CFTR Modulators for Treating Vascular Disease

Abstract

The present invention relates to the field of pharmaceutical compositions and the treatment and / or prevention of medical conditions including thrombosis or atherosclerosis associated with pathological platelet activation. The present invention further relates to cystic fibrosis transmembrane conductance regulator (CFTR) modulators used in the treatment and / or prevention of medical conditions including thrombosis or medical conditions including atherosclerosis and pathological platelet activation in human subjects. The present invention further relates to medical uses and corresponding therapeutic methods of administering CFTR modulators such as ivacaftor in the treatment and / or prevention of medical conditions including pathological platelet activation, adhesion and / or aggregation. In a further aspect, the present invention relates to pharmaceutical compositions comprising CFTR modulators such as ivacaftor.

Description

[Technical field]

[0001] The present invention relates to the field of pharmaceutical compositions and the treatment and / or prevention of medical conditions, including thrombosis or atherosclerosis, associated with pathological thrombocyte activation.

[0002] The present invention further relates to cystic fibrosis transmembrane conductance regulator (CFTR) modulators for use in the treatment and / or prevention of medical conditions, including thrombosis, in a human subject.

[0003] The present invention further relates to cystic fibrosis transmembrane conductance regulator (CFTR) modulators for use in the treatment and / or prevention of medical conditions, including atherosclerosis, associated with pathological platelet activation in a human subject.

[0004] The invention further relates to medical uses and corresponding therapeutic methods of administering CFTR modulators such as ivacaftor in the treatment and / or prevention of medical conditions involving pathological platelet activation, adhesion and / or aggregation.

[0005] In a further aspect, the invention relates to pharmaceutical compositions comprising a CFTR modulator, such as ivacaftor. [Background technology]

[0006] Blood coagulation is an essential protective mechanism of the body and requires platelet activation. The formation of blood clots or blood plugs (thrombi) in blood vessels is associated with many serious and even life-threatening diseases, such as thrombosis, thromboembolism, pneumonia, infectious diseases, inflammatory diseases, rheumatic diseases, blood diseases (e.g., thrombotic thrombocytopenic purpura), and cardiovascular diseases (e.g., atherosclerosis, stroke, myocardial infarction).

[0007] Platelet activation triggers the release of numerous pro-inflammatory substances such as eicosanoids, interleukins and chemokines. High local concentrations of these substances can result in the expression of genes of the so-called early inflammatory response in the actually antithrombotic endothelial cells of blood vessels, thereby modifying the chemotactic and adhesive properties of the endothelium locally and systemically. These changes can act as drivers of many disease processes, even down to COVID-19. As a result, platelet-endothelial cell interactions are enhanced and thrombus formation is initiated. The combination of disseminated intravascular coagulation and thrombotic microangiopathy then frequently leads to fatal thromboembolic events. Moreover, rates of cardiovascular events such as myocardial infarction and stroke remain elevated for years after surviving pneumonia.

[0008] Thrombosis is a vascular disease or circulatory system disorder (in vivo) in which blood clots (thrombus, blood plugs) form in blood vessels. Thrombosis can occur in any blood vessel. It is often a venous thrombosis, especially in the deep veins of the legs. Vascular diseases affect the arteries and veins of the circulatory system, causing various health problems such as high blood pressure, stroke, aneurysm, and peripheral arterial disease. Many of these are serious or even fatal.

[0009] Pulmonary vascular micro- and macrothrombosis has been observed in 20%-30% of patients with COVID-19, a rate significantly higher than in other critically ill patient groups (1%-10%).1-7 Such pulmonary or systemic proinflammatory processes induced by bacterial or viral pneumonia or resulting from systemic sepsis lead, among other things, to activation of systemic blood coagulation (hemostasis). The resulting tendency to coagulopathy is considered an important risk factor for the high morbidity and mortality of community-acquired or hospital-acquired pneumonia (CAP or HAP, respectively) or COVID-19 disease. 8、9

[0010] Thromboembolic conditions are important contributors to the CAP, HAP and COVID-19 disease groups as well as to many other local and systemic diseases that have so far been poorly managed therapeutically or preventively, such as systemic or extrapulmonary infectious and inflammatory diseases, hematological diseases and cardiovascular diseases, which impose a high personal, economic and socio-economic burden.

[0011] Many patients suffer for decades from a form of thrombosis, coagulation disorders, and / or thromboembolic events with an incurable and often fatal outcome, and associated health consequences. The health, personal, economic, and socio-economic burden is significant. Prophylaxis and treatment of coagulation disorders remain largely empirical. There is an urgent need for effective and approved pharmacological therapies for the treatment and prevention of thrombosis, coagulation disorders, and thromboembolic events. Numerous clinical trials of pharmacological interventions addressing this problem have failed. 10~12

[0012] In the literature, the treatment and / or prevention of, inter alia, venous thrombosis, thromboembolic diseases, atherosclerosis, coronary heart disease (such as angina pectoris and myocardial infarction), and stroke, as well as arterial thrombosis and other cardiovascular events, are proposed, but no details or success of treatment are taught, and in particular no mention is made of the infectious diseases or disease groups of CAP, HAP and COVID-19, which are substantially different in origin and mechanism from the other mentioned diseases.13-15 Moreover, treatment with typical anticoagulants such as aspirin did not have any beneficial effect on patients.16,17

[0013] Despite the high medical need, effective treatments remain limited and additional treatment options are urgently needed. Summary of the Invention [Problem to be solved by the invention]

[0014] In light of the prior art, the technical problem underlying the present invention is to provide alternative or improved means of treating and / or preventing medical conditions involving thrombosis. The technical problem can also be viewed as providing a means of treating and / or preventing medical conditions involving pathological platelet activation, in particular platelet hyperactivation.

[0015] The technical problem can also be viewed as providing a means of treating and / or preventing medical conditions including atherosclerosis and hyperplatelet activation. The technical problem can also be viewed as providing a means of treating and / or preventing medical conditions including vascular diseases associated with hypercoagulable, thrombotic and / or thromboembolic events.

[0016] The technical challenge can also be seen as the provision of means to treat and / or prevent the occurrence of thrombocytopathy, coagulopathy and / or embolism that arises with or persists after the onset of an infectious disease such as COVID-19. [Means for solving the problem]

[0017] This problem is solved by the features of the independent claims. Preferred embodiments of the invention are provided by the dependent claims.

[0018] In one aspect, the invention relates to cystic fibrosis transmembrane conductance regulator (CFTR) modulators for use in the treatment and / or prevention of medical conditions, including thrombosis, in a human subject.

[0019] As detailed herein, the use of CFTR modulators to treat and / or prevent pathological platelet activation, aggregation, and / or adhesion, atherosclerosis, thrombosis, and thromboembolism represents a novel and advantageous approach towards the development of effective therapeutic strategies for the diseases and disorders described herein.

[0020] Currently, there are no effective drug therapies available. Experiments with patient platelets, e.g., COVID-19 blood cells, have been performed and provide evidence that CFTR modulators are effective in treating the medical conditions described herein, particularly pathological platelet activation, aggregation, and / or adhesion.

[0021] In one embodiment, a CFTR modulator is administered to a human subject to treat thrombosis.

[0022] Under non-pathological physiological conditions, in primary hemostasis, platelets are activated by the process of platelet adhesion, which induces further coagulation and platelet aggregation for the formation of a white clot. These mechanisms promote further platelet activation and aggregation for secondary hemostasis, including platelet activation and formation of active thrombin, and coagulation. Thus, platelet dysfunction can be characterized by pathological aggregation, proliferation, activation, or adhesion of platelets.

[0023] In some embodiments, the pathological platelet activation comprises hyper-activation of platelets.

[0024] To the inventors' knowledge, it has not previously been disclosed or suggested that modulation of CFTR function alters platelet function from a pathological, hyperactivated state to a physiological (non-pathological) activated state.

[0025] In one embodiment, pathological platelet activation is also a platelet dysfunction disorder, in one embodiment, pathological platelet activation includes platelet hyperactivation, pathological platelet aggregation, pathological platelet adhesion, and / or pathological platelet-mediated coagulation, such as hypercoagulability.

[0026] In some embodiments, CFTR modulators are used to treat and / or prevent pathological platelet activation, preferably excessive platelet activation.

[0027] In another embodiment, CFTR modulators are used to treat and / or prevent medical conditions associated with pathological platelet activation, preferably excessive platelet activation.

[0028] In one embodiment, the pathological platelet activation is associated with platelet-mediated coagulation disorders such as embolism and / or hypercoagulability / thrombophilia.

[0029] In one embodiment, the CFTR modulators are used to treat thrombocytosis, coagulation disorders, and / or embolism.In one embodiment, the CFTR modulators are used to prevent thrombocytosis, coagulation disorders, and / or embolism.

[0030] As shown in Example 1, the inventors have identified the chloride channel Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) as a key regulator for normalizing platelet function in COVID-19 patients. The inventors demonstrate that treatment with the CFTR modulator ivacaftor attenuates agonist-induced platelet activation, aggregation and adhesion. These protective properties are preserved in platelets from COVID-19 patients, indicating the therapeutic potential of CFTR modulators, for example in the treatment of severe COVID-19.

[0031] In one embodiment, administration of a CFTR modulator treats and / or prevents a medical condition involving impaired platelet function.

[0032] In some embodiments, the subject is receiving or has been receiving an additional treatment with a drug, such as a drug approved by the FDA or EMA for the treatment of a medical condition described herein. In some embodiments, the additional treatment is not a CFTR modulator or does not include a CFTR modulator. In some embodiments, the invention relates to the co-administration of a therapeutically effective amount of a CFTR modulator and a treatment other than a CFTR modulator.

[0033] In one embodiment, the symptoms of the medical conditions described herein can be acute and / or chronic, hi one embodiment, the symptoms of the medical conditions described herein can be new symptoms, recurrent symptoms, intermittent symptoms, episodic symptoms, transient symptoms, or persistent symptoms.

[0034] In one embodiment, the efficacy and physiological response of the treatments described herein are determined by measuring activation markers expressed on the surface of platelets (e.g., CD62p, CD63, CD41 / CD61), measuring calcium influx into platelets, or diagnosing thrombosis (e.g., using the Wells score for leg vein thrombosis, compression ultrasound, computed tomography, or magnetic resonance imaging).

[0035] Patients suffering from the diseases described herein are at significantly increased risk of death. A particular advantage of treatment with a CFTR modulator is that the risk of death is reduced, if not completely eliminated.

[0036] In some embodiments, the medical condition includes a platelet-mediated coagulation disorder, such as embolism and / or hypercoagulability / thrombophilia.

[0037] In the prior art, treatment with a CFTR modulator has not been found to result in normalization of platelet function or be effective against coagulation disorders, altering platelet function from a hypercoagulable to a normal coagulation state. In one embodiment, the CFTR modulator prevents platelet hyperactivation and / or hypercoagulability.

[0038] Surprisingly, CFTR modulators exert an anticoagulant effect by increasing the activity of CFTR, opposing the occurrence of thrombocytopathy, coagulopathy, and / or embolism, for example in bacterial and viral pneumonia.

[0039] As shown in Example 1, platelets from COVID-19 patients are hyperactivated as seen by overexpression of surface activation markers (CD62p, CD63, CD41 / CD61) and have increased calcium influx. Platelets from COVID-19 patients show enhanced surface expression of activation markers CD62p (p-selectin) and CD63 depending on disease severity, thus demonstrating a hypercoagulable state in COVID-19. Surprisingly, the increased expression of these activation markers could be reproduced in platelets from healthy donors stimulated with any of the three platelet agonists adenosine diphosphate (ADP), thrombin receptor activating protein-6 (TRAP6), or platelet activating factor (PAF).

[0040] These findings are important with regard to the hyperactivation of platelets associated with pneumonia in COVID-19. Agonist-induced hyperactivation of platelets was normalized by treatment and pretreatment with ivacaftor, a CFTR modulator for physiological platelet activation (Figure 1, Figure 2). We show that pretreatment of platelets with ivacaftor, a CFTR enhancer, results in a significant reduction in calcium influx through calcium channels. In our experiments, for reference, forskolin, an activator of adenylate cyclase commonly used to activate CFTR in experimental studies, was used in parallel. Surprisingly, the protective effect of ivacaftor was qualitatively similar to that of forskolin. Although the non-specific effects of systemic adenylate cyclase activation prevent the clinical use of forskolin, CFTR modulators have proven safe and effective for the treatment of CF patients, and their use, especially long-term use, was not associated with a high risk of bleeding disorders.

[0041] In one embodiment, CFTR modulators are used to treat hypercoagulability / thrombophilia.

[0042] In some embodiments, the CFTR modulator is administered to a subject having, suspected of having, or at risk of having a platelet-mediated coagulation disorder, such as hypercoagulability / thrombophilia.

[0043] In one embodiment, treatment with a CFTR modulator reduces platelet-mediated coagulation disorders. In some embodiments, the CFTR modulator improves one or more symptoms of a coagulation disorder. The CFTR modulators used in the interventional methods described herein are intended to prevent, slow or reduce disease progression involving platelet-mediated coagulation disorders, such as hypercoagulability / thrombophilia, or to reduce acute or non-acute embolism. In some embodiments, the CFTR modulator improves one or more symptoms of embolism.

[0044] In one embodiment, the efficacy and physiological response of the treatments described herein are determined by measuring platelet-mediated coagulopathy, for example as described in Example 1.

[0045] As is commonly understood in the art, calcium is the major "second messenger" of platelet activation. The present inventors have demonstrated a striking effect of ivacaftor on agonist-induced elevation of intracellular calcium levels. In platelets from healthy donors or severe COVID-19 patients, activation with either ADP, TRAP6, or PAF resulted in a clear increase in [Ca 2+ Surprisingly, pretreatment of platelets with ivacaftor significantly attenuated the agonist-induced calcium rise (Example 1).

[0046] In some embodiments, the subject being treated is suffering from a thrombotic and / or thromboembolic event.

[0047] Thrombotic and / or thromboembolic events play an important role in many local and systemic diseases. Pulmonary vascular micro- and macrothrombosis occurs particularly in critically ill patients and is associated with significant morbidity and mortality in these patients.

[0048] In one embodiment, the CFTR modulator is for preventing and / or treating a pulmonary disorder. In one embodiment, treatment with a CFTR modulator reduces the lethality of the pulmonary disorder. A particular advantage is that treatment with a CFTR modulator reduces, if not completely eliminates, the risk of death.

[0049] In some embodiments, the CFTR modulator is administered to a subject having, suspected of having, or at risk of developing a thrombotic event. In one embodiment, the thrombotic event is venous thrombosis, e.g., superficial venous thrombosis, deep vein thrombosis, pulmonary embolism, lung embolism, superficial thrombophlebitis, or venous thromboembolism. In one embodiment, the thrombotic event is arterial thrombosis, e.g., myocardial infarction, ischemic stroke, critical limb ischemia, stroke, or mesenteric ischemia. In one embodiment, the thrombotic event occurs in a cardiac chamber. In one embodiment, the thrombus blocks blood flow at the site where it forms. In one embodiment, the thrombotic event includes the occurrence of one or more thrombi. In one embodiment, the thromboembolic event includes a thrombus dislodged by the blood flow, which embolizes to a distant blood vessel.

[0050] In some embodiments, the CFTR modulator is administered to a subject having, suspected of having, or at risk of developing a thromboembolic event, such as venous thromboembolism.

[0051] In an embodiment, thrombosis is a gradual process that may lead to the blockage and loss of blood vessels and / or vasculature. In one embodiment, a CFTR modulator is administered to a subject suspected of having or at risk of developing a thrombotic and / or thromboembolic event. Treatment with a CFTR modulator can prevent blockage and loss of blood vessels and / or vasculature. A particular advantage of treatment with a CFTR modulator is a significant reduction in the incidence or mortality of thrombotic and / or thromboembolic events. CFTR modulators have been found to be well tolerated. Treatment can also be performed over a long period of time, even for years, without causing severe side effects. This significantly reduces the mortality associated with thrombotic and / or thromboembolic events.

[0052] In one embodiment, treatment with a CFTR modulator reduces the occurrence of thrombotic and / or thromboembolic events. The CFTR modulators used in the interventional procedures described herein are intended to prevent, slow or reduce the progression of thrombotic and / or thromboembolic events, such as thrombosis, or to alleviate acute or non-acute embolism. In some embodiments, the CFTR modulator ameliorates one or more symptoms of a thrombotic and / or thromboembolic event.

[0053] In one embodiment, treatment with a CFTR modulator ameliorates platelet hyperactivation to a non-pathological stage of platelet function, particularly platelet activation.

[0054] In one embodiment, the efficacy and physiological response of the treatments described herein are determined by a reduction in the incidence of thrombotic and / or thromboembolic events and by measuring platelet activation as described herein.

[0055] In some embodiments, the medical condition is associated with a human pathogenic infection, such as a viral infection, a bacterial infection, a fungal infection, or a parasitic infection.

[0056] In one embodiment, the pathological platelet activation, thrombosis, coagulopathy, and / or thromboembolic event occurs and / or persists in a human subject following an initial onset of infection with a human pathogen.

