. In telemetered monkeys, there were no effects on cardiovascular parameters, including blood pressure, heart rate, or electrocardiogram, after single oral doses of Compound A as the free base up to 100 mg / kg. In a 13-week toxicity study in monkeys, no Compound A-related effects were observed on electrocardiogram values ​​at doses up to 100 mg / kg / day. These studies indicate that the risk of adverse cardiovascular effects with Compound A, particularly on cardiac electrophysiology, is low.

[0207] Inhibitory effect on adrenal steroidogenesis The effect of Compound A on adrenal steroidogenesis was determined in human adrenal cortex NCI-H295R cell cultures by measuring 12 steroid hormones after 3 days of incubation. The effect on adrenal steroidogenesis was most extensive on aldosterone production. > Compound A at 0.11 micromol / L caused a 50% decrease in aldosterone secretion; a similar decrease (>50%) was also observed at concentrations > At the highest concentration (3 micromol / L), decreases in pregnenolone, progesterone, 17α-hydroxyprogesterone, 11-DOC, corticosterone, and cortisol were observed. >A 50% reduction was not achieved. All effects on adrenal steroidogenesis were mechanism-based, and no nonspecific inhibitory effects were observed.

[0208] Adrenal histopathology in a 13-week toxicity study In a chronic 13-week daily toxicity study in rats, > Histopathological findings at a dose of 150 mg / kg / day included vacuolation of the zona fasciculata cells and hypertrophy of the zona glomerulosa cells in the adrenal glands, consistent with the expected pharmacological effects of Compound A. The no-observed-adverse-effect level (NOAEL) was 50 mg / kg / day.

[0209] In a chronic 13-week daily toxicity study in monkeys, dose-related effects were observed on aldosterone precursors and aldosterone, but no effects on cortisol. Hypertrophy of the zona glomerulosa cells in the adrenal cortex and a decrease in PAC were observed at all dose levels. Glomerular hypertrophy of the adrenal cortex was observed in all Compound A-treated groups, with minimal observation in one animal at 100 mg / kg / day after a 4-week recovery period. Minimal cell death in the zona glomerulosa was observed in Compound A-treated animals (100 mg / kg / day) and in one female at 30 mg / kg / day, but not after a 4-week recovery period. The NOAEL was 30 mg / kg / day in males and 10 mg / kg / day in females.

[0210] Pharmacological effects in animal studies A single oral dose of Compound A significantly reduced PAC in sodium-depleted monkeys. However, a single oral dose of Compound A had no effect on PCC in ACTH-loaded monkeys at a dose 100-fold higher than the dose that inhibited PAC production. These results indicate that Compound A inhibits CYP11B2 with 100-fold higher selectivity than CYP11B1.

[0211] clinical research A total of 245 participants were screened, of which 116 were randomly assigned. All participants randomly assigned to Part 1, Part 3, and Part 4 completed the study as per the protocol. One participant in Cohort 3 of Part 2 discontinued on Day 2 due to an AE of sinus tachycardia and only received a single dose of 360 mg Compound A HBr on Day 1.

[0212] Safety and Tolerability No serious AEs occurred during the study. The overall incidence of TEAEs was similar between Compound A HBr-treated participants (41 of 87 [47%]) and placebo-treated participants (18 of 29 [62%]). Across all cohorts, (mild) dizziness was reported in 9 Compound A HBr-treated participants (10.3%) compared with 1 placebo participant (3.4%). No other trends in the frequency of TEAEs were identified across single-dose or repeat-dose levels of Compound A HBr.

[0213] Pharmacokinetics In the dose range of 5 to 800 mg of Compound A HBr, the 95% CI of the slope of the AUC included unity, which is 0-last and AUC 0-∞ In terms of the dose-proportional increase in systemic exposure, max The slope estimate (95% CI) of was 1.104 (1.043-1.164), and C max A slightly greater than dose-proportional increase in T was observed in the range of 5 to 800 mg (Figure 8; Table 3). max The median of is between 1 and 1.5 hours, and t 1 / 2 The mean values ​​ranged between 7.92 and 10.54 hours.

[0214] The AUC and C were measured after oral administration of Compound A HBr at doses ranging from 40 to 360 mg once daily for 7 days. maxSystemic exposure in terms of dose appeared to increase slightly more than dose proportionally over the range of doses tested on days 1 and 7 (Figure 9; Table 4). AUC and C max For , the slope estimates ranged from 1.136 to 1.146 (95% CI, 1.011-1.281), and the AUC 0-τ For t = 0.001, the estimated slope was 1.147 (95% CI, 1.060-1.234). Steady state was achieved by approximately day 5, and very little accumulation of Compound A HBr was observed after multiple dosing compared to day 1, with mean percent accumulation values ​​ranging from 1.15 to 1.19 throughout the dose range. Similar to single dose administration, t 1 / 2 After a single administration of 100 mg of compound A HBr, max Exposures in terms of CI and AUC were 25% and 19%, respectively, higher in female participants than in male participants, but the differences were not statistically significant based on the 90% CI. max and AUC is > In men aged 65 years, the PK was approximately 14% and 12%, respectively, lower than in men aged <65 years. The gender- and age-related effects on the PK of Compound A HBr were not statistically significant based on 90% CI. [Table 5] [Table 6]

[0215] Pharmacology All single dose levels of Compound A·HBr showed clear reductions in PAC compared to baseline 4 and 8 hours after dosing (Figure 10). At the lowest dose levels (5-50 mg Compound A·HBr), PAC returned to near-baseline values ​​within 24 hours after dosing. At the highest dose levels (100-800 mg Compound A·HBr), the reduction in PAC persisted until 24 hours after dosing. At 24 hours after dosing, a single dose of Compound A·HBr reduced PAC by approximately -40% at doses of 100 and 200 mg and by approximately -70% at doses of 400 and 800 mg compared to placebo. The reductions in PAC were statistically significant at doses of 100 and 800 mg Compound A·HBr. PAC showed the greatest reductions at 4 and 8 hours after administration (pooled geometric mean proportions [90% CI]: 0.20 [0.15-0.26] and 0.15 [0.11-0.21], respectively, at the 400 mg dose versus placebo). Single doses of Compound A HBr ranging from 10 to 800 mg significantly reduced the AUC of PAC in a dose-dependent manner with statistically significant reductions ranging from -36% to -77% versus placebo. 0-24 Compound A HBr at 100 mg dose and Compound A HBr at 120 mg dose multiple times allowed recovery to baseline aldosterone levels by 16 hours (Figures 10-12).

[0216] In parts 3 and 4, changes from baseline in PAC and serum cortisol concentrations 24 hours after a single dose of 100 mg Compound A HBr were similar in male and female participants and in participants <65 and >65 years of age.

[0217] Time profiles of percent change from baseline in aldosterone in SAD demonstrated a return to baseline at doses of 20 mg and below (Figure 13). Individual PK in the SAD group and the time course of aldosterone suppression and recovery demonstrated a clear PK-PD relationship (Figure 14). The inhibitory effect of Compound A HBr on aldosterone was dose-related, with no dose-related effect on cortisol in SAD (Figures 15 and 16).

[0218] The effects of Compound A·HBr on plasma renin activity and increases in 11-DOC from the MAD, and the effects of Compound A·HBr on renal sodium and potassium handling from the SAD and MAD portions of the study show increases in urinary sodium and urinary Na+ / K+ ratios, with a modest effect on increases in plasma K+ (Figures 17, 18, 19, and 20). The AUC for aldosterone are shown in Tables 5 and 6.

[0219] AUC of PAC compared with placebo within 24 hours after seven doses of once-daily 0-24 A statistically significant decrease of approximately -50% based on 90% CI was observed at the 360 ​​mg dose of Compound A·HBr. At all dose levels tested, PAC decreased in a clear dose-dependent manner between 2 and 12 h after dosing on day 7. Notably, at the lower dose levels (40 and 120 mg), the decrease in PAC was less pronounced than that observed after a single dose of Compound A·HBr. Compared to placebo, PAC decreased at 24 h on days 2 to 5 only at the 360 ​​mg dose, with no change observed on days 6 and 7. A clear rebound in PAC, ranging from 70% to 160% compared to placebo, was observed at all dose levels of Compound A·HBr, starting 24 h after the last dose on day 7. These increases were sustained at least until day 10, for 3 days after the last dose. No relevant changes from baseline were observed in serum cortisol and plasma 11-deoxycortisol concentrations during repeated administration of Compound A·HBr.

