Methods and compositions for treating glucocorticoid excess

Abstract

The present disclosure provides a method of treatment for glucocorticoid excess in a patient in need thereof, comprising administering to the patient a pseudoirreversible HSD-1 inhibitor.

Description

[Technical field]

[0001] This application claims the benefit of priority to U.S. Provisional Patent Application No. 63 / 364,759, filed May 16, 2022, the disclosure of which is incorporated by reference herein as if set forth in its entirety. [Background technology]

[0002] Glucocorticoids (GCs) are corticosteroids that bind to the glucocorticoid receptor (GR), which is present on many cell types in the human body. In addition, GCs also bind to the mineralocorticoid receptor (MR) and non-genomic receptors. GCs are involved in cardiovascular, metabolic, immune, bone, muscle, dermatological, ocular, psychiatric, cognitive, circadian, and homeostatic functions. GC excess in humans can cause a variety of symptoms and diseases.

[0003] GCs can be endogenous (natural) or synthetic. Cortisol is the key endogenous glucocorticoid. Natural GCs include others that are active (e.g., corticosterone) and others that are considered inactive if they do not activate the GR or MR (e.g., cortisone). Synthetic glucocorticoids include prednisone, prednisolone, methylprednisolone, dexamethasone, and their derivatives, among many others. Both cortisol (typically as the drug known as hydrocortisone) and synthetic GCs are used as drugs to treat autoimmune diseases and other conditions.

[0004] There are three major known forms of GC excess in humans: (1) excess of the native GC cortisol due to ACTH- or CRH-secreting tumors, including Cushing's disease (pituitary adenomas), ectopic ACTH secretion, and ectopic CRH secretion; (2) excess of cortisol due to cortisol-secreting tumors, including autonomous cortisol secretion [ACS; also known as mild autonomous cortisol secretion (MACS) or mild autonomous cortisol excess (MACE)] and adrenal Cushing's syndrome; (3) excess of hydrocortisone or synthetic GCs during administration for the treatment of autoimmune or other disorders or to prevent transplanted organ rejection. Summary of the Invention [Means for solving the problem]

[0005] HSD-1 is an intracellular enzyme that converts GC from inactive (e.g., cortisone, prednisone) to active (e.g., cortisol, prednisolone) forms. It is believed to be the major source of intracellular cortisol and the major source of intracellularly synthesized GC in many cell types. Excess intracellular GC activates GR and MR along with non-genomic receptors, resulting in tissue-specific morbidity observed in subjects with GC excess. Thus, HSD-1 inhibition may ameliorate those conditions. This disclosure describes an important type of HSD-1 inhibitor, the pseudo-irreversible HSD-1 inhibitor.

[0006] A method of treatment for glucocorticoid excess in a patient in need thereof is provided, comprising administering to the patient a pseudoirreversible HSD-1 inhibitor.

[0007] Also provided is a method for ameliorating, preventing or reversing symptoms of glucocorticoid excess in a patient in need thereof, comprising administering to the patient a pseudoirreversible HSD-1 inhibitor.

[0008] Also provided is a method of reducing urinary tetrahydrocortisol levels in a patient with glucocorticoid excess, comprising administering a pseudoirreversible HSD-1 inhibitor to the patient, wherein the urinary tetrahydrocortisol levels are elevated compared to an asymptomatic patient.

[0009] These and other aspects of the present invention will become apparent upon reference to the following detailed description. To this end, various references are set forth herein which describe in more detail certain background information, procedures, compounds, and / or compositions, each of which is incorporated herein by reference in its entirety. [Brief description of the drawings]