[0057] In one embodiment, the human subject has or has had an infection caused by a human pathogen, such as a viral infection, a bacterial infection, a fungal infection or a parasitic infection.

[0058] In one embodiment, the human subject has or has had a viral infection selected from the group consisting of SARS-CoV-2 infection, SARS coronavirus infection, influenza virus infection, coronavirus infection, respiratory syndrome infection, dengue virus infection, avian influenza virus infection, swine influenza virus infection, Ebola virus infection, yellow fever virus infection, and enterovirus infection, preferably SARS-CoV-2 infection.

[0059] In one embodiment, the subject has or has had a bacterial infection selected from the group consisting of a Legionella infection, a Chlamydia infection, a Pneumococcal infection, a Haemophilus influenzae infection, a Staphylococcus aureus infection, an Escherichia coli infection, a Salmonella species infection, and a Meningococcal infection.

[0060] In one embodiment, the human has or has had a parasitic infection selected from the group consisting of malaria infections, including Plasmodium falciparum infection, Plasmodium malariae infection, Plasmodium ovale infection, and Plasmodium vivax infection.

[0061] In some embodiments, the subject has or is suspected of having a fungal infection selected from the group consisting of an Aspergillus fumigatus infection, an Aspergillus fumigatus infection, a Candida infection (e.g., Candida albicans), a Histoplasma capsulatum infection, and a Pneumocystis jirovecii infection.

[0062] In one embodiment, the pathological platelet activation, thrombosis, coagulopathy, and / or thromboembolic event occurs independent of infection.

[0063] In some embodiments, the onset of an infectious disease is characterized by the presence of symptoms of the infectious disease and / or by detection of an infectious disease in the subject, including, for example, detection of components of a human pathogen by PCR testing, flow cytometric analysis, ELISA testing, or antigen testing.

[0064] In some embodiments, the infection is a respiratory viral infection, preferably a SARS coronavirus infection, more preferably a SARS-CoV-2 infection.

[0065] In some embodiments, the treatment comprises administering a CFTR modulator to a subject who has or has had a respiratory viral infection or a SARS coronavirus infection.

[0066] In some embodiments, the treatment comprises administering a CFTR modulator to a subject who has or has had a SARS-CoV-2 infection, wherein the subject has a medical condition as described herein, which arises or persists after the onset of the first symptoms of SARS-CoV-2 infection.

[0067] It has not been deduced from the prior art that CFTR is a target for preventing or treating disease-associated platelet hyperactivation, such as that associated with pneumonia, and for controlling hypercoagulable states.

[0068] The present invention further relates to cystic fibrosis transmembrane conductance regulator (CFTR) modulators for use in the treatment and / or prevention of medical conditions involving atherosclerosis and pathological platelet activation.

[0069] In one embodiment, CFTR modulators are used to treat hypercoagulability / thrombophilia.

[0070] In some embodiments, the CFTR modulator is administered to a subject having, suspected of having, or at risk of having a platelet-mediated coagulation disorder, such as hypercoagulability / thrombophilia.

[0071] In one embodiment, treatment with a CFTR modulator reduces atherosclerosis, pathological platelet activation, such as platelet hyperactivation, and / or hypercoagulability. The CFTR modulators used in the interventional methods described herein are intended to prevent, slow or reduce disease progression, including atherosclerosis, platelet hyperactivation, and / or hypercoagulability, or reduce acute or non-acute atherosclerosis. In some embodiments, the CFTR modulator improves one or more symptoms of atherosclerosis.

[0072] In one embodiment, treatment with a CFTR modulator reduces mortality in patients suffering from atherosclerosis. A particular advantage is that treatment with a CFTR modulator reduces, if not completely eliminates, the risk of death due to atherosclerosis.

[0073] In one embodiment, the efficacy and physiological response of the treatments described herein are determined by measuring the severity of stenosis, area of ​​stenosis, and hyperactivation of platelets, as detectable by angiography, stress testing, Doppler ultrasound, or computed tomography.

[0074] In some embodiments, the medical condition comprises a platelet-mediated stage of atherosclerotic disease.

[0075] For example, platelets are involved in the early and late stages of atherosclerosis involved in the development of atherosclerosis in the coronary or carotid arteries.

[0076] In one embodiment, CFTR modulators are used to treat platelet hyperactivation and / or hypercoagulability / thrombophilia in early stage atherosclerosis. In one embodiment, CFTR modulators are used to treat platelet hyperactivation and / or hypercoagulability / thrombophilia in late stage atherosclerosis. The early stage is preferably the first or initial stage of atherosclerosis development. The late stage is preferably the third stage of atherosclerosis development. Platelets are generally involved in the pathogenesis of first and third stage atherosclerosis.

[0077] In some embodiments, the CFTR modulator ameliorates one or more symptoms of early stage atherosclerosis. In some embodiments, the CFTR modulator ameliorates one or more symptoms of late stage atherosclerosis.

[0078] In one embodiment, the CFTR modulator is preferably administered to prevent the development and / or progression of atherosclerosis at the first stage of atherosclerosis. In one embodiment, the CFTR modulator is preferably administered to treat atherosclerosis at the third stage of atherosclerosis. The CFTR modulator provides beneficial effects at both stages.

[0079] In some embodiments, the medical condition is selected from the group consisting of coronary artery disease, myocardial infarction, angina, stroke, transient ischemic attack, and peripheral arterial disease.

[0080] In some embodiments, the medical condition comprises a platelet-mediated vascular disease.

[0081] In some embodiments, a CFTR modulator is administered to a subject having, suspected of having, or at risk of having a platelet-mediated vascular disease. In one embodiment, platelet hyperactivation and arterial thrombosis mediated vascular disease includes myocardial infarction, non-fatal stroke, peripheral vascular disease, and / or peripheral arterial disease, and vascular death.

[0082] In vascular diseases, abnormal clotting occurs which can lead to arterial disease, venous disease, lymphatic disease, impaired blood flow, and ischemia. Platelet dysfunction, including hyperactivation, mediates or increases the risk of vascular diseases, where the vascular diseases can be selected from the group of aneurysms, atherosclerosis, peripheral arterial disease, blood clots in veins, myocardial infarction, non-fatal stroke, peripheral vascular disease, and / or peripheral arterial disease, blood clotting disorders, and vascular death.

[0083] CFTR modulators used in the interventional methods described herein are intended to prevent, slow or reduce disease progression, including platelet hyperactivation and arterial thrombosis-mediated vascular disease and vascular death. In some embodiments, the CFTR modulators improve one or more symptoms of platelet-mediated vascular disease, such as cyanosis, chest pain, heart attack, uncontrolled hypertension, heart failure, leg pain, and cramps.

[0084] In one embodiment, the efficacy and physiological response of the treatments described herein is measured by a reduction in the incidence of non-fatal myocardial infarction, non-fatal stroke or vascular death in patients at high risk of occlusive vascular events, and / or a reduction in the need for cardiovascular surgery, such as bypass surgery or angiogenesis.

[0085] In one embodiment, CFTR modulators prevent thrombosis, embolism, and / or fatal outcomes of diseases caused by pathological platelet-mediated atherosclerosis.

[0086] In some embodiments, the medical condition involves pathological platelet activation, adhesion and / or aggregation.

[0087] In some embodiments, the CFTR modulator is administered to a subject having, suspected of having, or at risk of having pathologic platelet activation, adhesion and / or aggregation.

[0088] Ca 2+ Influx mediates the shape changes of activated platelets and their aggregation and adhesion. Ivacaftor significantly attenuates platelet aggregation in vitro. In Example 1, the use of CFTR modulators increased the Ca influx into platelets via calcium channels. 2+ The present inventors have shown that Ca influx is reciprocally attenuated. 2+CFTR mediates both the shape change and secretion of activated platelets, as well as their aggregation and adhesion. Surprisingly, CFTR modulators also inhibit Ca 2+ Pretreatment with CFTR modulators can also significantly attenuate platelet Ca2+-dependent aggregation (Figure 2). 2+ In a microfluidic in vitro disease model of damaged blood vessels, the number and size of agonist-induced thrombus formation in the blood of COVID-19 patients was remarkably and significantly reduced to levels measured in the blood of healthy volunteers (Figure 2).

[0089] It could not be deduced from the prior art that ivacaftor significantly attenuates platelet aggregation and calcium levels, even when cells are pretreated with ivacaftor. The pretreatment experiments provide proof of concept of a beneficial and significant effect as a preventative strategy.

[0090] In one embodiment, treatment with a CFTR modulator reduces pathological platelet activation, aggregation, and adhesion to physiological levels compared to healthy, unaffected controls.

[0091] CFTR modulators for use in the interventional methods described herein are intended to prevent, slow or reduce disease progression, including pathological platelet aggregation and adhesion, or to prevent and / or reduce acute or non-acute thrombus formation. In some embodiments, the CFTR modulator ameliorates one or more symptoms of thrombus formation, such as blocked veins or arteries.

[0092] In one embodiment, the efficacy and physiological response of the treatments described herein are determined by measuring platelet aggregation, e.g., as detected by aggregometry, and platelet adhesion, e.g., as detected by a microfluidic in vitro disease model of injured blood vessels.

[0093] In some embodiments, the CFTR modulator is administered to a subject who does not have cystic fibrosis.

[0094] CFTR modulators have been developed for cystic fibrosis patients who have a mutated form of the CFTR gene, by improving the expression and / or activity of the CFTR ion channel in the cell membrane.

[0095] It could not be deduced from the prior art that CFTR modulators also increase the activity of non-mutated CFTR protein, which is normally expressed, for example, in the platelets of non-cystic fibrosis patients, including biological activity.

[0096] One of skill in the art could not have predicted that a CFTR modulator such as ivacaftor, a CFTR potentiator that enhances the activity of mutant CFTR, would also improve the activity of non-mutated CFTR protein. It is surprising that the CFTR potentiator ivacaftor can reduce or prevent the activation of non-mutated CFTR protein and thus produce the medical effects described herein.

[0097] In some embodiments, the CFTR modulator is administered to a subject who also has cystic fibrosis.

[0098] Cystic fibrosis is a severe genetic disorder that primarily affects the lungs, but also the pancreas, liver, kidneys and intestines. Long-term problems include lung infections, difficulty in breathing and producing phlegm. Cystic fibrosis often leads to early death.

[0099] In one embodiment, a CFTR modulator is administered to a cystic fibrosis patient having, suspected of having, or at risk of developing thrombosis, thrombocytopathy, coagulopathy, and / or a thromboembolic event. As shown in Example 2, cystic fibrosis patients treated with a CFTR modulator have a beneficial effect on the risk of developing thrombosis, thrombocytopathy, coagulopathy, and / or a thromboembolic event compared to untreated cystic fibrosis patients.

[0100] Surprisingly, a retrospective analysis of multicenter patient data from CF patients affected by COVID-19 (TriNetX network) showed better outcomes in CF patients who became infected with SARS-CoV-2 while receiving treatment with CFTR modulators.

[0101] Treatment with CFTR modulators is particularly beneficial in reducing pathological platelet activation and the risk of developing thrombosis, thrombocytopathy, coagulopathy, and / or thromboembolic events in cystic fibrosis and non-cystic fibrosis patients.

[0102] In some embodiments, the CFTR modulator is a CFTR activator, a CFTR potentiator, a CFTR corrector or a CFTR amplifier, preferably a CFTR potentiator or a CFTR corrector.

[0103] In some embodiments, the CFTR modulator is selected from the group consisting of ivacaftor, lumacaftor, tezacaftor, and elexacaftor.

[0104] In one embodiment, one or more CFTR modulators can be administered to a human subject.

[0105] In one embodiment, a CFTR modulator is administered for the treatment of thrombosis and embolism to a human subject suffering from community-acquired pneumonia, hospital-acquired pneumonia, and COVID-19.

[0106] In one embodiment, a CFTR modulator is administered to prevent thrombosis and embolism to human subjects with community-acquired pneumonia, hospital-acquired pneumonia, and COVID-19.

[0107] In one embodiment, a CFTR modulator is administered to a human subject suffering from an inflammatory and / or infectious disease, such as sepsis and pneumonia, for the treatment of thrombosis and embolism.

[0108] In one embodiment, the dysfunction of the CFTR channel is a conditional dysfunction, hi one embodiment, the infection or inflammation is associated with a conditional dysfunction of the CFTR channel.

[0109] In one embodiment, a CFTR modulator is administered to a human subject suffering from a platelet-mediated vascular disease, such as atherosclerosis, peripheral vascular disease, myocardial infarction, stroke, and vascular death, for the treatment and / or prevention of thrombosis and embolism.

[0110] As shown in Example 2, treatment of cystic fibrosis patients with CFTR modulators reduced the risk of coronary heart disease by 63.7% and the risk of atherosclerosis by 73.9%. It could not be derived from the prior art that CFTR modulators, including ivacaftor, lumacaftor, tezacaftor or elexacaftor, have a significant beneficial effect on coronary heart disease and atherosclerosis.

[0111] In one embodiment, the CFTR modulator is ivacaftor.

[0112] In one embodiment, ivacaftor is administered for the treatment and / or prevention of thrombosis and embolism to human subjects with community-acquired pneumonia, hospital-acquired pneumonia, and COVID-19.

[0113] In some embodiments, including treatment of a medical condition comprising thrombosis in a subject suffering from a SARS coronavirus infection, preferably a SARS-CoV-2 infection, the CFTR modulator is ivacaftor.

[0114] In one embodiment, treatment involves administering ivacaftor to a subject who has or has had a SARS-CoV-2 infection, and the subject has a medical condition involving thrombosis, a thrombotic event, platelet hyperactivation associated with pneumonia, thrombocytopathy, and / or a coagulation disorder.

[0115] In some embodiments, symptoms of infection with a SARS virus include fever, sore throat, cough, muscle pain or fatigue, and in some embodiments, additionally, sputum production, headache, hemoptysis, and / or diarrhea. In some embodiments, symptoms of infection with a SARS coronavirus, such as SARS-CoV-2, include fever, sore throat, cough, loss of taste and / or smell, shortness of breath, and / or fatigue.

[0116] In one embodiment, the CFTR modulator reduces the degree of thrombosis associated with microangiopathy and prevents fatal thromboembolic events in a subject.

[0117] In some embodiments, the dosage and frequency of the CFTR modulator, preferably ivacaftor, is: (a) dosages of 2 mg / day to 2000 mg / day, preferably 20 mg / day to 1000 mg / day, more preferably 100 mg / day to 200 mg / day for human subjects weighing up to 30 kg, and 200 mg / day to 400 mg / day for human subjects weighing more than 30 kg; and / or (b) two to four times per day, preferably twice per day, via subcutaneous, intravenous or oral administration routes, preferably via tablets at a dose of 1 mg to 1000 mg per dose for human subjects weighing up to 30 kg, more preferably at a dose of 10 mg to 500 mg per dose, even more preferably at a dose of 50 mg to 100 mg per dose, and at a dose of 100 mg to 200 mg per dose for human subjects weighing more than 30 kg; Includes.

[0118] In one embodiment, a therapeutically effective amount of at least one CFTR modulator is administered to a human subject in need thereof.

[0119] In some embodiments, ivacaftor is used to treat chronic thrombosis and / or atherosclerosis in a human subject, where ivacaftor is administered at a daily dose of 100 mg / day to 200 mg / day for human subjects weighing up to 30 kg, and 200 mg / day to 400 mg / day for human subjects weighing more than 30 kg.

[0120] In some embodiments, one or more CFTR modulators are administered to a human subject for use in treating chronic thrombosis and / or atherosclerosis in the subject.

[0121] In some embodiments, the treatment comprises administering a CFTR modulator 2-4 times per day for at least 1 week, at least 1 month, at least 1 year, or for life, preferably 2-4 times per day, e.g., for 1 month to a subject without cystic fibrosis or for the rest of a subject with cystic fibrosis, wherein the route of administration is preferably oral, preferably oral delivery of a single dose of 50 mg to 100 mg up to 30 kg body weight, and 100 mg to 200 mg per dose above 30 kg body weight.

[0122] In preferred embodiments, the compound is administered at a concentration or amount or according to a dosage regime already established in the art, such as one that has been approved by a regulatory agency (e.g., by the FDA or EMA), or at a dose currently being evaluated in a Phase 2 clinical trial and / or according to the maximum tolerated dose according to a Phase I trial.

[0123] Some embodiments of the specific relative amounts referenced herein are based on clinically approved or currently tested doses of the various compounds described herein that are combined in the pharmaceutical compositions described herein.

[0124] In some embodiments, CFTR modulators ameliorate one or more symptoms of thrombosis and / or atherosclerosis as described herein, for example, platelet hyperactivation, hypercoagulability / thrombophilia, pathological adhesion and / or aggregation can be effectively treated by oral administration at a daily dose of about 2 mg / day to 2000 mg / day, preferably 20 mg / day to 1000 mg / day, more preferably 100 mg / day to 200 mg / day for human subjects weighing up to 30 kg, and 200 mg / day to 400 mg / day for human subjects weighing more than 30 kg.

[0125] In one embodiment, the treatment, dosage and / or frequency of administration of the CFTR modulator is configured to reduce calcium influx into target cells, preferably platelets.