[0220] At all dose levels, Compound A·HBr completely blunted the ACTH-stimulated aldosterone response on day 6 compared to placebo, but had no effect on the cortisol response. At 360 mg Compound A·HBr, ACTH stimulation on day 6 showed a trend toward increased 11-DOC and 11-deoxycortisol concentrations compared to placebo. These results confirm that Compound A is a potent and highly selective inhibitor of CYP11B2 that reduces PAC without affecting serum cortisol concentrations in healthy volunteers.

[0221] Furthermore, once-daily administration of Compound A appeared to increase serum 11-DOC, plasma renin activity, and potassium concentrations at all dose levels compared with placebo. These effects disappeared immediately after treatment was stopped. Also, urinary log 10 (10xNa + / K + ) ratios were initially increased on day 1 at all multiple dose levels, but the ratios returned to baseline levels at the next sampling time point at the end of the dosing period on day 7. From days 7 to 9, the urinary log 10 (10xNa + / K + ) ratio was observed, suggesting a rebound effect in the sodium / potassium ratio as well. [Table 7] [Table 8]

[0222] Consideration The renin-angiotensin-androstene system (RAAS) plays a central role in controlling intravascular volume, blood pressure, and serum potassium concentration. See Yin, L. et al. (2012);Nehme, A. et al. (2019). Normally, short and long negative feedback loops maintain homeostasis in the RAAS system. See Chong, C. et al. (2017). Low intravascular volume increases renal prorenin expression, leading to increased renin-mediated conversion of angiotensinogen to angiotensin-1 (Ang-1), angiotensin-converting enzyme (ACE) conversion of Ang-1 to angiotensin-2 (Ang-2), and binding of Ang-2 to the angiotensin type 1 receptor in the adrenal cortex, stimulating the production of aldosterone. See Laragh, JH & Sealey JE (2011);Nehme, A. et al. (2019). Increased aldosterone then binds to mineralocorticoid receptors (MR) and ultimately increases sodium reabsorption in the distal nephron. See Yin, L. et al. (2012); Atlas, SA (2007); Brown, JM et al. (2020). This sodium reabsorption increases intravascular volume, thus reducing prorenin production and closing a long negative feedback loop to ensure homeostasis. See Yin, L. et al. (2012). A short feedback loop in the adrenal gland plays a complementary role, as increased aldosterone in the adrenal gland binds locally to MR and regulates further production of aldosterone. See Chong, C. et al. (2017).

[0223] Because of the importance of the RAAS system in maintaining volume and blood pressure control, each step in the pathway has been explored as a therapeutic target to treat hypertension. The earliest therapeutic agent used in humans was spironolactone, a steroidal inhibitor of MR, but its use has been hampered by side effects, particularly estrogen. See Brown, JM et al. (2020); Williams, B. et al. (2015). More recently, improved nonsteroidal MR inhibitors have also been developed. Several ACE inhibitors and angiotensin receptor blockers (ARBs) have been used since the second half of the 20th century. See Laragh, JH & Sealey JE (2011); Atlas, SA (2007). More recently, renin inhibitors have been added to the therapeutic armamentarium, broadly targeting upstream components of the pathway. See Laragh, JH & Sealey JE (2011); Atlas, SA (2007). Unfortunately, each of these solutions has significant limitations, and the unmet medical need remains high. See Atlas, S. A. (2007).

[0224] One such limitation is the hyperkalemia associated with MR antagonists, especially in chronic kidney disease (CKD). In addition, cortisol binds to the MR, which coexists with enzymes that degrade cortisol. In CKD, this activity is low and cortisol stimulates the MR. Blocking the action of both aldosterone and cortisol in CKD can result in hyperkalemia. See Pfizer (2020). Because aldosterone synthase inhibitors (ASIs) do not interfere with the binding of corticosteroids to the MR, they function as weak agonists of the MR, making hyperkalemia less likely even in patients with impaired renal function. Fulminant organ remodeling, such as vascular smooth muscle cell hypertrophy, cardiovascular fibrosis, and renal interstitial fibrosis, is mediated by aldosterone, at least in part, through its non-MR-dependent effects.

[0225] Although one would expect that preventing the production or action of angiotensin II would prevent aldosterone secretion, this is not universally the case. Studies in left ventricular dysfunction (RESOLVD) have shown that RAAS inhibition with ACE inhibitors and ARBs does not suppress aldosterone secretion over time. This phenomenon has been described as "aldosterone escape." The situation is further complicated by the increasing recognition of classical hyperaldosteronism and obesity-related inadequate aldosterone production as the underlying cause of treatment-resistant hypertension. See Brown, JM et al. (2020); Calhoun, DA et al. (2002); Calhoun, DA (2016). Overall, the global prevalence of treatment-resistant hypertension is estimated to be 10.3%, but the proportion is even higher among patients with CKD, kidney transplant patients, and the elderly (22.9%, 56.0%, and 12.3%, respectively). Noubiap, JJ et al. (2018). Salt-sensitive hypertension is commonly associated with obesity and African-American descent, although the mechanism of action for these associations has not been firmly established. See Calhoun, DA et al. (2002); Calhoun, DA (2016). These diverse individuals are not generally considered to equate to the classical hyperaldosterone population, but perhaps more appropriately have acquired abnormalities in systems biology that interfere with the normal feedback loops that control aldosterone production.

[0226] Primary aldosteronism (PA) is a syndrome of uncontrolled renin-independent aldosterone production leading to hypertension and cardiovascular disease. It can occur in >20% of patients with resistant hypertension and is the most common cause of secondary hypertension. See Brown, JM et al. (2020); Calhoun, DA (2016); Parasiliti-Caprino, M. et al. (2020); Pfizer (2020); Strauch, B. et al. (2003). PA is usually caused by adrenal adenomas or unilateral or bilateral adrenal hyperplasia (BAH); in rare cases, it may be caused by adrenal cancer or the inherited condition of familial hyperaldosteronism. Unilateral adenomas can be cured surgically, but MR antagonists are the treatment of choice for surgically unresectable causes. Compared with primary (or essential) hypertension, PA causes more end-organ damage and is associated with excess cardiovascular morbidity, including heart failure, stroke, nonfatal myocardial infarction, and atrial fibrillation. See Byrd, JB (2015);Monticone, S. et al. (2017). Biochemically, PA is defined by a high aldosterone-renin ratio, confirmed by fludrocortisone suppression test, captopril challenge test, or saline stress test. See Calhoun, DA et al. (2002);Strauch, B. et al. (2003).

[0227] Evidence supporting aldosterone inhibition as a viable solution for treating resistant hypertension was provided by the PATHWAY-2 trial. See Williams, B. et al. (2015). Individuals with the lowest plasma renin activity, indicative of aldosterone-mediated negative feedback on renin production, showed dramatic reductions in blood pressure when treated with spironolactone. This contrasts with the relatively modest reductions in blood pressure seen in individuals with normal to elevated plasma renin, which were not achieved with α- or β-blockers. See Williams, B. et al. (2015). In a relatively small study, spironolactone at 25 to 50 mg once daily demonstrated an acceptable safety profile. However, MR blockers are associated with approximately 10% incidence of clinically meaningful, and sometimes life-threatening, hyperkalemia, especially in individuals with concomitant heart failure or CKD and in individuals being treated with complex drug regimens that include renin-angiotensin system pathway blockers. See Kem, David C. et al., “Circadian rhythm of plasma aldosterone concentration in patients with primary aldosteronism.” The Journal of clinical investigation 52.9(1973):2272-2277.