[0010] BRIEF DESCRIPTION OF THE DRAWINGS [Figure 1] Figure 1 shows adipose HSD-1 inhibition by SP1-62. Adipose HSD-1 inhibition was detectable 2-4 hours after a single dose, reached maximum measurable levels during the second dosing interval, and was nearly identical during the second and 14th dosing intervals. [Diagram 2] Figure 1 shows hepatic HSD-1 inhibition by SPI-62 (formerly ASP3662). Data shown is the unitless ratio of urinary tetrahydrocortisol to tetrahydrocortisone, a standard measure of hepatic HSD-1 activity. The final daily dose of SPI-62 was administered on day 14. Follow-up visit was approximately day 28. [Diagram 3] FIG. 1 shows brain HSD-1 inhibition by SPI-62. Data shown are magnetic resonance (left) and positron emission (center, right) imaging of the same individual before (left, center) and after (right) a single SPI-62 dose. [Figure 4] Urinary HSD-1 ratios are shown for doses of 3 mg, 6 mg, 10 mg, 30 mg, and 60 mg. Urinary HSD-1 ratios in urine collections were measured at 0-6 hours (○), 6-12 hours (◇), 12-24 hours (+), 24-48 hours (●), and 48-72 hours (

number

[0023] Figure 1 shows food intake and body weight statistics for mice receiving corticosterone (CORT) in drinking water and SPI-62 by gavage or vehicle for 5 weeks. Food intake was measured twice weekly; weekly averages are shown. Body weight was measured daily; averages are shown. [Figure 14] Figure 1 shows a target-mediated pharmacokinetic (TMDD) pharmacokinetic-pharmacodynamic (PK / PD) model for SPI-62, including inhibition of adipose HSD-1 as an effect. AS2570469 is the major metabolite of SPI-62, formed by conversion of the amide to a carboxylic acid. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0011] Detailed Description of the Disclosure overview Methods are provided for treating patients with glucocorticoid (GC) excess by administering a pseudoirreversible inhibitor of 11β-hydroxysteroid dehydrogenase type 1 (HSD-1) to the patient. Methods are also provided for improving or preventing certain symptoms of patients with GC excess by administering a pseudoirreversible HSD-1 inhibitor. Methods are also provided for reducing urinary tetrahydrocortisol levels in patients with glucocorticoid excess, comprising administering a pseudoirreversible HSD-1 inhibitor to the patient, wherein the urinary tetrahydrocortisol levels are elevated compared to asymptomatic patients. Methods are also provided for treating or improving certain symptoms of patients with GC excess by co-administration of a pseudoirreversible HSD-1 inhibitor with a GC drug.

[0012] In some embodiments, glucocorticoid excess refers to a pathological or physiological state in an individual where the level of urinary tetrahydrocortisol or other products of glucocorticoid breakdown is elevated relative to a reference patient or sample, or relative to a patient not experiencing glucocorticoid excess. In some embodiments, symptoms of glucocorticoid excess include cardiovascular, metabolic, immunological, bone, muscular, dermatological, ophthalmic, psychiatric, cognitive, circadian, or homeostatic symptoms.

[0013] In some embodiments, the pseudo-irreversible HSD-1 inhibitor does not show tachyphylaxis to human adipose HSD-1 inhibition. In some embodiments, the HSD-1 inhibitor is selected from SPI-62 and BI-187004, or a pharmaceutically acceptable salt thereof. In some embodiments, the HSD-1 inhibitor is SPI-62, or a pharmaceutically acceptable salt thereof.

[0014] In some embodiments, the pseudo-irreversible HSD-1 inhibitor is characterized by human pharmacokinetics consistent with target-mediated pharmacokinetics. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62, ABT-384, MK-0736, MK-0916, BMS-823778, UE-2343, AMG-221, and BI-187004, or a pharmaceutically acceptable salt thereof.

[0015] In some embodiments, the plasma exposure of the pseudoirreversible HSD-1 inhibitor is less than dose-proportional after a single low dose and is dose-proportional after multiple low doses. In some embodiments, the dose is 10 mg or less, or 6 mg or less, or 4 mg or less.