[0126] The CFTR modulator ivacaftor inhibited agonist-induced [Ca] upregulation in platelets from severe COVID-19 patients. 2+]i response. In addition, adhesion of both unstimulated and stimulated platelets in whole blood of severe COVID-19 patients is reduced. Circulating platelet-leukocyte aggregates correlate with COVID-19 severity. In the prior art, other anticoagulants known to those skilled in the art, such as aspirin, apixaban, or P2Y12 inhibitors, could not bring about a significant reduction in thromboembolic events. Surprisingly, CFTR modulation attenuates platelet activation, adhesion, and aggregation in the blood of acute COVID-19 patients, showing beneficial results over the prior art in terms of reducing cardiovascular and thromboembolic complications in the clinic.

[0127] CFTR modulators have been developed and approved for the purpose of increasing the amount and / or probability of CFTR channel opening in the cell membrane of cystic fibrosis patients, but not for increasing the channel activity or expression of non-mutated CFTR. Moreover, COVID-19 patients already show increased CFTR expression (see Examples and Example 4). Thus, in contrast to the use of CFTR modulators known to those skilled in the art when chronic dysfunction exists, the condition disclosed herein is a conditional dysfunction that is distinct from chronic dysfunction. As shown in the Examples, CFTR is functional and its expression is increased in the patient population disclosed herein. Given that the prior art is based on defective CFTR function, i.e. chronic dysfunction, it is believed that the skilled artisan would not have been motivated to further improve channel function, for example, in COVID-19 patients with preserved CFTR function.

[0128] In one embodiment, the treatment, dosage and / or frequency of administration of the CFTR modulator is configured to reduce pathological platelet activation, adhesion and / or aggregation.

[0129] As noted above, no anticoagulant effect on platelets would be expected in the absence of a mutation in CFTR, and because CFTR expression is already elevated (see Example 4), one skilled in the art would not consider further enhancing or improving CFTR function. Surprisingly, CFTR modulators have an anticoagulant effect on platelets regardless of CFTR mutations.

[0130] This effect can be surprisingly enhanced by the combined administration of CFTR modulators, which can combine more than one CFTR enhancer, more than one CFTR corrector, and / or more than one CFTR amplifier. Combinations of CFTR enhancers, CFTR correctors, and CFTR amplifiers are also effective. Combinations are already known in the prior art and are available as two-, three-, and four-component combinations. Those skilled in the art can easily select other useful combinations from available CFTR modulators.

[0131] In one embodiment, the CFTR modulators are administered in combination, such as a combination of one or more CFTR correctors and one or more CFTR amplifiers and / or one or more CFTR enhancers.

[0132] In one embodiment, treatment is administered in a combination that includes a CFTR enhancer and one or more CFTR correctors.

[0133] In one embodiment, treatment is administered with a combination including ivacaftor, tezacaftor, and elexacaftor.

[0134] In one embodiment, treatment is administered with a combination comprising ivacaftor and lumacaftor.

[0135] In one embodiment, the treatment, dosage and / or frequency of administration of the CFTR modulator is configured to reduce the level of platelet activation to or below the level present prior to the treatment.

[0136] In one embodiment, the levels are determined in a sample comprising and / or derived from a body fluid and / or cell from the subject, preferably blood, serum or plasma. The sample is preferably taken and analyzed as described in Example 1.

[0137] In one embodiment, the treatment is administered at a dosage and frequency configured to prevent pathological platelet activation, adhesion and / or aggregation.

[0138] In one embodiment, the treatment is administered at a dosage and frequency configured to reduce pathological levels of platelet activation, adhesion, aggregation, and / or to reduce the level of platelet activation to at least 5%, 10%, 20%, 30%, 40% or at least 50% of the level present prior to treatment.

[0139] In one embodiment, the treatment is administered at a dosage and frequency configured to prevent and / or reduce levels of calcium influx and / or surface expression of platelet activation markers to levels at least 20% below levels at the start of treatment, where the platelet activation markers include CD62p, CD63, and / or CD41 / CD61.

[0140] In one embodiment, calcium influx, surface expression of platelet activation markers, platelet activation, platelet adhesion, platelet aggregation, and intracellular calcium levels are determined as described in the Examples, and other means known to those skilled in the art.

[0141] Those skilled in the art can practice the present invention based on the experimental and textual support provided herein, in combination with general knowledge in the art. By using the quantitative evaluation criteria described in the examples to determine the reduction in the level of one or more platelet activation, adhesion and / or aggregation, or by using alternative quantitative means, the combination of pharmaceutical compounds and their required dosages can be determined and adjusted to obtain the beneficial effects described herein.

[0142] In one embodiment, a CFTR modulator is administered alone to a subject described herein. In one embodiment, a CFTR modulator is administered in combination with a non-CFTR modulator to a subject described herein.

[0143] The present invention further relates to pharmaceutical compositions comprising a CFTR modulator for use in the treatment and / or prevention of the medical conditions described herein, wherein said CFTR modulator is present in admixture with a pharma- ceutical acceptable carrier and / or formulated in a pharmaceutical buffer.

[0144] In another aspect, the invention relates to a pharmaceutical composition comprising a CFTR modulator for use in the treatment of atherosclerosis associated with thrombosis and / or pathological platelet activation in a human subject.

[0145] The compositions provided by the present disclosure may be capable of slowing or halting the progression and / or persistence of medical conditions including thrombosis and / or atherosclerosis described herein, such as platelet hyperactivation, hypercoagulability / thrombophilia, pathological adhesion and / or aggregation. The use of samples received from three cohorts of COVID-19 patients and controls is an advantage of the present disclosure and a strength of the study. The present disclosure first shows the association of CFTR activity with thrombosis and / or atherosclerosis, including platelet hyperactivation, hypercoagulability / thrombophilia, pathological adhesion and / or aggregation in human subjects, and provides a means of treating the above diseases.

[0146] Further examples of pharmaceutical compositions, medical conditions, treatments, subjects, and targets are detailed below.

[0147] The description of the features of the invention relating to treatment and diagnostic methods, and compositions comprising CFTR modulators used to treat various medical conditions, also applies to the compositions themselves, and vice versa: any feature disclosed herein for any given embodiment may be applied to other embodiments, as deemed reasonable by one of skill in the art.

[0148] Detailed Description of the Invention Singular expressions should be understood to include the plural form of the concept unless otherwise specified. Thus, singular articles (e.g., "a," "an," "the," etc. in English) should be understood to include the plural form of the concept unless otherwise specified. Furthermore, terms used in this specification should be understood to have the meanings generally accepted in the art unless otherwise specified.

[0149] Cystic fibrosis transmembrane conductance regulator (CFTR) "Cystic fibrosis transmembrane conductance regulator" or "CFTR" is a protein that forms an anion channel found in the apical membrane of many secretory cells. CFTR consists of 1480 amino acids and functions as an ATP-binding cassette (ABC) transporter. The channel consists of five domains: two transmembrane domains (TMD1 and TMD2), each with six hydrophobic segments (M1-M6 and M7-M12), that form the channel pore, a regulatory domain (R) that initiates opening, and two nucleotide-binding domains (NBD1 and NBD2) that finally induce channel opening. Opening is cAMP (cyclic adenosine monophosphate) dependent: after cAMP activation, the regulatory domain is phosphorylated by a protein kinase, followed by ATP binding to the two NBDs. NBD1 and NBD2 then form a dimer, which causes the opening of the channel pore. Hydrolysis of ATP closes the channel again. In addition to its function as an ion channel, the CFTR protein is also involved in the regulation of other channels, such as ENaC (epithelial sodium channel), ROMK1 and ROMK2 (potassium channels), or ORCC (outwardly rectifying chloride channel), and interacts with other proteins. Expression of the CFTR gene is tissue-specific, with the CFTR protein being found in high proportions in the intestinal mucosa and biliary system, but also in the pancreas, lungs, sweat glands, and reproductive organs.

[0150] To date, over 2100 CFTR gene mutations have been described, of which 382 are currently classified as causing cystic fibrosis (https: / / cftr2.org / mutations_history).

[0151] "Cystic fibrosis" is an autosomal recessive, life-shortening, multisystemic disease. CF is caused by a defect due to mutations in the CFTR (cystic fibrosis transmembrane conductance regulator) protein, an anion channel in exocrine glands. Approximately 45,000 patients are currently registered in Europe. This results in an average prevalence of 8.4 / 100,000 population (pe) in Europe, with significant geographic variation, ranging from 1.0 / 100,000 pe in Latvia to 29.8 / 100,000 pe in Ireland. The incidence in Germany is currently estimated to be 1:3300-1:4800 in newborns. Approximately 30,000 patients are currently registered in the United States.

[0152] CFTR mutations are functionally classified into six mutation classes: - Class I: Contains mutations that result in no production of the CFTR protein. - Class II: Includes mutations that lead to defects in protein folding and consequent endoplasmic reticulum retention and subsequent premature proteasomal degradation. - Class III: CFTR channels are expressed in the cell membrane and contain mutations that display dysregulation that severely reduces the open probability. - Class IV: Contains mutations that result in a marked reduction in the ionic conductance of the CFTR channel expressed in the apical cell membrane. - Class V: Contains mutations that reduce the number of functional CFTR channels. - Class VI: includes mutations that result in severely impaired membrane stability of the functional CFTR protein, resulting in premature protein degradation.

[0153] The reduced function of the CFTR channel leads to a reduction in apical chloride secretion or reabsorption in sweat glands. In some tissues, such as the airways, there is also hyperactivity of apical ENaC, with the result of excessive reabsorption of sodium ions from the lumen. As a result, the influx of interstitial water into the lumen of the gland is restricted, which leads to excessive viscous secretion and also to inflammation. These in turn lead to obstruction of the lumen and excretory ducts of exocrine glands. In the airways, the replenishment of so-called airway surface liquid (ASL) is reduced, which impairs mucociliary clearance. Bicarbonate ions are also secreted through the CFTR channel. In response to the reduced CFTR function, a decrease in the pH of secretions is caused. Animal models have shown that acidification of the airways leads to inhibition of endogenous antimicrobial peptides. Affected organ systems include, among others, the airways, the digestive tract, and the reproductive organs. CF is the most common genetic disease in the Caucasian population. Symptoms of CF include nasal polyps, chronic sinusitis, anosmia, recurrent bronchopulmonary infections, bronchial obstruction, atelectasis, infections caused by gram-negative bacteria such as Pseudomonas aeruginosa, by Staph. aureus and Haemophilus influenzae, or by fungi, bronchiectasis, allergic bronchopulmonary aspergillosis, pulmonary hyperinflation, hemoptysis, pneumothorax, respiratory failure, dyspnea, pulmonary hypertension, exocrine pancreatic insufficiency, recurrent or chronic pancreatitis, type 3 diabetes mellitus, meconium ileus, failure to thrive, rectal prolapse, distal intestinal obstruction syndrome, biliary cirrhosis, fibrosis, primary sclerosing cholangitis, cholelithiasis, osteoporosis, arthropathy, and salt-losing syndrome.

[0154] CFTR Modulators As used herein, the term "CFTR modulator" refers to its general meaning in the art and is understood as any agent or compound that modulates, preferably improves or restores, the function of CFTR protein, preferably the channel function of CFTR protein. Any agent or compound that acts on the function or expression of CFTR protein, regardless of the mechanism on CFTR channel, is summarized by regulatory authorities and the skilled artisan as a CFTR modulator. CFTR modulators are clinically approved for increasing the amount and / or probability of channel opening and / or channel conductance of CFTR in the cell membrane of CF patients. With reference to their mechanism of action, CFTR modulators include potentiators, correctors and amplifiers. One important function is to increase conductance and restore the physiological function of the channel. For example, when the conductance of CFTR channel is increased and thus the physiological function of CFTR channel is restored, restoration may include an increase in the amount and / or probability of channel opening and / or channel conductance. The CFTR protein is known as an ion channel for chloride ions, allowing chloride ions to pass through cell membranes, for example to increase the chloride ion concentration within the cell. In cells, organs or organisms that have defective CFTR proteins caused by one or more mutations in the CFTR gene or any of the nucleic acid regions that control / modulate CFTR gene expression, the chloride ion channel may be absent, disrupted or non-functional.

[0155] As described in more detail herein, "CFTR modulators" are known as part of common general knowledge based on this functional definition, and the functionality of this class of compounds is recognized in the art to have clear technical meaning. Verification of the key functions can be performed without undue experimentation using tests or procedures known in the art and set forth herein, and the present disclosure and examples herein demonstrate that this activity can be achieved by a variety of compounds in this functional class and is relevant to the present invention.

[0156] CFTR protein function is determined by measuring chloride flux and / or intracellular chloride levels, which can be achieved using methods known in the art, for example, by measuring single channel activity by patch clamp techniques, by measuring short circuit currents in Ussing chambers, or by measuring changes in intracellular Cl levels with Cl-sensitive fluorescent dyes in response to extracellular Cl- concentration.

[0157] As described herein, defects in CFTR protein function result in reduced chloride flux across cell membranes. CFTR modulators have been shown to effectively target the disruption of specific CFTR proteins and / or CFTR protein levels. CFTR modulators are preferably used to improve disrupted CFTR protein function and / or CFTR protein levels. As described herein, CFTR modulators are preferably used to treat and / or prevent medical conditions described herein that are associated with CFTR protein function, where the CFTR protein is a non-mutated CFTR protein. CFTR modulators are used to treat and / or prevent medical conditions described herein that are associated with CFTR protein function, where the CFTR protein is a mutated CFTR protein associated with cystic fibrosis.

[0158] CFTR modulators have been developed for use in treating cystic fibrosis, particularly for different functional perturbations associated with one or more of the mutation classes described herein.The first CFTR modulators were identified by high-throughput functional screening (HTS) of a large number of chemical compounds against cell cultures with different CFTR mutations.Various compounds that act as CFTR modulators are known in the prior art (Table 1).CFTR modulators can be CFTR activators, CFTR enhancers, CFTR correctors or CFTR amplifiers, preferably CFTR enhancers or CFTR correctors.

[0159] The term "potentiator" refers to an agent or compound that enhances the action of a target structure, such as a protein. The CFTR protein has a tunnel-like shape that can be closed by a gate. CFTR potentiators are predicted to enhance the channel conductance and functionality of CFTR already expressed in the apical cell membrane. For example, CFTR potentiators are located in the membrane and increase the channel opening or gating probability of perturbed CFTR proteins with gating (class III) and / or conductance (class IV) mutations. This can again be determined by determining chloride flux.

[0160] In embodiments, the CFTR enhancer may be selected from, but is not limited to, ivacaftor (CAS No.: 873054-44-5, marketed under the trade name Kalydeco™ by Vertex Pharmaceuticals), GLPG2451 (CAS No.: 2055015-61, marketed by Galapagos NV) and GLPG1837 (CAS No.: 1654725-02-6, marketed by Galapagos NV), QBW251 10 (marketed by Novartis), PTI-808 (marketed by Proteostasis Therapeutics), FDL176 (marketed by Flatley Discovery Lab), 4,6,4'-trimethylangelicin (TMA, a synthetic derivative of angelicin), CFpot-532, CoPo-22 or a derivative or pharma- ceutically acceptable salt thereof.

[0161] The term "corrector" refers to an agent or compound that improves or modifies the assembly of a target structure, e.g., corrects protein folding.

[0162] CFTR correctors are predicted to improve the correct folding of the nascent amino acid chain translated from the mutant CFTR gene into the correct three-dimensional structure, the transport of the protein product expressed by the mutant CFTR gene to the cell membrane, and / or the stability of the protein product of the mutant CFTR gene at the cell membrane.

[0163] CFTR correctors are predicted to allow and / or enhance incorporation of CFTR protein into cell membranes, thereby bringing more CFTR protein to the cell membrane, even in those cases where protein function is impaired. CFTR protein function can be determined by measuring chloride flux across the cell membrane.

[0164] CFTR correctors have been developed for cystic fibrosis patients who carry the F508del mutation in at least one CFTR gene allele, where such a mutation prevents the CFTR protein from forming a functional three-dimensional shape (class II mutation).

[0165] In embodiments, the CFTR corrector may be any of a variety of compounds, including, but not limited to, lumacaftor (CAS No.: 936727-05-8, VX-809, available from Vertex Pharmaceuticals), C18 (VRT-534) (an analog of lumacaftor), VRT-768, VRT-325, tezacaftor (CAS No.: 1152311-62-0, VX-661, available from Vertex Pharmaceuticals), elexacaftor (CAS No.: 2216712-66-0, VX-445, available from Vertex Pharmaceuticals), vamocaftor (CAS No.: 2204245-48-5, VX 659, available from Vertex Pharmaceuticals), vamocaftor potassium (CAS 2204245-47-4, VX 659 potassium salt, available from Vertex Pharmaceuticals), and the like. The therapeutic agent may be selected from: pocenacaftor (CAS No.: 2095064-05-2, PTI-801, marketed by Proteostasis Therapeutics), cabosonestat (CAS No.: 1371587-51-7, N91115, marketed by Nivalis Therapeutics), GLPG2222 (CAS No.: 1918143-53-9, marketed by Galapagos NV), GLPG2737 (marketed by Galapagos NV), or a derivative, or a pharma- ceutically acceptable salt thereof.