[0228] See also Kovesdy, CP (2017);Young, WF (2007). MR blockers also have the additional property of interfering with short feedback (paracrine) loops in the adrenal gland, resulting in a substantial increase in aldosterone production that signals through non-genomic pathways in vascular smooth muscle cells and may have deleterious cardiovascular effects. See Yin, L. et al. (2012);Brown, JM et al. (2020). Osilodrostat is the only ASI to have completed mid-stage clinical development so far. In hyperaldosteronistic individuals, osilodrostat slightly lowered blood pressure, although it was blocked due to insufficient selectivity for aldosterone synthesis relative to cortisol. This led to accumulation of the active intermediate 11-deoxycorticosterone (11-DOC), which may replace aldosterone as the primary MR agonist, thus reducing potential benefit. See Schumacher, CD et al. (2013). Based on this finding, development was discontinued, and until recently, no other ASIs with sufficient selectivity and otherwise favorable pharmacokinetic and safety profiles have been developed. However, because this medical need persists, interest in developing ASIs to treat hypertension and reduce associated cardiovascular complications remains high.

[0229] Aldosterone synthase (CYP11B2) is a mitochondrial cytochrome P450 (CYP) enzyme that converts 11-DOC to aldosterone in three consecutive steps: corticosterone, which is converted to 11-hydroxycorticosterone, which is converted to aldosterone. See Yin, L. et al. (2012). CYP11B1, a key enzyme in the biosynthesis of glucocorticoids, shares high homology (>93%) with CYP11B2. High selectivity for CYP11B2 over CYP11B1 is an essential property for successful ASI. See Hartmann, R. et al. (2003). Of potential importance is the ability to restore key aspects of system homeostasis, including the possibility of inhibiting defective aldosterone synthase for periods of time each day to allow for metabolism and clearance of 11-DOC and reduce the potential for exacerbating hyperkalemia. The development of improved, more selective inhibitors of CYP11B2 suitable for human use has proven challenging, with only two drugs reaching clinical stage testing in recent times. One of these drugs is Compound A, described in this report, a newly synthesized, orally administered, non-peptidic small molecule that is a highly selective inhibitor of CYP11B2. In healthy human volunteers, Compound A demonstrated optimized pharmacokinetic (PK) and pharmacodynamic (PD) evidence of inhibition of renal ureteral aldosterone signaling without suppressing basal or stimulated cortisol production across a wide range of doses. Based on these findings, Compound A has progressed into novel targeted Phase II trials in individuals with hypertension and evidence of autonomous aldosterone overproduction. Compound A was submitted to a safety and efficacy study in patients with uncontrolled hypertension (target-HTN). See Clinical Trials.gov identifier: NCT05001945.

[0230] Compound A Compound A is a potent inhibitor of hCYP11B2 with minimal inhibition of hCYP11B1 at expected clinical doses (1.27 nmol / L vs. 475 nmol / L, respectively). The approximately 374-fold selectivity of Compound A for hCYP11B2 vs. hCYP11B1 was much greater than the 3.6-fold selectivity observed with the control compound, osilodrostat. In animal studies, a single oral dose of free base Compound A significantly reduced PAC in sodium-depleted monkeys, whereas PCC was unaffected in ACTH-loaded monkeys, indicating that Compound A is a highly potent and selective inhibitor of CYP11B2 in vivo. Findings from toxicity studies were considered to be relevant to its pharmacological activity.

[0231] Administration of Compound A in the SAD and MAD portions was well tolerated in healthy men at single doses of up to 800 mg under fasted conditions and at once daily doses of up to 360 mg under fed conditions. Compound A was also well tolerated in healthy women and men aged >65 years. Participant sex and age did not significantly affect the PK of Compound A.

[0232] PAC AUC after administration of a single dose of Compound A compared to placebo 0-24 No statistically significant decrease was observed in PAC (AUC 0-24 ) was reduced by 40% at a single 100-200 mg dose and by 70% at a single 400-800 mg dose. In contrast to the significant reduction in aldosterone, no meaningful effect on serum cortisol levels was observed at any dose tested. The lack of effect of Compound A on serum cortisol levels was also seen in the MAD part of the study (Part 2), both at baseline and in response to ACTH stimulation. Changes in PAC were similar between male and female participants. > The same was true among men aged 65 vs <65 years.

[0233] Measuring the effect of Compound A on renal sodium excretion provides a direct measure of the effect of aldosterone on renal tubular function, thus providing the potential to reduce intravascular volume and ameliorate volume-dependent systemic hypertension. In the SAD portion of the study, a dose of Compound A was administered > At 10 mg, urinary log 10 (10xNa + / K + ) ratio, confirming that the observed reduction in aldosterone has the expected functional effect, at least during the initial suppression of aldosterone production. A dose-dependent effect on the duration of aldosterone suppression was demonstrated by measuring PAC. The MAD portion of the study showed that Compound A doses of 40, 120, and 360 mg maintained maximum PAC suppression for approximately 12 hours.

[0234] Urinary electrolyte measurements confirmed that there was a rapid onset of natriuresis at all doses tested, but the duration and stability of sodium depletion are not addressed by these measurements. Indeed, if aldosterone suppression was too brief, there may be compensatory sodium retention later in the day with concomitant kaliuresis without sustained effects on intravascular volume and blood pressure. However, serum potassium measurements, and to a lesser extent sodium measurements, help address this issue. Within 2 days of initiating Compound A treatment, serum potassium rose by approximately 0.5 mmol / L in all three dose cohorts (part 2) and remained elevated throughout the remaining 7 days of treatment. When Compound A treatment was discontinued, serum potassium levels rapidly declined toward pretreatment baseline. If the duration of aldosterone suppression was insufficient to maintain the renal ureteral effect, then one would expect that the rise in serum potassium (and the slower decrease in serum sodium) would not have been sustained, especially in the lower dose cohorts. This provides strong PD evidence that the duration of suppression of aldosterone production was sufficient to maintain sodium status and fluid depletion.

[0235] Aldosterone secretion has a typical circadian pattern, beginning with a spike in the pre-wake hours, followed by a gradual decline over time during the day. Thus, suppression of aldosterone production during the day would be expected to have a significant and sustained effect on downstream biological effects, including electrolyte and volume homeostasis, even if suppression was absent or incomplete during sleep. A single dose of 100 mg of Compound A, and repeated doses of 120 mg of Compound A, allowed aldosterone levels to return to baseline by 16 hours (Figures 10-12). This is important because complete suppression of aldosterone can result in a persistent state of hyperkalemia and mild non-anion gap metabolic acidosis. See Szylman, P. et al. (1976); Harris, AN et al. (2018).

[0236] Hyperkalemia is known to be problematic for the MR antagonist spironolactone, which has a complex series of active metabolites, some of which have half-lives exceeding 24 hours. Spironolactone is used relatively infrequently, despite being a highly effective antihypertensive, with a maximum risk of hyperkalemia of 10%. Once-daily dosing of Compound A without substantial accumulation is expected to be an important determinant of safety. If hyperkalemia develops, discontinuation of Compound A should allow rapid resolution of hyperkalemia.

[0237] One of the limiting factors of osilodrostat was the excessive accumulation of 11-DOC. As 11-DOC itself is an MR agonist, its accumulation may counteract the potential benefits of inhibiting aldosterone synthesis. In the MAD part of the study, compound A was observed to increase serum levels of 11-DOC. However, accumulation was relatively insignificant in the 40 mg and 120 mg per day cohorts and did not exceed the normal range. In contrast, the 360 ​​mg per day dose cohort showed a much more dramatic rise in 11-DOC to levels that might be expected to be problematic. Given that the maximal PD effect on renal electrolyte control is a relatively flat dose response near the maximum at 40 mg per day, the 11-DOC accumulation data suggest that dose selection for treating hypertension should avoid high dose levels and focus on doses up to 120 mg per day.

[0238] Overall, the results of this series of pharmacology studies demonstrated that Compound A is a selective inhibitor of hCYP11B2 and is not associated with any central nervous system, respiratory system, or cardiovascular AEs.

[0239] opinion The development of improved, more selective inhibitors of CYP11B2 suitable for use in humans has proven to be a challenge. Preclinical and clinical development of Compound A, a novel, highly selective hCYP11B2 inhibitor, demonstrated a favorable safety profile in non-human primates and healthy human participants. In healthy human participants, Compound A demonstrated optimized PK and PD evidence of inhibition of renal tubular aldosterone signaling across a broad dose range and did not suppress basal or stimulated cortisol production. Based on these findings, Compound A has progressed into a novel targeted Phase 2 trial in individuals with hypertension and evidence of autonomous aldosterone overproduction. See Monticone, S. et al. (2017).