[0016] In some embodiments, the pseudo-irreversible HSD-1 inhibitor is characterized by human pharmacodynamics consistent with target-mediated pharmacokinetics. In some embodiments, the pharmacodynamic half-life of the HSD-1 inhibitor for hepatic HSD-1 inhibition is extended compared to its pharmacokinetic half-life. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is characterized by a pharmacodynamic half-life for human hepatic HSD-1 inhibition of at least 1 week. In some embodiments, the pharmacodynamic half-life for human hepatic HSD-1 inhibition is at least 2 weeks. In some embodiments, the pharmacodynamic half-life for human hepatic HSD-1 inhibition is at least 4 weeks. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62 and ABT-384, or a pharmaceutically acceptable salt thereof.

[0017] In some embodiments, the pseudo-irreversible HSD-1 inhibitor is characterized by fast-on, slow-off in vitro binding kinetics to human HSD-1. In some embodiments, the residence time of the HSD-1 inhibitor is at least about 500 seconds. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62, ABT-384, KR-67607, UE-2343, and BI-187004, or a pharma- ceutically acceptable salt thereof.

[0018] In some embodiments, the pseudo-irreversible HSD-1 inhibitors are characterized by apparent fast-on, slow-off in vivo binding kinetics to human HSD-1. off is 0.3h -1 In some embodiments, the model estimated k off is 1.0h -1 In some embodiments, the model estimated k off is 3.0h -1 In some embodiments, the pseudoirreversible HSD-1 inhibitor is selected from SPI-62 and ABT-384, or a pharma- ceutically acceptable salt thereof.

[0019] In some embodiments, pseudo-irreversible HSD-1 inhibitors are characterized by having greater potency in vivo than in vitro. In some embodiments, the K estimated in a model of the HSD-1 inhibitor is d is an HSD-1 inhibitor K i In some embodiments, the model-estimated K d is K i In some embodiments, the model-estimated K d That K i In some embodiments, the model-estimated K d is K i In some embodiments, the model-estimated fat IC of an HSD-1 inhibitor is at least 200-fold lower.50 is lower than that of HSD-1 inhibitors measured in vitro. In some embodiments, the model-estimated fat IC 50 is at least 100-fold lower than when measured in vitro. In some embodiments, the model-estimated fat IC 50 is at least 300-fold lower than when measured in vitro. In some embodiments, the model-estimated fat IC 50 is at least 700-fold lower than when measured in vitro. In some embodiments, the pseudo-irreversible inhibitor is SPI-62, or a pharma- ceutically acceptable salt thereof.

[0020] In some embodiments, the pseudo-irreversible HSD-1 inhibitor forms a hydrogen bond with the pyrophosphate of NADPH in the human HSD-1 active site. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62, ABT-384, KR-67607, SAR-184481, Compound A, and Compound B, or a pharma- ceutically acceptable salt thereof.

[0021] In some embodiments, the pseudo-irreversible HSD-1 inhibitor forms an aromatic stacking interaction with NADPH in the human HSD-1 active site. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from BMS-823778, MK-0916, Compound C, and Compound D, or a pharma- ceutically acceptable salt thereof.

[0022] Also provided is a method for ameliorating or preventing symptoms of glucocorticoid excess in a patient in need thereof, comprising administering to the patient a brain-penetrating pseudo-irreversible HSD-1 inhibitor. In one embodiment, the symptoms include psychiatric (e.g., mood), cognitive, or circadian (e.g., sleep) symptoms. In some embodiments, the psychiatric symptoms are selected from depression, anxiety, hypomania, mania, and psychosis; or the cognitive symptoms are selected from impairments in memory, visuospatial processing, reasoning, verbal learning, and verbal performance; or the circadian symptoms are selected from insomnia, daytime fatigue, sleep apnea, fragmented sleep, increased nocturnal motor activity, and abnormal REM sleep.