[0166] The term "amplifier" refers to an agent or compound that enhances the activity of a corrector or enhancer by increasing the number of target structures available to the corrector or enhancer, e.g., increasing protein levels by improving translation of mRNA.

[0167] CFTR amplifiers also potentiate other CFTR modulator activities by stabilizing CFTR mRNA during translation, thereby allowing more CFTR protein to be expressed and available for the action of correctors and enhancers.

[0168] CFTR amplifiers are expected to increase the amount of mutant CFTR messenger RNA and therefore the amount of CFTR protein. The amount of messenger RNA can be determined by methods known in the art, qRT-PCR, microarray, RT-PCR, or shotgun sequencing. CFTR amplifiers are designed for CFTR mutations that result in insufficient CFTR protein expression. CFTR amplifiers are a class of drugs that increase CFTR protein levels in cells and tissues. CFTR amplifiers increase the amount of mutant CFTR messenger RNA and therefore the amount of CFTR protein, thereby increasing the substrate for other CFTR modulators. Amplifiers themselves do not correct or improve the function of CFTR protein.

[0169] The CFTR amplifier can be selected from, but is not limited to, nesoricaftor (PTI-428, marketed by Proteostasis Therapeutics) and PTI-5 CH (Kenneth A. Giuliano et. al., SLAS Discov. 2018 Feb; 23 (2): 111-121) or a derivative or pharma- ceutically acceptable salt thereof.

[0170] CFTR modulators are also administered in combination, such as a combination of a CFTR corrector and one or more CFTR amplifiers and / or one or more CFTR enhancers. For example, a combination of lumacaftor and ivacaftor (approved by the FDA and EMA as Orkambi) or a combination of tezacaftor and ivacaftor (approved by the FDA as Symdeko) or a combination of elexacaftor, tezacaftor and ivacaftor (approved by the FDA as Kaftrio) can be used for treatment.

[0171] As an example, Kaftrio, also known as Trikafta, is a triple combination of ivacaftor (a CFTR potentiator), tezacaftor (a CFTR corrector), and elexacaftor (a CFTR corrector) and is an approved drug combination.

[0172] Table 1 - Structural formulas of exemplary CFTR modulators [Table 1] [Table 1-1] [Table 1-2]

[0173] Hemostasis, platelet activation, adhesion and / or aggregation Thrombocytes are blood cells that play an important role in blood clotting and closure of vascular injury. The term "platelet" can also be used for platelets and is used interchangeably herein. In the circulating blood, platelets are in an inactive state. In the event of injury and subsequent opening of the blood vessel, hemostasis occurs within a short time due to adhesion and aggregation of platelets and subsequent fibrin formation. Surface contact leads to platelet activation, which includes adhesion, shape change, aggregation, and release reactions. Activating factors such as ADP, collagen, thromboxane, and thrombin cause platelet shape changes, resulting in platelet aggregation.

[0174] Platelet activation is an important natural component of blood clotting and vascular closure in the body, but platelet activation is also associated with a variety of diseases, including thrombosis, vascular disease, and embolism.

[0175] "Hemostasis" also refers to the biological process that stops bleeding when blood vessels are injured. Further leakage of blood from the bloodstream is prevented, which is a prerequisite for wound healing. Hemostasis must be localized to the injured area and not falsely triggered by other events such as inflammation or infection. Hemostasis can be divided into two subprocesses, which interact with each other.

[0176] Under non-pathological physiological conditions, in primary hemostasis, platelets are activated by the process of platelet adhesion. Coagulation is also induced by the release of calcium ions, ADP, serotonin, and thromboxane A2. Platelets aggregate and form a white clot that temporarily closes the wound. These mechanisms promote further platelet activation and aggregation. Secondary hemostasis, or the blood clotting phase, includes an activation phase, which includes platelet activation and formation of active thrombin, and a coagulation phase. The white clot of primary hemostasis is transformed into a red clot. Thus, platelet dysfunction can be characterized by pathological aggregation, proliferation, or adhesion of platelets.

[0177] In one embodiment, pathological platelet activation is also a platelet dysfunction. In one embodiment, pathological platelet activation includes platelet hyperactivation, pathological platelet aggregation, pathological platelet adhesion, and / or pathological platelet-mediated coagulation, such as hypercoagulability. "Hypercoagulability" is an increase in blood coagulability.

[0178] Medical Indications and Conditions In one embodiment of the invention, there is provided a pharmaceutical composition comprising one or more CFTR modulators for use in the treatment of medical conditions involving thrombosis, thrombotic events and / or thromboembolic events.

[0179] In one embodiment of the invention, pharmaceutical compositions comprising one or more CFTR modulators are provided for use in the treatment of medical conditions involving atherosclerosis and pathological platelet activation.

[0180] A "medical condition" refers to any defect in the normal physiological function of a cell, a part of a tissue, an organ, a system of an organism, or an organism that may result from a variety of causes, such as infection, inflammation, environmental factors, or genetic defects, and that is characterized by an identifiable group of signs, symptoms, or both.

[0181] Medical conditions that may be treated or prevented using CFTR modulators include, without limitation, thrombosis, thrombotic events, embolism, thromboembolism, hypercoagulable states, atherosclerosis, intravascular coagulation, thrombotic microangiopathy, platelet hyperactivation associated with pneumonia, pathological platelet hyperactivation, pathological platelet aggregation, and / or pathological platelet adhesion.

[0182] A "disease" or "disorder" refers to any condition in which the normal physiological function of the body or any part thereof is impaired or disturbed, and which is generally manifested by characteristic signs and symptoms.

[0183] Diseases and / or disorders to be treated or prevented using CFTR modulators include, but are not limited to, pulmonary disorders, thrombocytosis, coagulation disorders, coronary artery disease, arteriosclerosis, myocardial infarction, angina pectoris, stroke, transient ischemic attack, peripheral arterial disease, infectious diseases, CAP, HAP, COVID-19, systemic or extrapulmonary infectious, inflammatory diseases, rheumatic diseases such as systemic lupus erythematosus or Schönlein-Henoch purpura, hematological diseases such as thrombotic thrombocytopenic purpura, cardiovascular diseases such as arteriosclerosis, stroke, myocardial infarction, or acute or chronic pulmonary thromboembolism. Preferably, the medical conditions described herein are associated with pathological platelet activation, adhesion and / or aggregation.

[0184] In one embodiment of the invention, pharmaceutical compositions comprising one or more CFTR modulators are provided for use in the treatment of medical conditions, including pulmonary disorders.

[0185] The pulmonary disorder may be selected from, but is not limited to, pulmonary hypertension associated with or caused by certain primary disorders such as atherosclerosis, cardiovascular disease (coronary artery disease (CAD) (CVD, such as angina and myocardial infarction, commonly known as heart attack)), stroke, heart failure, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, abnormalities in heart rhythm, congenital heart disease, valvular heart disease, carditis, aortic aneurysm, peripheral arterial disease, thromboembolic disease, and venous thrombosis, secondary pulmonary disorders, secondary pulmonary hypertension.

[0186] Human subjects with pathological platelet activation, aggregation and / or adhesion, atherosclerosis, thrombosis, thromboembolism have a particular constellation of signs and symptoms that are grouped into specific diseases or disorders described herein.

[0187] As used herein, a "patient having symptoms" of a disease or disorder described herein is a subject exhibiting one or more of the diseases or disorders. As used herein, a "patient at risk of developing" a disease or disorder described herein relates to a subject who is at increased (e.g., above average) risk of developing the disease or disorder, preferably different from any given person in the general population.

[0188] As used herein, a "patient with symptoms of infectious disease" is a subject who is exhibiting one or more of the following symptoms, without limitation: fever, diarrhea, fatigue, muscle pain, coughing, animal bites, trouble breathing, severe headache with fever, skin rash or swelling, unexplained or persistent fever, or vision problems. Other symptoms may be fever and chills, very low body temperature, decreased urine output (oliguria), tachycardia, shortness of breath, nausea and vomiting. In a preferred embodiment, the symptoms of infectious disease are fever, diarrhea, fatigue, muscle pain, tachycardia, shortness of breath, nausea and vomiting, and / or coughing. As used herein, "infectious disease" includes all diseases or disorders associated with bacterial and / or viral and / or fungal and / or parasitic infections.

[0189] As used herein, a patient having "symptoms of a respiratory tract viral infection" is a subject exhibiting one or more of the following cold-like symptoms or flu-like illness, including, but not limited to, fever, cough, runny nose, sneezing, sore throat, trouble breathing, headache, muscle pain, fatigue, rapid heartbeat, rapid breathing, nausea and vomiting, loss of taste and / or smell and / or feeling unwell (feeling unwell).

[0190] As used herein, the term "patient at risk of developing Severe Acute Respiratory Syndrome (SARS)" relates to a subject at increased (e.g., above average) risk of developing SARS, preferably different from any given person in the general population. In some embodiments, the patient has symptoms of SARS or symptoms of SARS coronavirus infection. In some embodiments, the patient has no symptoms of SARS or symptoms of SARS coronavirus infection. In some embodiments, the subject is a subject who has come into contact with a person with SARS coronavirus infection or symptoms. In some embodiments, a person at risk of developing SARS is a person who has been tested for the presence of SARS coronavirus infection. In some embodiments, a person at risk of developing SARS is a person who has tested positive for the presence of SARS coronavirus infection, preferably coronavirus infection.

[0191] In some embodiments, the patient has or is at risk of developing Severe Acute Respiratory Syndrome (SARS) has a coronavirus infection.

[0192] Thrombosis, thrombotic and / or thromboembolic events "Thrombosis" or "thrombotic event" refers to the formation of a blood clot in a blood vessel that obstructs blood flow through the circulatory system. Blood clots can form in the body under certain conditions, even when the blood vessel is not injured.

[0193] "Thromboembolism" refers to the blockage of another blood vessel by a blood clot (thrombus) that forms in one blood vessel and is carried by the bloodstream away from the vessel and blocks another blood vessel.

[0194] An "embolus" is a blood clot, or a part of a blood clot that has broken away from a blood vessel and spread throughout the body.

[0195] "Coagulopathy" or "blood coagulation disorder" refers to a disorder of blood clotting (hemostasis). Decreased blood clotting accompanied by an increased tendency to bleed (bleeding diathesis) is referred to as a negative coagulopathy, whereas increased blood clotting (hypercoagulability) is referred to as a positive coagulopathy. Coagulopathy, by definition, is caused by a deficiency or dysfunction of a clotting factor.

[0196] "Platelet dysfunction" refers to any problem with the platelets themselves or an external factor that alters normal platelet function.

[0197] "Thrombocytopathies" refers to any of several blood disorders characterized by impaired platelet (thrombocyte) function resulting in prolonged bleeding times, defective clot formation, and a tendency to bleed. Inherited plateletopathies include von Willebrand's disease, thrombasthenia characterized by abnormal clot retraction and impaired platelet aggregation, and Bernard-Soulier syndrome, characterized by abnormally large platelets. In addition, plateletopathies are sometimes seen in Down's syndrome and Wiskott-Aldrich syndrome (immune disorders).

[0198] "Platelet-mediated vascular disease" refers to any disease caused by thrombocyte or platelet hyperactivation, vascular inflammation, and arterial or venous thrombosis, including, but not limited to, atherosclerosis, peripheral vascular disease, coronary and peripheral artery disease, myocardial infarction, pulmonary embolism, and stroke. Platelet-mediated vascular disease can lead to vascular death.

[0199] Thrombosis can occur in veins (venous thrombosis) or arteries (arterial thrombosis). Venous thrombosis results in congestion in the affected part of the body, while arterial thrombosis (and less severe venous thrombosis) affects the blood supply and causes damage to the tissues supplied by that artery (ischemia and necrosis). Part of the arterial or venous thrombus breaks off as an embolus, travels through the bloodstream, and lodges as an embolism elsewhere. This type of embolism is called thromboembolism. When venous thromboembolism (commonly called VTE) occurs in the lungs, it can become complicated as a pulmonary embolism. Arterial embolism can travel further into the affected blood vessel where it can lodge as an embolism.

[0200] A distinction must be made between arterial thrombosis (eg myocardial infarction, stroke), which is caused by clot formation in an artery, and venous thrombotic events such as phlebitis, venous thrombosis and pulmonary embolism.

[0201] In Germany, approximately 100,000 people die each year (approximately 500,000 across Europe) from venous thromboembolism resulting from thrombotic events.

[0202] Arterial thrombotic events such as myocardial infarction and stroke occur mostly in individuals with "classical" risk factors (hypertension, diabetes, lipid metabolism disorders, obesity, nicotine consumption) and are found mainly in advanced years. When arterial thrombotic events occur in individuals without corresponding risk factors, it should be remembered that coagulation defects also increase the risk of arterial thrombosis and contribute to the occurrence of the corresponding thrombotic events. When arterial events occur in young patients without the relevant risk factors and without a sufficient risk profile, a coagulation workup is recommended. Examples of coagulation defects that increase the risk of arterial thrombotic events include antiphospholipid syndrome (APLS) and severe antithrombin deficiency.

[0203] In individuals with a congenital or acquired hypercoagulability of the blood ("thrombophilia") during life, venous thrombotic events, especially phlebitis, venous thrombosis, and pulmonary embolism, are more common. Common congenital risk factors for venous thrombotic events include factor V Leiden mutation, prothrombin mutation, and protein C, protein S, and antithrombin deficiency. An acquired disorder associated with an increased risk of venous thrombotic events among others is the so-called antiphospholipid syndrome (APLS). However, it is now known that many other factors lead to hypercoagulability of the blood or indicate a pre-existing hypercoagulability in the venous system and thus an increased risk of clot formation. It should be considered that the use of hormonal contraceptives (the pill), and hormone replacement therapy (HRT) increases the risk of thrombosis.

[0204] For both arterial and venous clot formation, "blood thinners" (antithrombotic drugs) are administered for treatment. Depending on the type of clot formation, the type of defect present, and other factors, the treatment of different patients can vary considerably. Furthermore, the tolerability, efficacy, and dosage of drugs are not the same in everyone and can vary significantly.

[0205] Deep vein thrombosis (DVT) is the formation of blood clots in deep veins. DVT most commonly affects veins in the legs, such as the femoral veins. Three factors are important for the formation of blood clots in deep veins: the speed of blood flow, the thickness of the blood, and the nature of the vessel walls. Classical signs of deep vein thrombosis include swelling, pain, and redness in the affected area.

[0206] Paget-Schroetter disease or upper extremity DVT (UEDVT) is the blockage of a vein in the arm (e.g., the axillary or subclavian veins) due to a blood clot. The condition usually occurs after vigorous exercise and is most commonly seen in young, otherwise healthy individuals. Men are more commonly affected than women.

[0207] Budd-Chiari syndrome is an obstruction of the hepatic portion of the hepatic vein or inferior vena cava. This form of thrombosis is manifested by abdominal pain, ascites, and hepatomegaly. Treatment varies between medical therapy and surgery with the use of shunts.

[0208] Portal vein thrombosis affects the hepatic portal vein and can lead to portal hypertension and reduced blood flow to the liver. Portal vein thrombosis usually occurs concomitantly with another disease, such as pancreatitis, cirrhosis, diverticulitis, or cholangiocarcinoma.

[0209] Renal vein thrombosis is the blockage of the renal vein by a blood clot, which usually results in reduced outflow from the kidney.

[0210] Cerebral venous sinus thrombosis (CVST) is a rare form of stroke resulting from blockage of the dural venous sinuses by a blood clot. Symptoms include symptoms of stroke such as headache, visual disturbances, weakness of the face and limbs on one side of the body, and seizures. Diagnosis is usually made by CT scan or MRI. The majority of those affected recover fully. Mortality is 4.3%.

[0211] Jugular vein thrombosis may occur due to infection, intravenous drug use, or malignancy. Jugular vein thrombosis may lead to a number of complications, including systemic sepsis, pulmonary embolism, and papilledema. Jugular vein thrombosis is characterized by sharp pain at the venous site, but may be difficult to diagnose because it may occur spontaneously.

[0212] Cavernous sinus thrombosis is a special form of cerebral venous sinus thrombosis in which there is thrombosis of the cavernous sinus at the base of the cerebral dura due to retrograde spread of infection from the facial danger triangle and endothelial damage. The facial vein in this area anastomoses with the superior and inferior ophthalmic veins of the orbit and drains immediately posteriorly into the cavernous sinus through the superior orbital fissure. Thus, facial staphylococcal or streptococcal infections such as nasal or upper lip pustules can spread directly into the cavernous sinus, causing stroke-like symptoms such as diplopia and strabismus, as well as spread of infection to meningitis.

[0213] Arterial thrombosis is the formation of a blood clot in an artery. In most cases, arterial thrombosis follows the rupture of an atheroma (a fatty deposit in the wall of a blood vessel), hence the name atherothrombosis. If the clot travels downstream, arterial embolism can occur, affecting any organ.

[0214] Arterial occlusion can also result from embolization by blood clots originating from the heart ("cardiogenic" embolism). The most common cause is atrial fibrillation, which causes blood stagnation in the atria that facilitates clot formation, although blood clots can also form in the heart for other reasons, such as infective endocarditis.