[0240] Pathophysiological novelty and relevance Compound A is (a) is selective for CYP11β2 beta-hydroxylase over CYP11β1 beta-hydroxylase; (b) results in a clinically meaningful reduction in aldosterone; (c) allowing a return to baseline aldosterone levels in approximately 16 hours with daily dosing; It is a novel CYP11β2 beta-hydroxylase inhibitor.

[0241] Reduction of PAC in patients with classical hyperaldosteronism is an important factor in addressing treatment-resistant hypertension as well as obesity-related inadequate aldosterone production. The main risk of complete inhibition of PAC is hyperkalemia, which may be avoided with the PK / PD profile of daily administration of Compound A.

[0242] Example 4 Randomized, double-blind, placebo-controlled, dose-ranging, multicenter study in patients with > The effect of orally administered compound A·HBr on blood pressure was evaluated for treating hypertension in 18-year-old male and female subjects.

[0243] Study design The study consists of two parts. To be enrolled in Part 1 of the study, subjects had to meet the following plasma renin activity (PRA) values ​​based on a morning measurement: < If the PRA value is >1 ng / mL / h in the morning measurement, then the subject may be eligible to participate in part 2 of the study.

[0244] In Part 1, age >163 participants aged 18 years were randomly assigned to 6 equal treatment groups (1:1:1:1:1:1) of 12.5mg BID, 25mg BID, 12.5mg QD, 50mg QD, 100mg QD, or placebo. After reviewing interim clinical data, the two lowest levels (12.5mg QD and 12.5mg BID) were stopped from further randomization due to lack of consistent meaningful reduction in blood pressure, but the patients randomized at that time remained in the study until completion. Thus, after reviewing interim clinical data, subjects were randomly assigned to 4 equal treatment groups (1:1:1:1) of 25mg BID, 50mg QD, 100mg QD, or placebo.

[0245] In part 2, 36 people were > Enrolled subjects aged 18 years were randomly assigned (5:1) to receive either 100 mg QD of Compound A·HBr or placebo, such that the Compound A·HBr treatment group consisted of approximately 30 subjects and the placebo treatment group consisted of approximately 6 subjects.

[0246] Subjects received the assigned study drug (Compound A HBr or placebo) orally according to the designated dosing regimen beginning on study day 1 and continuing for 8 weeks. All subjects in part 1 (regardless of dose group) received BID dosing, preserving the integrity of the blind; all QD dose groups received active drug as a morning dose. Subjects returned to the study site or met with the investigator or an approved home health care worker at the end of weeks 1, 2, 3, 4, 5, 6, 7, and 8 of the study (± 2 days) to assess and administer efficacy and safety as defined by the protocol, evaluate adverse events (AEs), and ensure compliance with study drug utilization. Subjects also had a telephone consultation and home blood pressure (BP) check approximately 3 days after their last dose of study drug. Subjects had up to 14 clinical visits, including a pre-screening visit, a screening / placebo run-in initiation visit, a second visit during placebo run-in, a clinical visit to initiate ABPM maneuvers, a randomization assignment visit, eight weekly visits during double-blind treatment, and an end-of-study visit scheduled 4 weeks after the last study treatment to assess final efficacy and safety.

[0247] The study design is outlined diagrammatically in FIG.

[0248] Automated Office Blood Pressure (AOBP) Operation The subjects' systolic and diastolic blood pressures were measured in the examination room using an automated oscillometric sphygmomanometer device after approximately 5 minutes of rest in a seated position.

[0249] Operation of 24-hour ambulatory blood pressure monitoring (ABPM) Ambulatory blood pressure measurements were accomplished using an ambulatory blood pressure measurement device, typically consisting of a blood pressure cuff worn on the subject's arm attached to a small recording device worn on the subject's belt or waistband.

[0250] The ABPM device is worn for 24 hours. Throughout this period, the device periodically records the subject's blood pressure during the subject's daily activities and while the subject is sleeping. Thus, ABPM provides a complete record of the subject's blood pressure over a 24-hour period.

[0251] Twenty-four-hour ABPM was measured in clinic at baseline and at study week 7. If for any reason the ABPM maneuver was deemed unsuccessful at the end of study week 7, it could be repeated at study week 8 and therefore no imputation was performed, regardless of the use of rescue medication. In addition, ABPM was also collected at the end of study week 4 in part 2. If a repeat test was performed, it superseded the initial test results from that visit.

[0252] Specific derived variables based on ABPM measurements include 24-hour, daytime, and nighttime averages of SBP, DBP, and heart rate.

[0253] Changes from baseline to week 7 in 24-hour mean SBP (and DBP) based on ABPM will be analyzed using ANCOVA with treatment group and baseline mean 24-hour values ​​as covariates.

[0254] Night dip, 100%x (daytime average SBP - nighttime average SBP) / daytime average SBP It is defined as:

[0255] It will be expressed as a percentage and summarized by treatment group and visit using descriptive statistics. In addition, the number and percentage of subjects with nocturnal dips in each of the dipper categories (Bloomfield & Park, 2015) will be presented by treatment group and visit. The categories are: (a) < 10% (b) 10% to 20% (inclusive) (c)>20% It is.

[0256] Eligibility Criteria Inclusion criteria The study was conducted with subjects who met the following inclusion criteria: (a) Age > Be 18 years of age, male, and a non-pregnant, non-breastfeeding female; (b) Systolic blood pressure (SBP) using the automated office blood pressure (AOBP) > be 130mmHg; (c) > History of antihypertensive treatment with two types of drugs; (d) Serum cortisol > 18 mcg / dL

[0257] Exclusion criteria Subjects were excluded from the study if they met any of the following exclusion criteria: (a) Concomitant use of an epithelial sodium channel blocker or an electrolyte corticoid receptor antagonist; (b) being subject to hypokalemia; (c) being subject to hyperkalemia; (d) subjects had serum cortisol <3 mcg / dL; (e) subjects had a serum sodium of <135 mEq / L; (f) Estimated glomerular filtration rate < 60 mL / min / 1.73 m 2 being subject to; (g) Type 1 or uncontrolled (hemoglobin A1c > 9%) being subject to type 2 diabetes; (h) Body mass index >40 kg / m 2 being subject to; (i) Subjects with unstable angina; (j) SBP for Part 1 prior to screening, at the start of screening / placebo run-in, or at random assignment > 175mmHg or diastolic blood pressure (DBP) > 100mmHg and for Part 2, SBP > 160mmHg or DBP > Subjects with a blood pressure of 100mmHg; (k) SBP during screening by sitting to standing > 20mmHg or DBP > Be subject to a decrease of 10 mmHg; (l) Subjects suspected of non-compliance with antihypertensive treatment, in the opinion of the investigator; (m) The subject has, in the opinion of the Investigator, any significant medical disease or indication; (n) Subjects with, in the opinion of the investigator, any medical or psychiatric condition, either acute or chronic; (o) Any of the following: (i) Topical corticoids; (ii) sympathomimetic decongestants; (iii) theophylline; (iv) phosphodiesterase type 5 inhibitors; (v) NSAIDs; (vi) intramuscular steroids; (vii) estrogen; (viii) Cytochrome; (ix) strong CYP3A and CYP3A4 inducers; Being a subject receiving treatment with (p) the subject has known hypersensitivity to Compound A HBr or any of the excipients; and (q) The subject is a night shift worker. were excluded based on

[0258] Arms and Interventions The study included the following arms and corresponding interventions: [Table 9]

[0259] Study endpoints Primary endpoint The primary outcome was the change in systolic blood pressure (SBP) measured in the office (using an automated oscillometric sphygmomanometer device, after approximately 5 minutes of rest in a seated position, as the average of the last 2 of 5 unattended measurements) from baseline to the end of the 8th week of the study.