[0023] In some embodiments, the methods described herein further comprise administering to the patient a glucocorticoid drug. In some embodiments, the HSD-1 inhibitor is administered in a fixed dose combination with the glucocorticoid drug. In some embodiments, the HSD-1 inhibitor and the glucocorticoid drug are co-packaged for separate administration. In some embodiments, the HSD-1 inhibitor is administered and packaged separately from the glucocorticoid drug. In some embodiments, the glucocorticoid drug is selected from prednisolone, methylprednisolone, dexamethasone, hydrocortisone, budesonide, deflazacort, beclomethasone, ciclesonide, fluticasone, mometasone, triamcinolone, flunisolide, clobetasol, betamethasone, fluocinonide, flurandrenolide, clocortolone, halobetasol, desoximetasone, desonide, halcinonide, prednicarbate, diflorasone, amcinonide, alclometasone, difluprednate, loteprednol, fluorometholone, rimexolone, and medrysone, or a pharma- ceutically acceptable salt or ester derivative thereof.

[0024] In some embodiments, the patient has an ACTH or CRH secreting tumor, hi some embodiments, the patient has a cortisol secreting tumor.

[0025] In another embodiment, the pseudoirreversible HSD-1 inhibitor is administered orally. In another embodiment, the pseudoirreversible HSD-1 inhibitor is administered intravenously. In another embodiment, the pseudoirreversible HSD-1 inhibitor is administered intramuscularly or subcutaneously. In another embodiment, the pseudoirreversible HSD-1 inhibitor is administered by inhalation or intranasally. In another embodiment, the pseudoirreversible HSD-1 inhibitor is administered intraocularly. In another embodiment, the pseudoirreversible HSD-1 inhibitor is administered topically.

[0026] This disclosure describes an important type of HSD-1 inhibitor, pseudo-irreversible HSD-1 inhibitors, which show previously unknown advantages for two members of its subclass, BI-187004 and SPI-62. Unlike certain other HSD-1 inhibitors (e.g., AZD4017, AZD8329, BI-135585), BI-187004 shows limited, and SPI-62 does not, tachyphylaxis of human adipose HSD-1 inhibition with multiple doses. Since adipose HSD-1 controls the significant cardiometabolic morbidity of GC excess, inhibitors that do not lose adipose HSD-1 can be expected to have clinical advantages over other HSD-1 inhibitors for the treatment of GC excess. Durable human adipose HSD-1 inhibition was believed to be a shared feature of pseudo-irreversible inhibitors, defined as HSD-1 inhibitors that exhibit one or more of the following four properties:

[0027] (1) Clinical pharmacokinetics is consistent with target-mediated pharmacokinetics (TMDD). After a single low dose, the majority of the administered dose is rapidly sequestered by the target, resulting in only a small fraction of drug molecules entering the central circulation. As a result, drug plasma concentrations are much lower than for drugs with linear kinetics. At higher single doses, less capable targets are rapidly saturated. The fraction of the dose that is sequestered by the target decreases inversely with dose. As a result, the drug appears to have linear pharmacokinetics at a single high dose, since the fraction captured by the target is minimal compared to the total dose. The significant nonlinear pharmacokinetics observed after an initial low dose changes to linear pharmacokinetics after repeated low doses.

[0028] (2) Clinical pharmacodynamics are consistent with TMDD. Target association early after low doses can be detected even before plasma levels are detectable. Over a wide dose range, target association may appear to be concentration-independent; high target association may be associated with low plasma levels. Pharmacological half-life may be significantly extended if the drug remains bound to the target in the microenvironment, even after plasma levels have fallen below detection limits.

[0029] (3) Enzyme residence time (k d -1 ) is longer than other HSD-1 inhibitors. This is due to the association constant (k on ) with a dissociation constant (k off ), which can be demonstrated via population PK modeling of clinical trial data. d , i.e., k on k for off The ratio of the measured K i As a result of fast-on, slow-off binding, the concentration that produces 50% of maximal HSD-1 inhibition in vivo (IC 50 ) is the IC measured in vitro 50 substantially lower, which can be shown via population PK-PD modeling of the clinical trial data.