[0215] Stroke is a rapid decline in brain function due to a disturbance in the blood supply to the brain. It can be due to ischemia, thrombus, embolus (sticky particles), or hemorrhage. In thrombotic stroke, a thrombus (blood clot) usually forms around an arteriosclerotic plaque. The onset of symptomatic thrombotic stroke is slow, as the blockage of the artery is gradual. Thrombotic stroke can be divided into two categories: large vessel disease and small vessel disease. The former involves blood vessels such as the internal carotid artery, vertebral artery, and circle of Willis. The latter can affect smaller blood vessels such as the branches of the circle of Willis.

[0216] Myocardial infarction or heart attack is caused by ischemia (absence of blood flow), often due to blockage of a coronary artery by a blood clot. This restriction results in insufficient oxygen supply to the heart muscle, leading to tissue death (infarction). A lesion forms, which is an infarction. A heart attack can be quickly fatal if not treated immediately. If diagnosed within 12 hours of the initial attack, treatment with thrombolytic drugs is initiated.

[0217] Arterial thrombi or emboli can form in the limbs, resulting in acute limb ischemia.

[0218] Further diseases include blood diseases, such as thrombotic thrombocytopenic purpura, and cardiovascular diseases, such as atherosclerosis, stroke, myocardial infarction, or acute or chronic pulmonary thromboembolism.

[0219] Symptoms of thrombosis include, but are not limited to, pain in one leg (usually the calf or inner thigh), swelling in the leg or arm, chest pain, numbness or weakness on one side of the body, and a sudden change in mental status.

[0220] Symptoms of thromboembolism include, but are not limited to, swelling, pain, cyanosis, heaviness, and convulsions in the affected extremity.

[0221] Symptoms of pneumonia, for example with respect to CAP, HAP, COVID-19, include, but are not limited to, cough that may produce greenish, yellow, or even bloody mucus, fever, sweats and shaking chills, shortness of breath, rapid shallow breathing, sharp or stabbing chest pain that worsens with deep breathing or coughing, loss of appetite, low energy, and fatigue, nausea and vomiting, especially in young children, and confusion.

[0222] Symptoms of sepsis include, but are not limited to, rapid heartbeat, hyperventilation, dizziness or fainting, changes in mental status such as confusion or disorientation, diarrhea, nausea and vomiting, slurred speech, severe muscle pain, severe shortness of breath, and less than normal urine production, for example not urinating for a day.

[0223] Atherosclerosis and Arteriosclerosis "Atherosclerosis" is a disease state of arteriosclerosis, in which abnormalities called lesions develop in the walls of arteries. These lesions can lead to narrowing due to the deposition of atheromatous plaque. There are usually no symptoms at the onset of the disease, but if developed, symptoms usually begin to appear during middle age. In severe cases, coronary artery disease, stroke, peripheral artery disease, or kidney problems can occur, depending on the artery affected.

[0224] Atherosclerosis may be asymptomatic for decades. Atherogenesis is the process of atheromatous plaque development and is characterized by arterial remodeling resulting in subendothelial deposition of fatty material called plaque. Atherosclerotic plaque accumulation is a slow process that develops over a period of years by a series of complex cellular processes within the arterial wall and in response to various local circulating vascular factors. Atherosclerosis progression is accompanied by morphological and pathophysiological changes, including the replacement of reversible early lesions (fatty streaks) with fibrous plaques.

[0225] Atherosclerotic disease is a three stage disease, the early and late stages are also platelet mediated phases of atherosclerotic disease.

[0226] The "early" or "first stage" of atherosclerosis is characterized by the deposition of low-density lipoprotein droplets, especially in macrophages, which results in the formation of foam cells. The formation and subsequent deposition of foam cells is the origin of the development of atherosclerotic plaques. Atheromas consist of a lipid core and a fibrous cap, which together cause the thickness of the arterial wall to change. Eventually the fibrous cap may rupture, leading to thrombosis and complete occlusion of the lumen.

[0227] Peripheral arteries supplying blood to the legs, arms and pelvis also experience significant stenosis due to plaque rupture and blood clots. Symptoms of stenosis include numbness and pain in the arms or legs. Another important site of plaque formation is the renal arteries that supply blood to the kidneys. The appearance and deposition of plaque leads to reduced blood flow to the kidneys and chronic kidney disease, which, as in all other areas, is usually asymptomatic only in the later stages.

[0228] The "late stage" or "third stage" of atherosclerosis is due to plaque rupture and involves repeated platelet-mediated healing responses.

[0229] Atherosclerosis can lead to arterial thrombosis, affecting people whose arteries are clogged with fatty deposits. The exact cause of the condition is unknown. Risk factors include abnormal cholesterol levels, elevated levels of inflammatory markers, high blood pressure, diabetes, smoking, obesity, family history, and an unhealthy diet. Plaque is made up of fats, cholesterol, calcium, and other substances found in the blood. The narrowing of the arteries restricts the flow of oxygen-containing blood to parts of the body. Diagnosis is based on a physical examination, an electrocardiogram, and exercise testing, among other tests.

[0230] Treatment for identified conditions may include medications to lower cholesterol, such as statins, blood pressure medication, or medications to reduce blood clotting, such as aspirin. Various procedures, such as percutaneous coronary intervention, coronary artery bypass surgery, or carotid endarterectomy, may also be performed.

[0231] Atherosclerosis usually begins at a young age and worsens with age: almost everyone is affected to some degree by age 65. In industrialized countries, atherosclerosis is the leading cause of death and disability.

[0232] Atherosclerosis can be asymptomatic for decades, because all plaque sites in the artery expand and blood flow remains unaffected. Even if most plaques rupture, they do not cause symptoms until the artery narrows sufficiently or is blocked by a blood clot. Signs and symptoms do not occur until severe narrowing or blockage impedes blood flow to various organs and causes symptoms. In most cases, patients do not realize that they have the disease until they experience other cardiovascular conditions, such as stroke or heart attack. However, these symptoms vary depending on the artery or organ that is affected.

[0233] nucleic acid The term "nucleic acid" as used herein refers to a polymer containing at least two deoxyribonucleotides or ribonucleotides in single-stranded or double-stranded form, and includes DNA, RNA, and hybrids thereof. DNA can be in the form of, for example, antisense molecules, RNA-DNA duplexes, PCR products, chimeric sequences, derivatives, and combinations of these groups. RNA can be in the form of small interfering RNA (siRNA), dicer substrate dsRNA, small hairpin RNA (shRNA), asymmetric interfering RNA (aiRNA), microRNA (miRNA), mRNA, and combinations thereof. DNA and RNA can form DNA-RNA hybrids. As used herein, the term "polynucleotide" or "nucleic acid molecule" refers to messenger RNA (mRNA), RNA, genomic RNA (gRNA), positive strand RNA (RNA(+)), negative strand RNA (RNA(-)), genomic DNA (gDNA), complementary DNA (cDNA), or recombinant DNA. Polynucleotide includes single-stranded and double-stranded polynucleotides. Polynucleotides of the invention preferably encompass polynucleotides or variants having at least about 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 96%, 97%, 98%, 99% or 100% sequence identity to any of the reference sequences described herein, and typically the variants retain at least one biological activity of the reference sequence.

[0234] "Gene" refers to a region of DNA that encodes a gene product, including regions that regulate the production of the gene product, whether or not the sequences that regulate the production of the gene product are adjacent to the coding sequence and / or the transcribed sequence. Genes include, but are not limited to, promoter sequences, terminators, translational regulatory sequences such as ribosome binding sites and internal ribosome entry sites, enhancers, silencers, insulators, boundary elements, origins of replication, matrix attachment sites, and locus control regions.

[0235] "Gene expression" is the conversion of the information encoded in a gene into a gene product. A gene product may be the direct transcription product of a gene (e.g., mRNA, tRNA, rRNA, antisense RNA, ribozyme, structural RNA, or any other type of RNA) or a protein produced by translation of an mRNA. Gene products also include RNA modified by processes such as capping, polyadenylation, methylation, and editing, and proteins modified by processes such as methylation, acetylation, phosphorylation, ubiquitination, ADP-ribosylation, myristoylation, and glycosylation. Gene expression is regulated by "expression control elements" or "regulatory sequences."

[0236] "Expression control element" or "regulatory sequence" as used herein refers to a segment of a nucleic acid molecule that can increase or decrease the expression of a certain gene in a cell of an organism. Expression control elements are known to those skilled in the art and include, for example, promoters, enhancers, silencers, polyadenylation signals, histone binding sequences, and CpG islands. "Increased expression" of a certain gene refers to a higher number of protein molecules expressed from the gene in a cell compared to when gene expression is not increased. "Reduced expression" of a certain gene refers to a lower number of protein molecules expressed from the gene in a cell compared to when gene expression is not reduced.

[0237] Sequence variations: "Sequence variant" or "genetic mutation" or "mutation" as used herein refers to a change in the nucleotide sequence of the genome, virus, mitochondrial DNA, and / or extrachromosomal DNA of an organism. Mutations arise due to errors during DNA or viral replication, mitosis, or meiosis, or due to other types of DNA damage (e.g., pyrimidine dimers caused by ultraviolet radiation), which may then undergo error-prone repair (particularly microhomology-mediated end joining), which may lead to other forms of repair errors, or errors during replication (translesion synthesis). Mutations may also arise due to insertion or deletion of DNA segments caused by mobile genetic elements.

[0238] Mutations can result in detectable changes in the observable characteristics (phenotype) of an organism. Mutations in genes can have no effect, can change the product of the gene, or can prevent the gene from functioning properly or completely. Mutations can also occur in non-genetic regions. A "pathogenic" sequence variant refers to a genetic mutation that causes disease. Methods for discovering and identifying sequence variants, particularly pathogenic sequence variants, are known to those skilled in the art.

[0239] Polypeptides "Peptide," "polypeptide," "polypeptide fragment," and "protein" are used interchangeably unless specified to the contrary and follow their conventional meaning, i.e., a sequence of amino acids. A polypeptide is not limited to a particular length and can include, for example, a full-length protein sequence or a fragment of a full-length protein, and can also include post-translational modifications of a polypeptide, such as glycosylation, acetylation, phosphorylation, etc., as well as other modifications known in the art, both naturally occurring and non-naturally occurring.

[0240] Treatment and Therapeutic Methods As used herein, "treatment" or "treating" encompasses any beneficial or desired effect on the symptoms or pathological deviations of a disease or pathological condition, and may include a reduction, even if minimal, of one or more measurable markers of the disease or condition being treated. Treatment may optionally involve either a reduction or amelioration of symptoms of the disease or condition, or a slowing of the progression of the disease or condition. "Treatment" does not necessarily indicate a complete eradication or cure of the disease or condition, or its associated symptoms.

[0241] In the present invention, "treatment" or "therapy" generally means obtaining a desired pharmacological and / or physiological effect. The effect may be prophylactic, in that it completely or partially prevents a disease and / or condition, for example by reducing the risk of a subject having the disease or condition, or it may be therapeutic, in that it partially or completely cures a disease and / or adverse effects of a disease.

[0242] In the present invention, "treatment" includes any treatment of a disease or condition in a mammal, particularly a human, such as the following treatments (a) to (c): (a) preventing the onset of the disease, condition or symptom in a patient; (b) suppressing the symptoms of the condition, i.e., preventing the progression of the symptoms; (c) ameliorating the symptoms of the condition, i.e., inducing regression of the disease or symptom.

[0243] As used herein, "prevent" and similar words, such as "prevented," "preventing," or "prophylactic," refer to an approach that prevents, inhibits, or reduces the likelihood of the onset or recurrence of a disease or condition. It also refers to delaying the onset or recurrence of a disease or condition, or delaying the onset or recurrence of symptoms of a disease or condition. As used herein, "prevention" and similar words also encompass reducing the intensity, impact, symptoms, and / or burden of a disease or condition prior to the onset or recurrence of a disease or condition.

[0244] In some embodiments, the time interval between treatments or preventions includes a period of hours (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 hours), days (2, 3, 4, 5, 6, or 7 days), weeks (1, 2, 3, 4, 5, 6, 7, or 8 weeks), or months (2, 3, 4, 5, or 6 months), preferably between 1 week and 3 months. In some embodiments, the time interval between one treatment or prevention and the next treatment may be the same, approximately the same, or may vary.

[0245] In some embodiments, the treatment comprises administering the CFTR modulator, derivative or pharma- ceutically acceptable salt thereof once or twice or three or four times per day for more than a day, more than a week, more than a month, or more than a year, preferably four times per day for a month.

[0246] In one embodiment, a method of treating or preventing thrombosis and / or embolism and related conditions in a subject in need thereof comprises administering an effective amount, e.g., a therapeutically effective amount, of a composition comprising a CFTR modulator as contemplated herein. Appropriate dosages can be determined by clinical trials, but the amount and frequency of administration will be determined by factors such as the condition of the patient and the type and severity of the patient's disease.

[0247] Administration of the compositions contemplated herein can be in any convenient manner, including aerosol inhalation, injection, ingestion, transfusion, implantation or transplantation, hi a preferred embodiment, the compositions are administered orally in tablet form.

[0248] The treatment of the present invention can be used or administered as determined by the skilled artisan to be appropriate. For example, in some embodiments, the time interval between treatments includes a period of several hours (2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 hours or 12 hours), several days (2 days, 3 days, 4 days, 5 days, 6 days or 7 days), several weeks (1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks or 8 weeks), or several months (2 months, 3 months, 4 months, 5 months or 6 months), preferably one day. In some embodiments, the time interval between one treatment and the next treatment may be the same, may be approximately the same, or may vary. In some embodiments, the treatment period for which the CFTR modulator, preferably ivacaftor, is administered to a subject can be for more than 1 day, more than 2 days, more than 3 days, more than 4 days, more than 5 days, more than 6 days, more than 7 days, more than 8 days, more than 9 days, more than 10 days, more than 11 days, more than 12 days, more than 13 days, more than 2 weeks, more than 3 weeks, more than 1 month, more than 2 months, more than 3 months, more than 4 months, more than 6 months, preferably 10 weeks.

[0249] Treatment of atherosclerotic disease and / or thrombosis Administration of the CFTR modulator is configured to reduce calcium influx into target cells, preferably platelets, such that pathological platelet activation, adhesion and / or aggregation is reduced, and / or the level of platelet activation is reduced to or below levels present prior to treatment.

[0250] Treatment criteria include a positive diagnosis of a disease selected from the group of pulmonary disorders, thrombocytosis, coagulation disorders, infectious diseases, CAP, HAP, COVID-19, systemic or extrapulmonary infectious, inflammatory diseases, rheumatic diseases such as systemic lupus erythematosus or Schönlein-Henoch purpura, hematological diseases such as thrombotic thrombocytopenic purpura, cardiovascular diseases such as arteriosclerosis, stroke, myocardial infarction, or acute or chronic pulmonary thromboembolism.

[0251] Treatment criteria are pathological platelet hyperactivation, hypercoagulable state, intracellular Ca 2+Positive detection of increased levels and / or expression of activation markers, including CD62p, CD63, and / or CD41 / CD61, on the surface of platelets.

[0252] Treatment criteria include positive detection of or risk of developing coagulation disorders, thrombocytosis, hypercoagulable states, embolism, thrombosis, thrombotic events, arteriosclerosis, thromboembolism, intravascular coagulation, thrombotic microangiopathy, platelet hyperactivation associated with pneumonia, and / or pathologic platelet hyperactivation.

[0253] Immune Cells and Inflammation "Immune cell" includes any cell of a vertebrate immune system, including lymphocytes such as B cells, cytotoxic T cells (i.e., CD8+ T cells), helper T cells (i.e., CD4+ T cells, including Th1 and Th2 cells), natural killer cells, and γδ T cells, monocytes, macrophages, neutrophils, dendritic cells, mast cells, eosinophils, and basophils.

[0254] The term "inflammation" also refers to the biological response of tissues to noxious stimuli, such as pathogens, cell damage (e.g., wounds), and / or irritants. The term "inflammatory response" refers to specific mechanisms that cause and regulate inflammation and activate immune cell migration, or cytokine production, vasodilation, in addition to other mechanisms known in the art. Ideally, inflammation is an intended protective function of the body that eliminates harmful stimuli and initiates the healing process of one or more affected tissues. However, excessive or chronic inflammation as described herein is associated with various diseases, such as viral infections, e.g., SARS-CoV-2 infection, hay fever, atherosclerosis, rheumatoid arthritis, and other diseases known in the medical community. Pathogenically, disturbance of immune regulation due to persistent immune activation is suspected. Excessive or chronic inflammation can result in platelet (hyper)activation due to constant exposure to inflammatory mediators.

[0255] Human Pathogens and Pathogenic Infectious Diseases "Human pathogen" refers to any biological or invasive agent that has physical or chemical properties capable of causing disease in humans.

[0256] The pathogenic infection may be a viral infection, a bacterial infection, a fungal infection or a parasitic infection.

[0257] The human pathogen causing a viral infection may be selected from the group consisting of rhinovirus, coronavirus, e.g., SARS-CoV-1 or SARS-CoV-2, MERS, influenza virus, respiratory syncytial virus (RSV), adenovirus, parainfluenza, herpes simplex virus, or cytomegalovirus pneumonia, respiratory syndrome virus, dengue virus, avian influenza virus, swine influenza virus, Ebola virus, yellow fever, and enterovirus.