[0260] Secondary endpoints Secondary endpoints of the study were: (a) Changes in 24-h ambulatory blood pressure monitoring (ABPM) parameters (systolic and diastolic) from baseline to week 7 of the study; (b) change in office-measured SBP from baseline to the end of study weeks 1, 2, 3, 4, 5, 6, and 7; (c) change in diastolic blood pressure (DBP) measured in the office from baseline to the end of study weeks 1, 2, 3, 4, 5, 6, 7, and 8; (d) BP measured in the office by the end of the 8th week of the study < Percentage of subjects achieving 130 / 80mmHg It is.

[0261] Pharmacodynamic endpoints The pharmacodynamic endpoints of this study were: (a) change in plasma 11-deoxycortisol and PRA from baseline to the end of study week 4 and to the end of follow-up (i.e., the end of study week 12 for part 1 and the end of study week 10 for part 2); (b) Changes in serum aldosterone, cortisol, and 11-deoxycorticosterone concentrations from baseline to the end of the fourth week of the study and to the end of follow-up It was.

[0262] Pharmacokinetic endpoints The kinetic endpoints of this study were area under the plasma concentration versus time curve (AUC), maximum plasma concentration (Cmax), time to maximum concentration (Tmax), and half-life (t 1 / 2 ) will be summarized descriptively for randomization (baseline) and study weeks 1, 4, and 8.

[0263] Safety evaluation items The safety endpoints of this study were: (a) incidence and severity of all spontaneously reported adverse events (AEs); (b) changes in vital signs (orthostatic SBP, orthostatic DBP, temperature, heart rate, and respiratory rate); (c) changes in electrocardiogram parameters (including heart rate intervals: PR, QRS, QT, and QT interval corrected using the Fridericia formula); (d) changes in clinical laboratory assessments (hematology, chemistry, coagulation, and urinalysis); (e) Change in SBP measured in the office from study week 8 (end of treatment period) to the end of follow-up (i.e., end of study week 12 in part 1 and end of study week 10 in part 2). It was.

[0264] Analysis method The following analysis populations will be defined in this study: Full Analysis Set (FAS)

[0265] The FAS will include all randomized subjects who have received at least one randomized dose of investigational drug (MLS-101 or placebo). The FAS will be the primary population for efficacy analyses. For analyses performed in the FAS, subjects will be analyzed according to the study treatment group to which they are randomized, unless otherwise specified.

[0266] Protocol-Compliant Set (PPS or PP) The per-protocol population includes all subjects in the FAS who completed the study's week 8 visit without any significant protocol violations that could affect the validity of the data for the primary efficacy assessment. In the analysis based on the PPS, subjects will be analyzed according to their randomized study treatment arm. All criteria for excluding subjects from the PPS will be based on a blinded review of the data before unblinding of the study.

[0267] The following criteria are met: (a) not meeting the inclusion / exclusion criteria; (b) Use of prohibited medications; subjects using rescue medication will not be excluded from the PPS unless the subject meets other criteria that would exclude the subject from the PPS. (c) non-compliance with investigational drug; (d) not being eligible for efficacy evaluation at the study's week 8 visit Patients may be excluded from the Per-Protocol Analysis Set if they meet any of the following criteria:

[0268] Alternative criteria for exclusion from the per-protocol analysis population were also applied to accommodate unanticipated events that occurred during the conduct of the study.

[0269] Analysis of the per-protocol analysis population will be supportive and limited to the primary endpoint (i.e., "product estimand").

[0270] Safety Analysis Set (SAF) The safety analysis population will include all enrolled subjects who have received at least one dose of the study drug (MLS-101 or placebo). In analyses performed on the safety analysis population, subjects will be analyzed according to their actual treatment received.

[0271] PK / PD analysis set (PKPD) The PK / PD analysis population will include all subjects in the SAF with sufficient data available to analyze pharmacokinetic and pharmacodynamic measures. In the PKPD-based analysis, subjects will be analyzed according to their actual treatment received.

[0272] Defining a Baseline Baseline is defined as the most recent available observation of the parameter of interest prior to the first administration of the investigational medicinal product (IMP) during the double-blind treatment period.

[0273] For AOBP measurements, and any other clinical or laboratory variables with reproducible assessments at screening and baseline visits, baseline is defined as the mean of the last two nonmissing values ​​before the first dose of IMP was administered during the double-blind treatment period.

[0274] The change from baseline was Post-Baseline Results - Baseline Results It is calculated as follows.

[0275] The % change from baseline was (Change from Baseline / Baseline Result) x 100% It is calculated as follows.

[0276] Summary of Results There was a dose-response relationship across the QD dose range, with the 50 mg and 100 mg doses associated with a mean reduction in systolic BP as measured by AOBP of -11 to -13 mmHg (protocol adherence, placebo-corrected, analysis of 100 mg cohort in Part 1 = -10.3 mmHg; full analysis population combining Part 1 and Part 2 (interim) = -9.9 mmHg; N = 58 active).

[0277] Once-daily dosing was as effective as twice-daily dosing, and the results of the two BID cohorts were not superior to those of the 50 mg and 100 mg QD cohorts.

[0278] In a pooled analysis of the 50 mg QD, 100 mg QD, 12.5 mg BID, and 25 mg BID cohorts (N=103), 25% of subjects had a change in BPsys >-25 mmHg and 41% had a change >-15 mmHg.

[0279] Using automated office blood pressure (AOBP), there was little difference in treatment response between individuals in part 1 and results available from part 2, suggesting that PRA did not appear to be a strong determinant of response (serum and urinary aldosterone were also of no benefit).

[0280] Twenty-four-hour ambulatory BP monitoring demonstrated an overnight reduction in systolic BP of -11.5 ± 2.9 mmHg in the 100 mg QD cohort, which was associated with increased nocturnal "BP-zipping," consistent with sustained overnight benefit after morning dosing.

[0281] The pooled (Part 1 and Part 2) 100 mg QD safety population (n=60) demonstrated good safety and tolerability with no effect on serum cortisol, few episodes of mild or moderate hyperkalemia, and no episodes of severe hyperkalemia.

[0282] Automated in-clinic blood pressure measurement results A full analysis set (FAS) safety analysis was performed using all subjects who completed the week 8 measurements. A per-protocol (PP) analysis was also performed using all subjects who completed treatment through the week 8 visit. Waterfall plots showing AOBP change in systolic blood pressure at week 8 from the FAS analysis of the placebo, 50 mg QD, and 100 mg QD groups, and the PP analysis of the 100 mg group are provided in FIG. 22. Waterfall plots showing AOBP change in systolic blood pressure at week 8 from the FAS analysis of the 12.5 mg QD, 12.5 mg BID, and 25 mg BID groups are provided in FIG. 23. Modeled and observed mean per-protocol values ​​are also shown for each group.

[0283] The mean change from baseline in systolic blood pressure is shown in Figure 24. This figure shows the mean change from baseline in systolic blood pressure in the full analysis set (FAS, all evaluable subjects receiving at least one dose of Compound A HBr) and in the protocol adherence (PP, at the Week 8 visit). >Part 2 data represent the mean mean at the final visit at weeks 5-6.

[0284] A dose-response of Compound A HBr was observed based on analyzing the change from baseline in systolic AOBP during the QD regimen. Figure 25 shows the mean change from baseline in automated office blood pressure observed at week 8 of the QD dosing regimen. The BID protocol adherence cohort is depicted on the far right of this graph.

[0285] Analyses were performed by pooling the change from baseline in systolic blood pressure at week 8 for the 50 mg QD, 100 mg QD, 12.5 mg BID, and 25 mg BID cohorts and then separating into quartiles based on the magnitude of systolic blood pressure response. Figure 26 is a graph showing the change from baseline in systolic blood pressure at week 8 for the pooled cohort, the lowest responding quartile, the highest responding quartile, and placebo. 25% of subjects achieved a drop in systolic blood pressure of >-23 mmHg, with a mean drop of -33.4+1.5 mmgHg. 41% of subjects achieved a drop in systolic blood pressure of >15 mmHg.

[0286] Figure 27 is a waterfall plot showing the change in systolic blood pressure from the placebo and 100 mg QD groups pooled from both Part 1 and Part 2. Part 2 data was taken from the mid-snapshot of all subjects who were randomized and whose last visit was, on average, at weeks 5-6, with a minimum of week 2.

[0287] Analysis of factors affecting blood pressure changes Analyses were performed to identify factors influencing the degree of blood pressure reduction in hypertensive subjects and are summarized in the table below. [Table 10]

[0288] All values ​​were determined using least-squares analysis of modeled means using all available information. **: Difference in effect between prior treatments with two and three or more drugs due to imbalance in placebo response

[0289] Ambulatory blood pressure monitoring (ABPM) results A graph showing an example of 24-hour ambulatory blood pressure measurements is provided in Figure 29. The graph illustrates 24-hour ambulatory blood pressure (systolic) versus baseline for one subject receiving Compound A HBr at 100 mg QD, showing mean 24-hour blood pressure reduction and restoration of normal nocturnal zipping pattern.

[0290] A graph showing the change in systolic blood pressure at week 8 versus baseline, as measured using the full ABPM analysis set, is provided in Figure 30. Waterfall plots showing the change in 24 hour and overnight average ABPM at week 8 versus baseline are provided in Figure 31. The 100 mg QD dose level provides superior 24 hour blood pressure reduction. Overnight blood pressure reduction from the 100 mg QD dose level appears to be superior to 25 mg BID.

[0291] The most consistent benefits across all metrics were observed in the 100 mg QD cohort, as summarized in the table below. [Table 11]

[0292] Night dip 100%x (24-hour free movement daytime SBP - 24-hour free movement measurement nighttime SBP) / 24-hour free movement measurement daytime It is defined as:

[0293] safety No serious adverse events (SAEs) related to the study drug were observed in the study. Adverse events requiring discontinuation of drug or dose reduction are provided below in Table 10, showing incidence in Part 1 versus incidence in Part 2. [Table 12]

[0294] Serum calcium The group mean serum potassium (K+) changes are shown in the table below. [Table 13]

[0295] The number of individuals in the 100 mg QD cohort who experienced or experienced multiple increases in serum potassium above the normal range during treatment are shown in the table below. [Table 14]

[0296] *: This was the only incident in which measurements were not verified with repeat measurements due to discontinuation of the study drug (protocol deviation).

[0297] Change in estimated glomerular filtration rate (eGFR) A dose-dependent and reversible decrease in eGFR was observed. This phenomenon has been reported with ACE / ARBs and more recently with SGLT2 inhibition due to a decrease in intraglomerular pressure, which may slow the progression of hypertensive nephropathy. A graph showing the change in estimated glomerular filtration rate (eGFR) in different dose cohorts is provided in Figure 28.

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[0314] Noubiap J.J.ら、(2018) Global prevalence of resistant hypertension: a meta-analysis of data from 3.2 million patients. Heart. 2018;105(2)

[0315] Parasiliti-Caprino, M.ら、(2020) Prevalence of primary aldosteronism and association with cardiovascular complications in patients with resistant and refractory hypertension. J Hypertens. 2020;38:1841-8

[0316] Pfizer、(2020) INSPRA prescribing information. 2020. Available at www.pfizer.com

[0317] Schumacher, C.D.ら、(2013) Aldosterone synthase inhibition for the treatment of hypertension and the derived mechanistic requirements for a new therapeutic strategy. J Hypertens. 2013;31:2085-93. doi: 10.1097 / HJH.0b013e328363570c

[0318] Strauch, B.ら、(2003) Prevalence of primary hyperaldosteronism in moderate to severe hypertension in the Central Europe region. J Hum Hypertens. 2003;17:349-52

[0319] Szylman, P.ら、(1976) Role of hyperkalemia in the metabolic acidosis of isolated hypoaldosteronism. N ENgl J Med. 1976;294(7):361-365

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[0322] Williams, G. H.、(1972) Studies of the control of plasma aldosterone concentration in normal man: I. Response to posture、acute and chronic volume depletion、and sodium loading. The Journal of clinical investigation, 51(7), 1731-1742

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Claims

1. A method of treating hypertension in a hypertensive subject comprising administering to the subject once or twice daily a CYP11β2 beta-hydroxylase inhibitor in an amount sufficient to inhibit 50% or more of the activity of CYP11β2 beta-hydroxylase in 40-60% of a 24-hour period, thereby treating hypertension in the hypertensive subject.

2. 2. The method of claim 1, wherein 50% or more of CYP11β2 beta-hydroxylase activity is inhibited for a period of 10 to 14 hours out of a 24 hour period.

3. 1. A method of treating hypertension in a hypertensive subject, comprising: a) administering to a subject once or twice daily an amount of a CYP11β2 beta-hydroxylase inhibitor sufficient to reduce the subject's serum aldosterone level by 50-90% for a period not shorter than 8 hours and not longer than 16 hours, compared to the subject's serum aldosterone level before administration of the drug; or b) administering to the subject once daily an amount of a CYP11β2 beta-hydroxylase inhibitor sufficient to inhibit 50% or more of the activity of CYP11β2 beta-hydroxylase for a period between 1 and 16 hours, preferably between 3 and 8 hours. The method includes:

4. CYP11β2 beta-hydroxylase inhibitors a) reducing the subject's serum aldosterone level by 60-80% for a period of time not shorter than 8 hours and not longer than 16 hours, compared to the subject's serum aldosterone level before administration of the drug; and / or b) causing the subject's serum aldosterone to return to or above the subject's pre-drug serum aldosterone level between 16 and 24 hours after administration of the dose; The method according to claim 3.

5. 5. The method according to any one of claims 1 to 4, wherein the hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof, preferably the hypertension subject is taking or has taken at least two of said hypertension medications.

6. a) a CYP11β2 beta-hydroxylase inhibitor is administered to the subject once a day, preferably in the morning; or b) a CYP11β2 beta-hydroxylase inhibitor is administered to the subject twice daily; The method according to any one of claims 1 to 5.

7. A certain amount of a CYP11β2 beta-hydroxylase inhibitor (a) is administered daily for at least one week; (b) administered daily for at least 2 weeks; (c) administered daily for at least four weeks; or (d) administered daily for at least 8 weeks The method according to any one of claims 1 to 6.

8. CYP11β2 beta-hydroxylase inhibitors a) is selective for inhibiting CYP11β2 beta-hydroxylase activity compared to inhibiting CYP11β1 beta-hydroxylase activity, preferably where the inhibition constant (Ki) for CYP11β1 beta-hydroxylase divided by the Ki for CYP11β2 beta-hydroxylase is greater than 100; b) administered to a hypertensive subject in an amount less than that which would cause the subject's serum and / or plasma 11-deoxycortisterone (11-DOC) levels to exceed 600 pmol / L, preferably less than that which would cause the subject's serum and / or plasma 11-DOC levels to exceed 400 pmol / L; c) is administered to a hypertensive subject in an amount less than that which results in accumulation of 11-DOC in the subject of greater than 0.1 ng / mL; d) is administered to a hypertensive subject in an amount that does not result in a clinically meaningful upregulation of the subject's adrenocortical hormone synthesis; e) For hypertensive subjects i) does not result in a clinically meaningful decrease in the subject's serum and / or plasma cortisol levels compared to the subject's serum and / or plasma cortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor; ii) does not result in a clinically meaningful increase in the serum and / or plasma level of 11-DOC in the subject compared to the serum and / or plasma level of 11-DOC in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or iii) does not result in a clinically meaningful increase in the subject's serum and / or plasma 11-deoxycortisol levels compared to the subject's serum and / or plasma 11-deoxycortisol levels prior to administration of the CYP11β2 beta-hydroxylase inhibitor. and / or f) For hypertensive subjects i) does not result in more than a 20% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor, and preferably does not result in more than a 10% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor; ii) does not result in more than a 20% increase in the serum and / or plasma 11-DOC level of the subject compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor, and preferably does not result in more than a 10% increase in the serum and / or plasma 11-DOC level of the subject compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor; and / or iii) does not result in more than a 20% increase in the subject's serum and / or plasma 11-deoxycortisol levels compared to the subject's serum and / or plasma 11-deoxycortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor, and preferably does not result in more than a 10% increase in the subject's serum and / or plasma 11-deoxycortisol levels compared to the subject's serum and / or plasma 11-deoxycortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor. The method of any one of claims 1 to 7, wherein the amount of

9. CYP11β2 beta-hydroxylase inhibitors have the formula (A): 【Chemistry 1】 or a pharma- ceutically acceptable salt thereof, preferably said compound is in the form of the HBr salt of the compound of formula (A).