[0258] Human pathogens causing bacterial infections include Chlamydia, Haemophilus influenzae, Staphylococcus aureus, Pseudomonas species such as Pseudomonas aeruginosa, Klebsiella pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila, Moraxella catarrhalis, Streptococcus species such as Streptococcus pneumoniae, Streptococcus viridans, and others. viridans, Streptococcus faecalis, Enterobacter, Salmonella, Escherichia coli, Proteus, Serratia, or Neisseria meningitidis.

[0259] The human pathogen causing a fungal infection can be selected from the group consisting of Aspergillus fumigatus, Aspergillus flavus, Candida infections (e.g., Candida albicans), Histoplasma capsulatum, Blastomyces, Cryptococcus neoformans, Pneumocystis jiroveci, Pneumocystis pneumoniae, or Coccidioides immitis.

[0260] The human pathogen causing a parasitic infection is selected from the group consisting of malaria infections, including Plasmodium falciparum infections, Plasmodium malariae infections, Plasmodium ovale infections, and Plasmodium vivax infections.

[0261] Pathologic platelet hyperactivation, aggregation, and / or hypercoagulopathy can occur in pulmonary diseases including ARDS, VILI, TRALI, or pneumonia. Pneumonia caused by human pathogens is a pulmonary disease that includes community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and severe community-acquired pneumonia (sCAP). sCAP exists when inflammation that was localized in the lungs spreads systemically throughout the body, leading to sepsis-related complications such as sepsis, septic shock, or organ failure. Ventilator-associated pneumonia (VAP) is a specialized form of HAP. Common pathogens in CAP are Streptococcus pneumoniae, influenza virus, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, and rarely Legionella pneumophila. Common pathogens of HAP are Pseudomonas aeruginosa, Enterobacter, Escherichia coli (E. coli), Proteus spp., Serratia spp., Klebsiella pneumoniae and another multiresistant pathogen.

[0262] Viral infections and viral load As used herein, the term "viral infection" describes a pathology in which a virus invades a healthy cell. The virus uses the cell's reproductive machinery to grow or replicate, eventually lysing the cell, thus resulting in cell death, release of viral particles, and infection of other cells by the newly generated progeny virus. The term "viral load" refers to a quantitative measure of viral genomes per invaded cell. Determination of viral genomic material can be used in such methods. Latent infection with certain viruses is also a possible outcome of viral infection. The term "viral growth" refers to viral infection and replication, and production of viral particles during and after infection of a host cell.

[0263] Virus, bacterial and / or fungal detection Infectious agents can be detected in suitable test samples. Examples of samples include swabs from wounds, stool samples, body fluids such as urine, cerebrospinal fluid, secretions from the respiratory tract (secretion), and special forms of blood samples (blood cultures). The skilled person can easily find a method to detect the infectious agent of interest. Typical methods to detect infectious agents include PCR, quantitative PCR, ELISA, FACS, whole genome sequencing, whole transcriptome sequencing, microscopic examination of specimens with special stains, antigen detection, Western blot, or microbiological differential smear. In one embodiment, infectious agents can be detected in samples obtained from ME / CFS patients. Highly recurrent HSV-1, HSV-2, or VZV infections can be diagnosed clinically. If there is a history of tick infection, Borrelia ELISA should be performed and if positive, a complementary Western blot should be performed. Suitable diagnostic procedures are known to the skilled person.

[0264] Coagulopathy, thrombosis, and thromboembolic events associated with SARS coronavirus infection Coagulopathy, thrombosis, and thromboembolic events can occur in human subjects who have, have had, or are at risk for developing Severe Acute Respiratory Syndrome (SARS) coronavirus infection.

[0265] Coronaviruses are a group of related viruses that cause disease in mammals and birds. The scientific name for coronaviruses is Orthocoronavirinae or Coronavirinae. Coronaviruses belong to the family Coronaviridae. The family Coronaviridae is divided into the subfamilies Coronavirinae and Torovirinae, which are further divided into six genera: Alphacoronavirus, Betacoronavirus, Gammacoronavirus, Deltacoronavirus, Torovirus, and Bafinivirus. In humans, coronaviruses cause respiratory infections that can be mild, such as some cases of the common cold, as well as other respiratory infections that can be fatal, such as SARS, MERS, and COVID-19.

[0266] Although the majority of cases cause mild symptoms, some progress to viral pneumonia, multiple organ failure, and thrombotic events.

[0267] SARS coronavirus-2 (SARS-CoV-2) infection can cause pulmonary vascular micro- and macrothrombosis, thrombotic microangiopathy, coagulopathy, thrombosis, embolism, and pneumonia with significant morbidity and increased risk of mortality.

[0268] Various species of human coronaviruses are known, including, but not limited to, human coronavirus OC43 (HCoV-OC43) of the genus β-CoV, human coronavirus HKU1 (HCoV-HKU1) of the genus β-CoV, human coronavirus 229E (HCoV-229E), α-CoV, human coronavirus NL63 (HCoV-NL63), α-CoV, Middle East Respiratory Syndrome-related coronavirus (MERS-CoV), severe acute respiratory syndrome coronavirus (SARS-CoV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Advances in nucleic acid sequencing technology (commonly referred to as next-generation sequencing, NGS) have provided a large set of sequence data obtained from various biological samples, making it possible to characterize both known and novel viral strains. Thus, established methods are available for the determination of coronavirus infection.

[0269] SARS is induced by droplet transmission and may show viral replication in the upper and lower respiratory tract or gastrointestinal mucosa. In parallel, the virus can also directly invade cells of different organs such as the liver, kidney, heart and brain. A further separate mechanism seems to be direct viral infiltration of T cells. A significant number of SARS patients with COVID-19 have clinically low levels of lymphocytes and platelets in the blood, also known as lymphopenia and thrombocytopenia, respectively. Clinically, patients present with respiratory symptoms such as dry cough and shortness of breath, fever or diarrhea, but may also develop symptoms related to acute liver, cardiac or renal injury. In less severe forms of SARS, patients may show mild symptoms or even no symptoms.

[0270] Clinical and scientific investigations have shown that SARS-CoV binds to epithelial cells via the angiotensin-converting enzyme 2 receptor (ACE2). ACE2 is a cell membrane-associated carboxypeptidase that is expressed in vascular endothelium, kidney, bladder, heart, nasal mucosa, bronchi, and lungs. One consequence of viral binding is epithelial and endothelial cell damage with vascular leakage, which induces the secretion of proinflammatory cytokines and chemokines. The virus also mediates ACE2 downregulation and shedding, which further promotes a dysfunctional renin-angiotensin system (RAS). Disruption of the RAS can result in inflammatory responses and vascular permeability. Focusing on the respiratory system, ACE2 shedding can lead to pulmonary vascular permeability and subsequent pulmonary edema.

[0271] Elderly patients (over 60 years of age), those with chronic diseases (e.g., cardiovascular disease, diabetes, cancer, COPD), or immunocompromised patients are considered at high risk of facing a severe outbreak of SARS. Smoking and obesity are also considered risk factors. Specific embodiments of SARS coronavirus include, without limitation, SARS or any coronavirus that induces a pathological deviation similar to SARS. Specific embodiments include, without limitation, SARS coronavirus (SARS-CoV-1), MERS-CoV, and SARS-CoV-2, which causes COVID-19. SARS-CoV-2 strains cause COVID-19, the disease that has led to the ongoing 2019-2020 coronavirus pandemic. The disease was first identified in December 2019 in Wuhan, the capital of Hubei Province, China, and has spread worldwide. Common symptoms include fever, cough, and shortness of breath. Other symptoms include muscle pain, diarrhea, sore throat, loss of taste and / or smell, and abdominal pain.

[0272] subject As used herein, the term "subject" refers to a mammal, such as a human, but may also include other animals, such as domestic animals (e.g., dogs, cats, etc.), agricultural animals (e.g., cows, sheep, pigs, horses, etc.), or laboratory animals (e.g., monkeys, rats, mice, rabbits, guinea pigs, etc.).

[0273] The term "patient" refers to a "subject" suffering from or suspected of suffering from thrombosis, a thrombotic event, embolism, thromboembolism, coagulation disorder, thrombocytopathy, hypercoagulable state, arteriosclerosis. The subject to be treated may further suffer from cystic fibrosis.

[0274] Host Cells and Target Cells The terms "host cell" and "target cell" as used herein refer to a single cell or cell culture that can be or has been a recipient of at least one of the agents described herein, either individually or in combination. A host cell encompasses the progeny of a single host cell, which may not necessarily be completely identical (morphology or overall DNA complementation) to the original parent cell due to natural, random or deliberate mutations and / or alterations. In one embodiment, a host cell also refers to a cell that has been or can be invaded by an infectious agent (e.g., a virus).

[0275] Pharmaceutically acceptable salts, pharmaceutical compositions and methods of administration The present invention also relates to pharmaceutical compositions comprising the compounds described herein. The present invention also relates to the enantiomers and / or tautomers of the compounds described herein, as well as pharma- ceutically acceptable salts of the compounds described herein.

[0276] In some embodiments, the CFTR modulator may be provided (i) as the compound itself (e.g., as a free base); (ii) as a pharma- ceutically acceptable salt of the compound; or (iii) as part of a pharmaceutical composition. In some embodiments of the above methods, uses, and pharmaceutical compositions, the additional therapeutic modality may be provided (i) as the compound itself (e.g., as a free base); (ii) as a pharma- ceutically acceptable salt of the compound; or (iii) as part of a pharmaceutical composition.

[0277] The "pharmaceutical acceptable salts" of the compounds described herein include salts obtained from the compounds when mixed with inorganic or organic acids or bases. In some embodiments, the salts can be generated in situ during the final isolation and purification of the compounds. In other embodiments, the salts can be generated in a separate synthetic step from the free form of the compounds. The preparation of the above pharmaceutical acceptable salts and other exemplary pharmaceutical acceptable salts is described in detail in Berg et al, "Pharmaceutical salts", J. Pharm. ScL, 1977:66:1-19, the entire disclosure of which is incorporated herein by reference. A pharmaceutical acceptable salt of a CFTR modulator is a salt that can be used in medicine. However, salts that are not pharmaceutical acceptable may also be useful in the production of CFTR modulators or their pharmaceutical acceptable salts.

[0278] With respect to CFTR modulators, suitable "pharmaceutically acceptable salts" refers to salts prepared from pharmaceutically acceptable non-toxic bases, including inorganic bases and organic bases. Salts derived from inorganic bases include aluminum, ammonium, calcium, copper, ferric, ferrous, lithium, magnesium, manganese, manganous, potassium, sodium, zinc, and the like. Particular embodiments include ammonium, calcium, magnesium, potassium, and sodium salts. Salts derived from pharma- ceutically acceptable organic non-toxic bases include salts of primary, secondary, and tertiary amines, substituted amines, including naturally occurring substituted amines, cyclic amines, arginine, betaine, caffeine, choline, N,N'-dibenzylethylenediamine, diethylamine, 2-diethylaminoethanol, 2-dimethylaminoethanol, ethanolamine, ethylenediamine, N-ethylmorpholine, N-ethylpiperidine, glucamine, glucosamine, histidine, hydrabamine, isopropylamine, lysine, methylglucamine, morpholine, piperazine, piperidine, polyamine resins, procaine, purines, theobromine, triethylamine, trimethylamine, tripropylamine, tromethamine, and the like.

[0279] The term "pharmaceutical composition" refers to a combination of an agent described herein and a pharmaceutically acceptable carrier. The phrase "pharmaceutically acceptable" refers to molecular entities and compositions that do not cause severe allergic reactions or similar untoward reactions when administered to humans. As used herein, "carrier" or "carrier material" includes any and all solvents, dispersion media, vehicles, coatings, diluents, antibacterial and antifungal agents, isotonic and absorption delaying agents, buffers, carrier solutions, suspensions, colloids, and the like. The use of such media and agents for pharmaceutical active substances is known in the art. Supplementary active ingredients can also be incorporated into the composition.

[0280] The pharmaceutical composition containing the active ingredient may be in a form suitable for oral use, such as tablets, chewable tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules, emulsions, hard or soft capsules, or syrups or elixirs. Compositions intended for oral use can be prepared according to any method known in the art for the manufacture of pharmaceutical compositions and for such compositions. Tablets contain the active ingredient in admixture with non-toxic pharma- ceutically acceptable excipients suitable for the manufacture of tablets. Tablets may be uncoated or may be coated by known techniques to delay disintegration and absorption in the gastrointestinal tract, thereby providing a sustained action over a longer period of time.

[0281] In one embodiment, a pharmaceutical composition comprising a CFTR modulator, preferably ivacaftor, as described herein is provided to a subject three times daily as a tablet or liquid formulation, preferably at 1 mg / kg / day to 2 mg / kg / day of the CFTR modulator, preferably administered as a tablet or via a stomach tube.

[0282] The CFTR modulator is usually formulated into a pharmaceutical composition. The pharmaceutical composition may optionally further comprise one or more additional pharma- ceutical active compounds, including one or more of the other above-defined CFTR modulators and / or combinations thereof. For example, ivacaftor may be combined with a CFTR corrector selected from lumacaftor or tezacaftor. The components of the kit of parts of the present invention may be formulated for simultaneous administration or for administration in any order. The components may be for repeated administration.

[0283] The administration of the compounds of the present invention or their pharmaceutically acceptable salts in pure form or as suitable pharmaceutical compositions can be carried out by any acceptable administration form or agent that provides similar utility.Accordingly, administration can be, for example, oral, nasal, parenteral, topical, transdermal, or rectal, sublingual, intramuscular, subcutaneous, or intravenous, for example, in the form of solid, semi-solid, lyophilized powder, or liquid dosage forms such as tablets, suppositories, pills, soft elastic gelatin capsules and hard gelatin capsules, powders, solutions, suspensions, or aerosols, preferably in unit dosage forms suitable for simple administration of precise dosages.The compositions include conventional pharmaceutical carriers or excipients, and the compounds of the present invention as active agents, and may further include other medicinal agents, pharmaceutical agents, carriers, adjuvants, etc.

[0284] Dosage levels on the order of about 1 mg to about 5000 mg per day are useful in treating indicated conditions in human subjects weighing up to 30 kg. For example, thrombosis and embolism can be effectively treated by administering a CFTR modulator at a dose of about 2 mg to about 2000 mg, preferably 20 mg to about 1000 mg, and more preferably 100 mg to about 200 mg per patient weighing up to 30 kg per day.

[0285] In treating indicated conditions in human subjects weighing over 30 kg, dosage levels on the order of about 1 mg to about 5000 mg per day are useful. For example, thrombosis and embolism can be effectively treated by administering a CFTR modulator at a dose of about 4 mg to about 4000 mg, preferably 40 mg to about 2000 mg, and more preferably 200 mg to about 400 mg per patient weighing over 30 kg per day.

[0286] The amount of active ingredient that can be combined with carrier materials to produce a single dosage form varies depending on the host treated and the particular mode of administration. For example, a formulation intended for oral administration to humans may vary from about 5% to about 95% of the total composition. A unit dosage form generally contains about 1 mg to about 500 mg of active ingredient. However, it will be understood that the specific dosage level for any particular patient will depend on a variety of factors, including the activity of the particular compound used, age, body weight, general health, sex, diet, time of administration, route of administration, excretion rate, drug combination, and the severity of the particular disease being treated. The effective dosage amount of the compounds according to the present invention will vary depending on factors including the particular compound, toxicity, and inhibitory activity, the condition being treated, and whether the compound is administered alone or in conjunction with other therapies.

[0287] Therapeutically effective and therapeutically meaningful The phrase "therapeutically effective" is intended to be consistent with a reasonable benefit / risk ratio, including without excessive toxicity, irritation, allergic response, and / or other problems or complications, within the scope of good medical judgment. As used herein, it refers to compounds, compositions, combinations, and / or dosage forms suitable for use in contact with a subject, which themselves produce a result useful in treating and / or curing a disease.

[0288] A "therapeutically meaningful amount," "therapeutically meaningful dosage," or "therapeutically effective amount" of a CFTR modulator, i.e., an agent or treatment such as ivacaftor, is an amount sufficient to produce a desired effect, e.g., improved CFTR chloride ion channel activity and chloride flux compared to levels detected in the absence of the CFTR modulator. Improved CFTR chloride ion channel activity and chloride flux is achieved when the levels obtained with the CFTR modulator are about 95%, 90%, 85%, 80%, 75%, 70%, 65%, 60%, 55%, 50%, 45%, 40%, 35%, 30%, 25%, 20%, 15%, 10%, 5%, or 0% of pre-treatment levels. Suitable assays for measuring chloride flux, intracellular chloride levels, and / or intracellular calcium levels include, for example, assays of chloride ions using techniques known to those of skill in the art, such as single channel activity by patch clamp techniques, short circuit currents in Ussing chambers, or changes in intracellular Cl levels in response to extracellular Cl concentration by Cl-sensitive fluorescent dyes, and phenotypic assays known to those of skill in the art.