10. a) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; b) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; c) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or d) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor given orally once daily.

10. The method of claim 9.

11. a) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; b) 25 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; c) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor given orally once daily; d) 50 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or e) 100 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily 10. The method of claim 9.

12. a) the subject's systolic blood pressure measured in the office is reduced compared to the subject's systolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or b) the subject's 24-hour ambulatory blood pressure is reduced compared to the subject's ambulatory systolic blood pressure before administration of the CYP11β2 beta-hydroxylase inhibitor. The method according to any one of claims 1 to 11.

13. a) the subject's systolic blood pressure measured in the office is reduced by at least 10 mmHg compared to the subject's systolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or b) the subject's ambulatory systolic blood pressure is reduced by at least 10 mmHg compared to the subject's ambulatory systolic blood pressure before administration of the CYP11β2 beta-hydroxylase inhibitor; The method according to any one of claims 1 to 12.

14. a) the subject's diastolic blood pressure measured in the office is reduced compared to the subject's diastolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; b) the subject's systolic and diastolic blood pressure measured in the office is reduced compared to the subject's systolic and diastolic blood pressure measured in the office prior to administration of the CYP11β2 beta-hydroxylase inhibitor; c) the subject's ambulatory systolic and diastolic blood pressure is reduced compared to the subject's ambulatory systolic and diastolic blood pressure before administration of the CYP11β2 beta-hydroxylase inhibitor; and / or d) the subject's systolic blood pressure is reduced to less than 130 mmHg, and / or the subject's diastolic blood pressure is reduced to less than 80 mmHg. The method according to any one of claims 1 to 13.

15. a) the subject's ambulatory systolic blood pressure and the subject's ambulatory diastolic blood pressure are reduced by at least 10 mmHg and at least 5 mmHg, respectively, compared to the subject's ambulatory systolic blood pressure and diastolic blood pressure before administration of the CYP11β2 beta-hydroxylase inhibitor; b) the subject's systolic blood pressure measured in the office and the subject's diastolic blood pressure measured in the office are reduced by at least 10 mmHg and at least 5 mmHg, respectively, compared to the subject's systolic blood pressure and diastolic blood pressure measured in the office before administration of the CYP11β2 beta-hydroxylase inhibitor; and / or c) the subject's systolic blood pressure is reduced to less than 130 mmHg, and / or the subject's diastolic blood pressure is reduced to less than 80 mmHg. The method of claim 14.

16. The mean systolic blood pressure during sleep in hypertensive subjects was a) is reduced compared to the mean systolic blood pressure during sleep in the hypertensive subject before administration of the CYP11β2 beta-hydroxylase inhibitor; and / or b) is reduced compared to the mean daytime systolic blood pressure in hypertensive subjects; Preferably, the mean systolic blood pressure during sleep in the hypertensive subject is i) a reduction of at least 10%, 10% to 40%, 10% to 30%, or 10% to 20% compared to the mean daytime systolic blood pressure in hypertensive subjects; and / or ii) a reduction of at least 8 mmHg, at least 10 mmHg, 8-55 mmHg, 10-45 mmHg, 10-45 mmHg, or 10-25 mmHg compared to the mean systolic blood pressure during sleep in the hypertensive subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor. The method according to any one of claims 1 to 15.

17. a) the duration of inhibition of CYP11β2 beta-hydroxylase activity is sufficient to maintain sodium status and fluid depletion in hypertensive subjects; b) does not produce a persistent state of hyperkalemia or mild non-anion gap metabolic acidosis in hypertensive subjects; c) the CYP11β2 beta-hydroxylase inhibitor does not substantially accumulate in the hypertensive subject, preferably wherein the lack of substantial accumulation of the CYP11β2 beta-hydroxylase inhibitor in the hypertensive subject allows the aldosterone level of the hypertensive subject to return to a pre-drug baseline within 24-48 hours after the CYP11β2 beta-hydroxylase inhibitor is administered, more preferably within 16-24 hours after the CYP11β2 beta-hydroxylase inhibitor is administered; d) the hypertensive subject's potassium level is generally maintained within the clinically normal range, preferably wherein the hypertensive subject's potassium level is slightly higher, more preferably wherein the hypertensive subject's potassium level is elevated by no more than 0.35 mmol / L, more preferably wherein the hypertensive subject's potassium level is maintained below a level of 5.5 mmol / L, more preferably wherein the hypertensive subject's potassium level is maintained between 3.5 mEq / L and 5.1 mEq / L; and / or e) CYP11β2 beta-hydroxylase inhibitors for hypertension: i) an amount that inhibits aldosterone production in a subject; ii) an amount that increases serum and / or plasma potassium levels in a subject; and / or iii) an amount that increases plasma renin activity (PRA) in a subject; Preferably, where: iv) an amount that reduces serum and / or plasma aldosterone AUC-24 in the subject by at least 25% compared to the aldosterone level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; v) increasing the serum and / or plasma potassium level in the subject by at least 0.2 mmol / L compared to the serum and / or plasma potassium level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or vi) an amount that increases PRA in a subject by at least 5 ng / mL / hour compared to the PRA in the subject prior to administration of a CYP11β2 beta-hydroxylase inhibitor; The method according to any one of claims 1 to 16, wherein the administration is

18. 18. The method of any one of claims 1 to 17, wherein the aldosterone levels in the hypertensive subject follow a substantially normal circadian rhythm.

19. For hypertension a) Plasma renin activity i) less than or equal to 4 ng / mL / hour; ii) is less than or equal to 3 ng / mL / hour; iii) is less than or equal to 2 ng / mL / hour; iv) is less than or equal to 1 ng / mL / hour; and / or v) 0.6 ng / mL / hour or less; and / or b) Plasma aldosterone concentration i) 6 ng / dL or greater as measured by immunoassay; and / or ii) ≥ 1 ng / dL as measured by LC-MS 19. The method according to any one of claims 1 to 18.

20. A method for treating hypertension in a hypertensive subject, comprising administering to the hypertensive subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily in an amount sufficient to reduce the hypertensive subject's ambulatory systolic blood pressure by at least 10 mmHg compared to the hypertensive subject's ambulatory systolic blood pressure before administration of the CYP11β2 beta-hydroxylase inhibitor.

21. A method for lowering systolic blood pressure in a hypertensive subject during sleep, comprising administering to the subject a CYP11β2 beta-hydroxylase inhibitor once or twice daily in an amount sufficient to lower the hypertensive subject's mean systolic blood pressure during sleep compared to (a) the hypertensive subject's mean systolic blood pressure during sleep before the CYP11β2 beta-hydroxylase inhibitor is administered, and / or (b) compared to the hypertensive subject's mean daytime systolic blood pressure.

22. The mean systolic blood pressure during sleep in hypertensive subjects was a) at least a 10%, 10% to 40%, 10% to 30%, or 10% to 20% reduction compared to mean daytime systolic blood pressure in hypertensive subjects; b) a reduction of at least 8 mmHg, at least 10 mmHg, at least 8-55 mmHg, 10-45 mmHg, or 10-25 mmHg compared to the mean systolic blood pressure during sleep in the hypertensive subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor.

22. The method of claim 21.

23. 23. The method according to any one of claims 20 to 22, wherein the hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof, preferably the hypertension subject is taking or has taken at least two of said hypertension medications.

24. a) 50% or more of CYP11β2 beta-hydroxylase activity is inhibited for 40-60% of the time during a 24-hour period; b) 50% or more of CYP11β2 beta-hydroxylase activity is inhibited for a period of 10 to 14 hours over a 24-hour period; c) whether the CYP11β2 beta-hydroxylase inhibitor reduces the subject's serum aldosterone level by 50-90% for a period not shorter than 8 hours and not longer than 16 hours compared to the subject's serum aldosterone level before administration of the drug; d) the CYP11β2 beta-hydroxylase inhibitor reduces the subject's serum aldosterone level by 60-80% for a period not shorter than 8 hours and not longer than 16 hours compared to the subject's serum aldosterone level before administration of the drug; e) restoring the subject's serum aldosterone to or above the subject's serum aldosterone level prior to administration of the drug between 16 and 24 hours after administration of the dose with a CYP11β2 beta-hydroxylase inhibitor; and / or A method according to any one of claims 20 to 23, wherein f) 50% or more of the activity of CYP11β2 beta-hydroxylase is inhibited for a period of 1 to 16 hours, or preferably 3 to 8 hours, out of a 24 hour period.

25. a) administering a CYP11β2 beta-hydroxylase inhibitor to a subject once daily, preferably in the morning; or b) administering a CYP11β2 beta-hydroxylase inhibitor twice daily to the subject; The method according to any one of claims 20 to 24.

26. CYP11β2 beta-hydroxylase inhibitors (a) is administered daily for at least one week; (b) administered daily for at least 2 weeks; (c) administered daily for at least four weeks; or (d) administered daily for at least 8 weeks; The method according to any one of claims 20 to 25.

27. a) a reduction in the ambulatory systolic blood pressure of the hypertensive subject by 10-55 mmHg, 10-50 mmHg, 10-45 mmHg, 10-40 mmHg, 10-35 mmHg, 10-30 mmHg, 10-25 mmHg, 10-20 mmHg, or 10-15 mmHg compared to the ambulatory systolic blood pressure of the hypertensive subject prior to administration of a CYP11β2 beta-hydroxylase inhibitor for a period of at least 8 weeks; and / or b) the ambulatory diastolic blood pressure of the hypertensive subject is reduced by 5-25 mmHg, 5-20 mmHg, or 5-15 mmHg, compared to the ambulatory diastolic blood pressure of the hypertensive subject prior to administration of a CYP11β2 beta-hydroxylase inhibitor for a period of at least 8 weeks; The method according to any one of claims 20 to 26.

28. a) the duration of inhibition of CYP11β2 beta-hydroxylase activity is sufficient to maintain sodium status and fluid depletion in hypertensive subjects; b) does not produce a persistent state of hyperkalemia or mild non-anion gap metabolic acidosis in hypertensive subjects; c) the CYP11β2 beta-hydroxylase inhibitor does not substantially accumulate in the hypertensive subject, preferably wherein the lack of substantial accumulation of the CYP11β2 beta-hydroxylase inhibitor in the hypertensive subject allows the aldosterone level of the hypertensive subject to return to a pre-drug baseline within 24-48 hours after the CYP11β2 beta-hydroxylase inhibitor is administered, more preferably within 16-24 hours after the CYP11β2 beta-hydroxylase inhibitor is administered; d) the hypertensive subject's potassium level is generally maintained within the clinically normal range, preferably wherein the hypertensive subject's potassium level is slightly higher, more preferably wherein the hypertensive subject's potassium level is elevated by no more than 0.35 mmol / L, more preferably wherein the hypertensive subject's potassium level is maintained below a level of 5.5 mmol / L, more preferably wherein the hypertensive subject's potassium level is maintained between 3.5 mEq / L and 5.1 mEq / L; and / or e) CYP11β2 beta-hydroxylase inhibitors for hypertension: i) an amount that inhibits aldosterone production in a subject; ii) an amount that increases serum and / or plasma potassium levels in a subject; and / or iii) an amount that increases plasma renin activity (PRA) in a subject; Preferably, where: iv) an amount that reduces serum and / or plasma aldosterone AUC-24 in the subject by at least 25% compared to the aldosterone level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; v) increasing the serum and / or plasma potassium level in the subject by at least 0.2 mmol / L compared to the serum and / or plasma potassium level in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or vi) an amount that increases PRA in a subject by at least 5 ng / ml / hr compared to the PRA in the subject prior to administration of a CYP11β2 beta-hydroxylase inhibitor; Administered at 28. The method according to any one of claims 20 to 27.

29. 29. The method of any one of claims 20 to 28, wherein the aldosterone levels in the hypertensive subject follow a substantially normal circadian rhythm.

30. CYP11β2 beta-hydroxylase inhibitors a) is selective for inhibiting CYP11β2 beta-hydroxylase activity compared to inhibiting CYP11β1 beta-hydroxylase activity, preferably where the inhibition constant (Ki) for CYP11β1 beta-hydroxylase divided by the Ki for CYP11β2 beta-hydroxylase is greater than 100; b) administered to a hypertensive subject in an amount less than that which would cause the subject's serum and / or plasma 11-deoxycortisterone (11-DOC) levels to exceed 600 pmol / L, preferably less than that which would cause the subject's serum and / or plasma 11-DOC levels to exceed 400 pmol / L; c) is administered to a hypertensive subject in an amount less than that which results in accumulation of 11-DOC in the subject of greater than 0.1 ng / ml; d) is administered to a hypertensive subject in an amount that does not result in a clinically meaningful upregulation of the subject's adrenocortical hormone synthesis; e) For hypertensive subjects i) does not result in a clinically meaningful decrease in the subject's serum and / or plasma cortisol levels compared to the subject's serum and / or plasma cortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor; ii) does not result in a clinically meaningful increase in the serum and / or plasma level of 11-DOC in the subject compared to the serum and / or plasma level of 11-DOC in the subject prior to administration of the CYP11β2 beta-hydroxylase inhibitor; and / or iii) does not result in a clinically meaningful increase in the subject's serum and / or plasma 11-deoxycortisol levels compared to the subject's serum and / or plasma 11-deoxycortisol levels prior to administration of the CYP11β2 beta-hydroxylase inhibitor. and / or f) For hypertensive subjects i) does not result in more than a 20% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor, and preferably does not result in more than a 10% decrease in the subject's serum and / or plasma cortisol level compared to the subject's serum and / or plasma cortisol level before administration of the CYP11β2 beta-hydroxylase inhibitor; ii) does not result in more than a 20% increase in the serum and / or plasma 11-DOC level of the subject compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor, and preferably does not result in more than a 10% increase in the serum and / or plasma 11-DOC level of the subject compared to the subject's serum and / or plasma 11-DOC level before administration of the CYP11β2 beta-hydroxylase inhibitor; and / or iii) does not result in more than a 20% increase in the subject's serum and / or plasma 11-deoxycortisol levels compared to the subject's serum and / or plasma 11-deoxycortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor, and preferably does not result in more than a 10% increase in the subject's serum and / or plasma 11-deoxycortisol levels compared to the subject's serum and / or plasma 11-deoxycortisol levels before administration of the CYP11β2 beta-hydroxylase inhibitor.

30. The method of any one of claims 20 to 29, wherein the amount of

31. CYP11β2 beta-hydroxylase inhibitors have the formula (A): 【Chemistry 2】 or a pharma- ceutically acceptable salt thereof, preferably said compound is in the form of the HBr salt of the compound of formula (A).

32. a) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; b) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; c) 5 mg to 100 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or d) 10 mg to 50 mg of a CYP11β2 beta-hydroxylase inhibitor given orally once daily.

32. The method of claim 31 .

33. a) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; b) 25 mg of a CYP11β2 beta-hydroxylase inhibitor given orally twice daily, 12 hours apart; c) 12.5 mg of a CYP11β2 beta-hydroxylase inhibitor given orally once daily; d) 50 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily; or e) 100 mg of a CYP11β2 beta-hydroxylase inhibitor administered orally once daily 32. The method of claim 31 .

34. For hypertension a) Plasma renin activity i) less than or equal to 4 ng / mL / hour; ii) is less than or equal to 3 ng / mL / hour; iii) is less than or equal to 2 ng / mL / hour; iv) is less than or equal to 1 ng / mL / hour; and / or v) 0.6 ng / mL / hour or less; and / or b) Plasma aldosterone concentration i) 6 ng / dL or greater as measured by immunoassay; and / or ii) ≥ 1 ng / dL as measured by LC-MS The method according to any one of claims 20 to 33.

35. The method according to any one of claims 1 to 34, wherein the hypertensive subject has secondary hypertension, preferably primary aldosteronism.

36. The method according to any one of claims 1 to 34, wherein the hypertensive subject does not have primary aldosteronism, preferably the hypertensive subject has primary hypertension.

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