[0289] "Enhancing," "improving," "enhancing," "elevating" or "modifying" CFTR chloride ion channel activity and chloride flux by a CFTR modulator, ivacaftor, refers to a detectable increase in CFTR chloride ion channel activity and chloride flux associated with a given CFTR modulator, ivacaftor. The degree of decrease in intracellular calcium levels and increase in CFTR chloride ion channel activity and chloride flux, ivacaftor, can be determined relative to intracellular chloride ion levels in the absence of the CFTR modulator, ivacaftor, preferably prior to the initiation of treatment with the CFTR modulator, ivacaftor. The detectable increase in intracellular calcium levels, CFTR chloride channel activity and chloride flux is about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the intracellular calcium levels, CFTR chloride channel activity and chloride flux detected before the start of treatment with the CFTR modulator, i.e., ivacaftor. Reduction of platelet hyperactivation, hypercoagulable state, and intracellular calcium levels and improvement of CFTR chloride channel activity and chloride flux by CFTR modulators is generally understood and measured by lowering intracellular calcium levels and improving CFTR chloride channel activity by responder cells in vitro or in vivo.

[0290] "Systemic administration" as used herein refers to the administration of a composition that results in the widespread biodistribution of the CFTR modulator, preferably ivacaftor, in the organism.Systemic administration means exposing a therapeutic amount of the agent to the preferred part of the body.Systemic administration of a composition can be achieved by any means known in the art, for example, intravenously, subcutaneously, intraperitoneally.

[0291] Coadministration In accordance with the present invention, the term "combined administration", otherwise known as simultaneous administration or joint treatment, includes in some embodiments administering separate formulations of the compounds described herein, thereby performing treatment simultaneously, within minutes of each other, at the same time of each other, on the same day, the same week, or the same month. Alternating administration of two agents is also considered an embodiment of combined administration. The term combined administration also includes staggered administration, such as administering one agent, followed by a subsequent administration of a second agent, optionally followed by administering the first agent again. Simultaneous administration of multiple agents is also considered an embodiment of combined administration. Simultaneous administration, in some embodiments, includes, for example, orally taking multiple compositions comprising multiple agents at the same time, for example, by taking separate tablets at the same time. A combination agent, such as a single formulation comprising multiple agents disclosed herein and, optionally, an additional antiviral agent and / or anti-inflammatory or anti-antibody targeting agent, can also be used to administer the various components simultaneously in a single dose or dosage.

[0292] For example, one or more CFTR modulators can be administered in combination to a human subject.

[0293] In another example, one or more CFTR modulators can be administered to a human subject in combination with at least one treatment other than the CFTR modulator.

[0294] Combination therapy or administration of one agent may be performed with, before, or after treatment with the other agent to be combined, with intervals ranging from minutes to weeks. In embodiments where the second and first agents are administered separately, it is generally ensured that no significant period of time passes between the respective delivery times, so that the first and second agents can still exert their advantageous combined synergistic effect on the treatment site. In such cases, it is contemplated that the subject will be contacted with both modalities within about 12 to 24 hours of each other, more preferably within about 3 to 12 hours of each other, with a delay of only about 6 hours being most preferred. In some circumstances, it may be desirable to extend the duration of treatment significantly, but allow several days (2, 3, 4, 5, 6, or 7 days) to several weeks (1, 2, 3, 4, 5, 6, 7, or 8 weeks) to pass between the respective administrations.

[0295] In the sense of the present invention, co-administration encompasses any mode of administration of the agents described herein, such that a beneficial additive therapeutic effect, preferably a synergistic effect, is achieved by co-administration of the two agents.

[0296] The invention will now be illustrated by way of example through the drawings disclosed herein. The drawings presented show certain non-limiting embodiments and are not intended to limit the scope of the invention. [Brief description of the drawings]

[0297] [Figure 1] FIG. 1 shows that platelets from COVID-19 patients are hyperactivated and exhibit significantly reduced [Ca2+]i responses to platelet activating agonists after pretreatment with ivacaftor. [Figure 1-1] Same as above [Diagram 2]FIG. 1 shows that pretreatment with the CFTR potentiator ivacaftor reduces agonist-induced platelet adhesion and aggregation in vitro. [Figure 2-1] Same as above [Diagram 3] FIG. 1 shows a retrospective risk analysis of CF patient "outcome" according to use / non-use of one of the CFTR modulators ivacaftor, lumacaftor, tezacaftor or elexacaftor within a large international cohort of CF patients from TriNetX Real World. [Figure 4] 1 is a graph showing an analysis of patient populations treated with CFTR modulators. [Diagram 5] FIG. 1 shows that CFTR is elevated in platelets from COVID-19 patients with severe disease course. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0298] Detailed description of the drawings: Figure 1: Platelets from COVID-19 patients are hyperactivated and show increased [Ca] responses to platelet activation agonists after pretreatment with ivacaftor. 2+]i response. (A) Overview of COVID-19 patient and healthy donor study cohorts classified according to the World Health Organization (WHO) clinical progression scale for COVID-1921. (B) Flow cytometry of surface expression of activation markers CD62p and CD63 on platelets from COVID-19 patients with moderate or severe disease course compared to healthy donors. (C) Surface expression of CD62p and CD63 on platelets isolated from blood of healthy donors and agonist stimulated with 50 μM ADP, 50 μM TRAP6, or 5 μM PAF after pretreatment in vitro with either vehicle, ivacaftor, or forskolin for 24 hours. (D) Ratiometric Ca expression on platelets after pretreatment with either vehicle, ivacaftor, or forskolin. 2+ Agonist-induced [Ca] was monitored by loading the Ca-sensitive dye Indo-1 AM and performing FACS. 2+ (E) Representative trajectories of the [Ca]i response measured in (D). 2+ Quantification as area under the curve (AUC) of the .ti transient. Each circle (B, C, E) represents a platelet from an individual patient / donor, and the bars show the mean. *P<0.05; **P<0.005; ***P<0.0005 (two-way ANOVA with Holm-Sidak post-hoc test (B) and Geisser-Greenhouse correction (C, E)). Data represent (B) CD62p (n=20 (healthy), n=32 (moderate), n=22 (severe)) and CD63 (n=20 (healthy), n=32 (moderate), n=23 (severe)); (C) ADP, TRAP-6, or PAF after pretreatment with vehicle, ivacaftor, or forskolin (n=13 each for all samples); (E) ADP, TRAP-6, or PAF after pretreatment with vehicle, ivacaftor, or forskolin (n=8 each for "healthy" and "severe"). NIV, noninvasive ventilation; ECMO, extracorporeal membrane oxygenation.

[0299] Figure 2: Pretreatment with the CFTR potentiator ivacaftor reduces agonist-induced platelet adhesion and aggregation in vitro. (A) Quantification of agonist-induced aggregation of platelets from moderately or severely ill COVID-19 patients compared to healthy donors by multielectrode aggregometry (MEA, Multiplate™ Analyzer, Roche Diagnostics International Ltd.). Blood samples were pretreated for 15 min with either vehicle, ivacaftor, or forskolin, and then stimulated with ADP, TRAP6, or PAF. (B) Representative fluorescent microscopy images of platelet adhesion on type IV collagen after 5 min of flow of recalcified whole blood pretreated for 15 min with vehicle, ivacaftor, or forskolin and either unstimulated or stimulated with the agonists ADP, TRAP-6, or PAF. Green signals represent CD42b+ platelets. (C) Quantification of the effect of ivacaftor on platelet adhesion (total CD42b+ area in the field of view). (D) Retrospective risk analysis of fatal outcome according to use / non-use of the CFTR modulators ivacaftor, lumacaftor, or tezacaftor in a large international cohort of CF patients with COVID-19 from the TriNetX Real World Database. Each circle (A, C) represents platelets from an individual patient / donor, and bars show the mean. *P<0.05; **P<0.005; ***P<0.0005 (2-way ANOVA, Holm-Sidak post-hoc test (A, C)). Data represent (A) ADP, TRAP-6, or PAF after pretreatment with vehicle, ivacaftor, or forskolin (n=7-19 for "healthy", n=8-15 for "moderate", and n=6-15 for "severe") and (C) ADP, TRAP-6, or PAF after pretreatment with vehicle, ivacaftor, or forskolin (n=4-8 for "healthy", n=9 for "moderate", and n=6-12 for "severe"). (B) Scale bar=100 μm.

[0300] Figure 3: Retrospective risk analysis of "outcome" in CF patients within a large international cohort of CF patients from TriNetX Real World according to use / non-use of one of the CFTR modulators ivacaftor, lumacaftor, tezacaftor or elexacaftor. A total of 12180 patients* were analyzed with 6081 patients* per group (- / + ivacaftor, lumacaftor, tezacaftor, or elexacaftor treatment). *P<0.05; **P<0.005; ***P≤0.0001.

[0301] Figure 4: Retrospective risk analysis of CF patient "outcomes" within a large international cohort of CF patients from TriNetX Real World, separated by gender, according to use / non-use of one of the CFTR modulators ivacaftor, lumacaftor, tezacaftor, or elexacaftor. A total of 4206 male patients (2103 patients per group) and 3828 female patients (1914 patients per group) with the indications disclosed herein, atherosclerosis, coronary artery disease, stroke, MI, and chronic kidney disease, would benefit from treatment with a CFTR modulator (ivacaftor, lumacaftor, tezacaftor, or elexacaftor), although for some indications, women (B) benefit more from CFTR treatment than men (A). *P<0.05; **P<0.005; ***P≦0.0001.

[0302] Figure 5: CFTR is elevated in platelets from COVID-19 patients with severe disease course. Representative immunoblots (A) and densitometric quantification (B) of CFTR protein abundance in platelets isolated from peripheral blood of COVID-19 patients with mild (n=21) and severe (n=23) disease course compared to healthy controls (n=14). *P ≤ 0.05; **P ≤ 0.005; ***P ≤ 0.001 by two-way ANOVA with Holm-Sidak multiple comparison test. EXAMPLES

[0303] The present invention is demonstrated through the examples disclosed herein. The examples presented show specific embodiments and are not intended to limit the scope of the present invention. The examples should be considered as providing non-limiting illustrations and technical support for the implementation of the present invention.

[0304] The following examples show the use of CFTR modulators in blood cells of COVID-19 and CF patients retrospectively. In a preferred embodiment, administration of CFTR modulators to blood cells of COVID-19 patients and healthy donors attenuates platelet activation and aggregation. In a preferred embodiment, a retrospective risk analysis for diseases associated with platelet hyperactivation, adhesion, and / or aggregation.

[0305] The following are described in more detail below: - Platelet activation and [Ca] in COVID-19 blood cells treated with CFTR 2+ ]iFlow cytometry for response. - Electrode aggregometry and fluorescence microscopy of platelet adhesion and aggregation under treatment with CFTR. - A retrospective risk analysis of outcomes in CF patients treated with or without ivacaftor, a CFTR enhancer that reduces agonist-induced platelet adhesion and aggregation in vitro. -Retrospective analysis of patients with atherosclerosis, coronary artery disease, stroke, MI, and chronic kidney disease who were treated with or without a CFTR modulator. - CFTR protein expression levels in COVID-19 patients

[0306] Example 1: CFTR modulators attenuate platelet activation and aggregation in blood of COVID-19 patients and healthy donors method Patient cohort: Citrated and hirudin-spiked blood samples from moderately or severely ill COVID-19 patients or healthy donor controls were collected at Charite-Universitaetsmedizin Berlin, Germany (Pa-COVID-19 cohort study, ethical approvals EA2 / 066 / 20 and EA2 / 075 / 15) and at the Amsterdam University Medical Centers (AUMC), the Netherlands (ethical approval METc number 2021.0520). Patients were included if they had a positive PCR test for SARS-CoV-2 and were over 18 years old. Patients receiving treatment with antiplatelet drugs were excluded. Details regarding the study cohort are presented in Figure 1A.

[0307] Flow cytometry: Blood samples were collected and stained as previously described 3Briefly, blood was stained directly in dilution buffer (NaCl 137 mM, KCl 2.7 mM, MgCl21 mM, 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES) 20 mM, glucose 5.6 mM, bovine serum albumin 1 g / l, pH 7.4) containing mouse anti-human anti-CD42b (GPIb) phycoerythrin (PE, clone HIP1), anti-CD62p (P-selectin) phycoerythrin-cyanine 7 (PE / Cy7, clone AK4), anti-CD63 (GP53) and Brilliant Violet 421 (clone H5C6), all from BioLegend (San Diego, CA, USA), and cells were then fixed with 2 mL of 0.2% PFA in PBS. To analyze isolated platelets, citrated whole blood was centrifuged at 150 g for 15 min to separate platelet-rich plasma (PRP) from blood cells. PRP was collected and centrifuged again at 1000 g for 15 min. Platelets were then resuspended in 10% CPDA buffer (Sigma-Aldrich, St. Louis, MO, USA) in PBS and incubated for 24 h in the presence of either vehicle (DMSO, Sigma-Aldrich, St. Louis, MO, USA), 10 μM ivacaftor (Cayman Chemicals, Ann Arbor, MI, USA) or 5 μM forskolin (Fisher Scientific, Pittsburgh, PA, USA) before staining was applied as described above. Analyses were performed on a BD FACSCanto™ II (BD Biosciences, Franklin Lakes, NJ, USA) flow cytometer equipped with violet (405 nm), blue (488 nm), and red (633 nm) solid-state lasers. All measurements were analyzed using FlowJo (version 8, Tree Star, Inc., Ashland, OR, USA).

[0308] Ca 2+Transient analysis: Platelet-rich plasma (PRP) was stained with anti-CD42b and loaded with Indo-1 AM (Invitrogen, Waltham, MA, USA) in the presence of either vehicle (DMSO, 10 μM ivacaftor or 5 μM forskolin) for 30 min at 37°C with gentle agitation. The stained PRP was diluted in Tyrode's Buffer (134 mM NaCl, 12 mM NaHCO3, 2.90 mM KCl, 0.34 mM Na2HPO4, 3 mM MgCl2, 2 mM CaCl2, 20 mM HEPES, 5 mM glucose, pH 7.4.) supplemented with heparin and PGI1, and the Ca concentration of CD42b+ platelets was then determined. 2+ Indo-1 (405 nm) bound to Ca 2+ The ratio of fluorescence of bound and unbound Indo-1 (530 nm) was monitored with a FACSymphony™ A5 (BD Biosciences, Franklin Lakes, NJ, USA) equipped with ultraviolet (355 nm), violet (405 nm), blue (488 nm), yellow (561 nm), and red (637 nm) solid-state lasers. 2+ After monitoring the concentration for 30 s, platelets were stimulated with either 5 μM PAF (Tocris Bioscience, Bristol, England, GB), 50 μM ADP (Sigma-Aldrich, St. Louis, MO, USA), or 50 μM TRAP-6 (purchased from Cayman Chemicals, Ann Arbor, MI, USA), and intracellular Ca was measured. 2+ Concentration ([Ca 2+ ]i) was monitored for an additional 2 min. Results are expressed as area under the curve (AUC) in arbitrary units.

[0309] Multielectrode aggregometry: Whole blood impedance measurements using multielectrode aggregometry (MEA) were performed on a Multiplate™ analyzer from Roche (Basel, Switzerland). Hirudin-spiked whole blood samples were treated with either vehicle (DMSO), 10 μM ivacaftor or 5 μM forskolin for 15 min at 37° C. 300 μl of hirudin-spiked whole blood was diluted in 300 μL 0.9% NaCl at 37° C. in which test cells were stimulated with either 5 μM PAF, 6.5 μM ADP or 33 μM TRAP6 (Roche (Basel, Switzerland)) according to the manufacturer's instructions. Results are expressed as area under the curve (AUC) in arbitrary units.

[0310] Vascular injury flow assay: Citrated blood was stained with anti-CD42b ((GPIb) allophycocyanin (APC, clone REA 185, Miltenyi Biotec, Bergisch Gladbach, Germany)) and treated with either vehicle (DMSO), 10 μM ivacaftor or 5 μM forskolin for 15 min at 37°C, after which microfluidic flow assays were performed as previously described. 2Briefly, pretreated whole blood was diluted 1:4 in modified Tyrode's Buffer (134 mM NaCl, 12 mM NaHCO3, 2.90 mM KCl, 0.34 mM Na2HPO4, 3 mM MgCl2, 2.1 mM CaCl2, 20 mM HEPES, 5 mM glucose, 1 g / l BSA, pH adjusted to 7.4) and immediately flowed through a collagen IV-coated microchannel flow chamber (6 Channel μ-Slide VI 0.4, Ibidi, Martinsried, Germany) at a flow rate of 20 mL / h for 5 min. After flow, cells were fixed with 4% PFA for 30 min and washed extensively with PBS. Five randomly selected regions of interest (ROIs) for each experimental condition were imaged using an Invitrogen™ EVOS™ fluorescent microscope, and quantification of the total area covered by CD42b+ was performed using ImageJ (Version 13.0.6, US National Institutes of Health and LOCI, University of Wisconsin).

[0311] TriNetX Real World Database Analysis: COVID-19 positive cystic fibrosis patients were identified by the presence of ICD-10 code E84.9 and a SARS-CoV-2 related RNA diagnosis within the past 20 months. Data were collected from electronic health records of the TriNetX Real World database provided by the global health research network of approximately 89 million patients from more than 60 health organizations across 11 countries (https: / / trinetx.com / real-world-data / ). The system deploys a linked, continuously updated global health research network representing more than 300 million patients. In this study, we performed a retrospective analysis of a large international COVID-19 cohort including 1602 patients treated with ivacaftor, lumacaftor and tezacaftor and 103065 *caftor-untreated Covid-19 cases. The relationship between ivacaftor, lumacaftor and tezacaftor is 2:1:1. Group comparisons were calculated between COVID-19 positive cystic fibrosis patients and controls without COVID-19. TriNetX analysis tools were used to obtain baseline characteristics, match cohorts using propensity score matching, and analyze outcomes of interest in the final cohorts. For each analysis, selection was made on diagnosis of SARS-CoV-2 infection within 20 months as the index event. Baseline characteristics including demographics, diagnoses, procedures, and medications were obtained. Propensity score matching was used to match cohorts. Cohorts were matched 1:1 by propensity score using a nearest neighbor greedy matching algorithm with a caliper of 0.25 times the standard deviation. The primary outcome was defined as mechanical ventilation or death. Association measures including risk differences, risk ratios, and odds ratios with their respective 95% CIs were calculated using TriNetX tools.

[0312] Results and Discussion Compared to platelets isolated from healthy donors, platelets from COVID-19 patients showed enhanced surface expression of the activation markers CD62p (p-selectin) and CD63 in response to disease severity (Figure 1B), suggesting a hypercoagulable state in COVID-19. The increased expression of these activation markers could be reproduced in platelets from healthy donors stimulated with either the three platelet agonists adenosine diphosphate (ADP), thrombin receptor-activating protein-6 (TRAP6), or platelet-activating factor (PAF). Furthermore, upregulation of CD62p and CD63 was prevented in platelets pretreated for 24 h with either the CFTR enhancer ivacaftor, or the adenylate cyclase activator and highly effective, but clinically inapplicable, platelet activation inhibitor forskolin (Figure 1C). Second, intracellular Ca2+ was identified as the major “second messenger” of platelet activation. 2+ Concentration ([Ca 2+ We assessed the effect of ivacaftor on agonist-induced increases in [Ca]i. Activation with either ADP, TRAP6, or PAF induced clear [Ca] responses that did not differ in shape or area under the curve (AUC) between platelets from healthy donors or platelets from patients with severe COVID-19. 2+ ]i responses were induced (Figures 1D and 1E). Except for TRAP6-stimulated healthy platelets, pretreatment with ivacaftor did not suppress agonist-induced [Ca 2+ ]i increase was significantly attenuated, again qualitatively replicating the effect of forskolin. 2+ Influx mediates the shape changes of activated platelets and their aggregation and adhesion. Therefore, we tested whether ivacaftor could also attenuate platelet aggregation in vitro. Multielectrode aggregometry was used to measure the [Ca 2+Similar to the effect on β-lactamase inhibitors, pretreatment with ivacaftor showed a general trend to reduce agonist-induced aggregation in platelets from both COVID-19 patients and healthy donors, but this finding only reached significance for individual agonist-platelet combinations (Figure 2A). Thus, here again, ivacaftor phenocopied the effect of forskolin. Finally, in a fluid in vitro vascular disease model mimicking platelet-extracellular matrix interactions, ivacaftor also showed a general trend to reduce agonist-induced platelet adhesion in whole blood from COVID-19 patients with moderate or severe disease and healthy donors, which reached significance for the majority of agonist-platelet combinations, qualitatively mirroring the effect of forskolin (Figure 2B, Figure 2C). Because CFTR modulators are clinically approved for CF, the TriNetX Real World database was retrospectively analyzed for CF patients with COVID-19 who were treated with ivacaftor, lumacaftor, or tezacaftor compared with an untreated cohort. Treatment with a CFTR modulator substantially reduced the risk of fatality by 55.9% (OR 0.438, CI 0.226-0.85; Table 2 and Figure 2D), whereas the reduction in risk of mechanical ventilation was only 22.2% (OR 0.776, CI 0.432-1.394; Table 2 and Figure 2D), which did not reach significance.

[0313] Table 2: Demographic outcomes of patients with cystic fibrosis with COVID-19: use / non-use of ivacaftor, lumacaftor or tezacaftor analyzed for (A) outcome: mechanical ventilation, and (B) outcome: death. [Table 2]

[0314] Here, we demonstrate that pharmacological modulation of CFTR with ivacaftor attenuates agonist-induced platelet activation, aggregation, and adhesion. These protective properties are preserved in platelets from COVID-19 patients, indicating the therapeutic potential of CFTR modulators in the treatment of severe COVID-19. This notion is supported by a retrospective analysis of multicenter patient data (TriNetX network) showing better outcomes in CF patients infected with SARS-CoV-2 while receiving treatment with CFTR modulators. Although the latter association may be confounded in part by differences in pre-COVID health status, CFTR mutations, or access to healthcare, the notion of a protective effect of CFTR modulation is supported by the recently identified hypercoagulability of platelets with deficient or mutated CFTR. The protective effect of ivacaftor was qualitatively similar to that of forskolin, an adenylate cyclase activator commonly used to activate CFTR in experimental studies. Although the non-specific effects of systemic adenylate cyclase activation preclude the clinical use of forskolin, CFTR modulators have been proven safe and effective for the treatment of CF patients, and their use is not associated with a higher risk of bleeding disorders; conversely, CFTR modulators may be beneficial for CF patients with menstrual hemoptysis. Previous studies have shown that loss of CFTR function in platelets reduces the uptake of Ca into the platelets. 2+ CFTR has been linked to the activity of transient receptor potential canonical 6 (TRPC6), which mediates influx, activation, and aggregation. Conversely, CFTR modulators may upregulate TRPC6 or alternative Ca 2+There remains a need to elucidate whether and, if so, the mechanism by which CFTR modulates the inflow channel opening probability. Because treatment of COVID-19 with aspirin failed to demonstrate a significant reduction in thromboembolic events in the Multicenter Recovery Trial, CFTR modulating approaches may serve as a more effective alternative for the clinical management of COVID-19 patients. Nevertheless, our findings identify CFTR modulators as a potential therapeutic approach to prevent thromboembolic events in severe COVID-19 and other systemic disorders characterized by platelet hypercoagulability.

[0315] Example 2: Risk analysis for CF patients treated or not with any "Caftol". A total of 12,180 patients, including 6,081 patients per group, were extracted from the TriNetX Real World database and analyzed (Table 3). This retrospective analysis compared CF patients who were treated with any one or more of "Caftor" ("Caftor" in this example is ivacaftor, lumacaftor, tezacaftor, elexacaftor) to untreated CF patients. CF patients treated with any "Caftor" had a significantly reduced risk of developing coronary heart disease (63.7%) and atherosclerosis (73.9%) (Figure 3).

[0316] Table 3: Demographic outcomes for patients with cystic fibrosis. [Table 3]

[0317] Example 3: Retrospective analysis of patients with atherosclerosis, coronary artery disease, stroke, MI, and chronic kidney disease with or without treatment with a CFTR modulator. This retrospective analysis compared patients who were treated with any one or more of "Caftor" ("Caftor" in this example is ivacaftor, lumacaftor, tezacaftor, elexacaftor) to untreated patients. Patients treated with any "Caftor" benefited from treatment with a CFTR modulator for atherosclerosis, coronary artery disease, stroke, MI, and chronic kidney disease, and had a reduced risk of death or receiving mechanical ventilation, especially in female patients (Figure 4A, Figure 4B).

[0318] Example 4: Increased CFTR protein expression in COVID-19 patients. Representative immunoblots (Figure 5A) and densitometric quantification (Figure 5B) of CFTR protein abundance in platelets isolated from peripheral blood of COVID-19 patients with mild (n=21) and severe (n=23) disease courses compared to healthy controls (n=14) are shown in Figure 5. CFTR expression at the protein level was increased in COVID-19 patients.

[0319] References 1 Cui, S., Chen, S., Li, X., Liu, S. & Wang, F. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost 18, 1421-1424, doi:10.1111 / jth.14830 (2020). 2 Klok, FA et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 191, 145-147, doi:10.1016 / j.thromres.2020.04.013 (2020). 3 Leonard-Lorant, I. et al. Acute Pulmonary Embolism in Patients with COVID-19 at CT Angiography and Relationship to d-Dimer Levels. Radiology 296, E189-E191, doi:10.1148 / radiol.2020201561 (2020). 4 Middeldorp, S. et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost 18, 1995-2002, doi:10.1111 / jth.14888 (2020). 5 Poissy, J. et al. Pulmonary Embolism in Patients With COVID-19: Awareness of an Increased Prevalence. Circulation 142, 184-186, doi:10.1161 / CIRCULATIONAHA.120.047430 (2020). 6 Corrigan, D., Prucnal, C. & Kabrhel, C. Pulmonary embolism: the diagnosis, risk-stratification, treatment and disposition of emergency department patients. Clin Exp Emerg Med 3, 117-125, doi:10.15441 / ceem.16.146 (2016). 7 Lim, W. et al. Failure of anticoagulant thromboprophylaxis: risk factors in medical-surgical critically ill patients*. Crit Care Med 43, 401-410, doi:10.1097 / CCM.0000000000000713 (2015). 8 Ackermann, M. et al. Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19. N Engl J Med 383, 120-128, doi:10.1056 / NEJMoa2015432 (2020). 9 Lang, M. et al. Hypoxaemia related to COVID-19: vascular and perfusion abnormalities on dual-energy CT. Lancet Infect Dis 20, 1365-1366, doi:10.1016 / S1473-3099(20)30367-4 (2020). 10 Bernard, G. R. et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344, 699-709, doi:10.1056 / NEJM200103083441001 (2001). 11 Nadel, S. et al. Drotrecogin alfa (activated) in children with severe sepsis: a multicentre phase III randomised controlled trial. Lancet 369, 836-843, doi:10.1016 / S0140-6736(07)60411-5 (2007). 12 Abraham, E. et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med 353, 1332-1341, doi:10.1056 / NEJMoa050935 (2005). 13 WO 2020 / 049189 A1 (OANATPHARMA GMBH [DE]) 12 March 2020 14 ANG HAN-YAN ET AL: "Platelet CFTR inhibition enhances arterial thrombosis via increasing intracellular Cl- concentration and activation of SGK1 signaling pathway", ACTA PHARMACOLOGICA SINICA, 3 March 2022 (2022-03-03), pages 1-13, XP55943709. 15 WO 2022 / 026863 A2 (UNIV EMORY [US]; CHILDRENS HEALTHCARE ATLANTA INC [US]) 3 February 2022 16. Group RC. Aspirin in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet 2022: 399(10320): 143-151. 13. Berger JS, Kornblith LZ, Gong MN, Reynolds HR, Cushman M, Cheng Y, McVerry BJ, Kim KS, Lopes RD, Atassi B, Berry S, Bochicchio G, de Oliveira Antunes M, Farkouh ME, Greenstein Y, Hade EM, Hudock K, Hyzy R, Khatri P, Kindzelski A, Kirwan BA. 17 Baumann Kreuziger L, Lawler PR, Leifer E, Lopez-Sendon M 402 oreno J, Lopez-Sendon J, Luther JF, Nigro Maia L, Quigley J, Sherwin R, Wahid L, Wilson J, Hochman JS, Neal MD, Investigators AC-a. Effect of P2Y12 Inhibitors on Survival Free of Organ Support Among Non-Critically Ill Hospitalized Patients With COVID-19: A Randomized Clinical Trial. JAMA 2022: 327(3): 227-236.

[0320] Drawing translation Figure 1A WHO clinical progression scale WHO clinical progression scale COVID-19+ hospitalization ECMO ventilation or vasopressors ventilation artificial respiration Oxygen by NIV or high flow No oxygen or oxygen by mask SARS-CoV-2 negative SARS-CoV-2 negative Severe Thrombotic events Mechanical ventilation moderate healthy health Figure 1B platelets platelets healthy health moderate Severe Figure 1C platelets platelets vehicle Ivacaftor Forskolin Figure 1D healthy health Severe ratio 390 nm / 495 nm 390 nm / 495 nm ratio time[sec.] time[sec.] vehicle Ivacaftor Forskolin Figure 1E healthy health Severe vehicle Ivacaftor Forskolin Figure 2A healthy health moderate Severe vehicle Ivacaftor Forskolin Figure 2B Severe vehicle unstimulated Ivacaftor Forskolin Figure 2C CD42b+area CD42b+area healthy health moderate Severe vehicle Ivacaftor Forskolin Figure 2D CF+COVID-19 cohort relative risk Ventilation Death death untreated Ivacaftor, Lumacaftor, or Tezacaftor Figure 3 risk Ventilation Death death Atherosclerosis Carotid heart disease Coronary artery disease Aneurysms Chronic kidney disease Deep vein thrombosis Heart attack Peripheral heart disease Pulmonary embolism Stroke untreated ivacaftor, lumacaftor, tezacaftor or elexacaftor Figure 4A untreated CF cohort CFTR-modulator CFTR-modulator risk Ventilation Death death Atherosclerosis Coronary artery disease Stroke Chronic kidney disease Figure 4B untreated CF cohort CFTR-modulator CFTR-modulator risk Ventilation Death death Atherosclerosis Coronary artery disease Stroke Chronic kidney disease Figure 5A β-actin healthy health Mild Severe C-Band (glycolysated) B-Band (unglycolysated) Figure 5B Fold change normalized to β-actin B-Band C-Band healthy health Mild Severe

Claims

1. A pharmaceutical product comprising a cystic fibrosis membrane conductance regulator (CFTR) modulator for use in the treatment and / or prevention of medical conditions, including thrombosis, in human subjects.

2. The pharmaceutical product according to claim 1, wherein the aforementioned medical condition includes platelet-mediated coagulation disorders such as embolism and / or hypercoagulation / thrombosis.

3. The pharmaceutical product according to claim 1, wherein the subject receiving treatment is suffering from a thrombotic event and / or a thromboembolic event.

4. The pharmaceutical product according to claim 1, wherein the aforementioned medical condition is related to a human pathogenic infection.

5. The pharmaceutical product according to claim 4, wherein the infectious disease is a respiratory viral infection.

6. The pharmaceutical product according to claim 5, wherein the respiratory viral infection is SARS coronavirus infection.

7. A pharmaceutical product comprising a cystic fibrosis membrane conductance regulator (CFTR) modulator used for the treatment and / or prevention of medical conditions including atherosclerosis and pathological platelet activation.

8. The pharmaceutical product according to claim 7, wherein the aforementioned medical condition is selected from the group consisting of coronary artery disease, myocardial infarction, angina pectoris, stroke, transient ischemic attack, and peripheral artery disease.

9. The pharmaceutical product according to claim 1 or 7, wherein the aforementioned medical condition includes platelet-mediated vascular disease.

10. The pharmaceutical product according to claim 1 or 7, wherein the medical condition includes pathological platelet activation, adhesion and / or aggregation.

11. The pharmaceutical product according to claim 1 or 7, administered to subjects who do not have cystic fibrosis.

12. The pharmaceutical product according to claim 1 or 7, which is administered to subjects who also suffer from cystic fibrosis.

13. The pharmaceutical product according to claim 1 or 7, wherein the CFTR modulator is a CFTR activator, a CFTR enhancer, a CFTR corrector, or a CFTR amplification factor.

14. The pharmaceutical product according to claim 1 or 7, wherein the CFTR modulator is selected from the group consisting of ibacaftol, lumacaftol, tezacaftol, and elexacafutol.

15. The pharmaceutical product according to claim 14, wherein the CFTR modulator is ibakhtol.

16. The pharmaceutical product according to claim 1 or 7, comprising treatment of a medical condition including thrombosis in a subject suffering from SARS coronavirus infection, wherein the CFTR modulator is ibacaftol.

17. The pharmaceutical product according to claim 16, comprising treatment of a medical condition including thrombosis in a subject suffering from SARS-CoV-2 infection, wherein the CFTR modulator is ibacaftol.

18. The dosage and frequency of the CFTR modulator are as follows: (a) 2 mg / day to 2000 mg / day, and / or (b) 2 to 4 times per day, A pharmaceutical product according to claim 1 or 7, comprising:

19. The dosage and frequency of the CFTR modulator are (c) Dosage of 100 mg / day to 200 mg / day for human subjects weighing up to 30 kg, or 200 mg / day to 400 mg / day for human subjects weighing more than 30 kg, and (d) Frequency twice daily, route of oral administration, dose of 50 mg to 100 mg per dose for human subjects weighing up to 30 kg, or dose of 100 mg to 200 mg per dose for human subjects weighing more than 30 kg. A pharmaceutical product according to claim 1 or 7, comprising:

20. The pharmacopoeia according to claim 1 or 7, wherein the administration, dosage, and / or frequency of the CFTR modulator is configured to reduce calcium influx into target cells in order to reduce pathological platelet activation, adhesion, and / or aggregation, and / or to reduce the level of platelet activation to or below the level present before the treatment.

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