[0030] (4) When bound to human HSD-1, it forms a non-covalent ternary complex with the enzyme and the cofactor NADPH, which is the structural basis for the slow-off binding and TMDD behavior. The binding energies of both the inhibitor and NADPH must be overcome for the inhibitor to dissociate from the enzyme. The ternary complex is also resistant to competition by HSD-1 substrates, which is particularly important in GC excess when circulating levels of the substrate increase. In some embodiments, hydrogen bonding and aromatic stacking interactions are distinct modes by which the HSD-1 inhibitors link or complex with NADPH in the active site.

[0031] Cortisol and Cortisone Cortisol is a glucocorticoid hormone produced and released by the adrenal glands. Less than 6% of circulating cortisol is bioavailable to tissues because it is extensively bound to corticosteroid-binding globulin and albumin. Circulating cortisone is substantially more bioavailable to tissues because it has only 12% the affinity of cortisol for corticosteroid-binding globulin. Elevated levels of glucocorticoids can cause insulin resistance by reducing insulin-dependent glucose uptake, enhancing hepatic gluconeogenesis, and inhibiting insulin secretion from pancreatic cells. Patients with persistent glucocorticoid excess can develop dyslipidemia, visceral obesity, and other metabolic syndromes. Other physiological symptoms can include elongated arms and legs, a flushed, rounded face, high blood pressure, osteoporosis, dermatological changes such as bruising and purple stretch marks, muscle weakness, and rapid weight gain, primarily in the face, chest, and abdomen, distinct from mood swings that manifest as anxiety, depression, or irritability.

[0032] It has been observed that administration of pseudo-irreversible HSD-1 inhibitors increases cortisone levels. For example, hepatic cortisone levels were substantially increased after both single and multiple doses of SPI-62, as evidenced by an increase in urinary tetrahydrocortisone, an excreted cortisone metabolite. In healthy adults (n=40) receiving a single dose of 10, 20, or 50 mg of SPI-62, the least squares mean (standard error) of tetrahydrocortisone was 32.71 (1.149) μmol compared to 9.19 (2.300) μmol after a single dose of matching placebo (n=10). In the same subjects after a 14-day dose, tetrahydrocortisone was 42.73 (1.968) μmol for SPI-62 and 8.51 (0.410) μmol for placebo. Similar results were also observed in elderly adults. Previous studies have also shown that administration of ABT-384 for 7-21 days to healthy adult and elderly subjects substantially increased hepatic cortisone levels, as evidenced by increases in urinary tetrahydrocortisone. In patients with painful diabetic peripheral neuropathy receiving 10 mg of SPI-62 for 6 weeks, circulating cortisone levels were substantially increased, while serum cortisol was unchanged. For example, on the last day of study drug administration, serum cortisone was 56.0 (2.37) nM for SPI-62 (n=36) and 38.8 (2.16) nM for placebo (n=36). Furthermore, after 2 weeks, serum cortisone was 49.5 (1.75) nM for SPI-62 and 38.7 (1.70) nM for placebo. Similar results for cortisone were not obtained in healthy adults.

[0033] Urinary tetrahydrocortisol In some embodiments, a pseudo-irreversible HSD-1 inhibitor can be administered to a patient to reduce the level of urinary tetrahydrocortisol in the patient. The major route of excretion of cortisol is through urinary metabolites. The sum of these metabolites best represents the entire glandular output of cortisol for the day. Cortisol is excreted primarily as 5-alpha-tetrahydrocortisol (5α-THF) and 5-beta-tetrahydrocortisol (5β-THF), as well as tetrahydrocortisone (THE). Less abundant urinary metabolites include cortol and cortolone. A small percentage (1-3%) is excreted as cortisol and cortisone, which are themselves metabolites of cortisol. Measurement of urinary cortisol and urinary tetrahydrocortisol over a 24-hour period can be used to indicate the daily level of cortisol production in a patient. Also provided is a method of reducing urinary tetrahydrocortisol levels in a patient, the method comprising administering a pseudoirreversible HSD-1 inhibitor to the patient, wherein the urinary tetrahydrocortisol levels are elevated compared to an asymptomatic patient.

[0034] Compound structure of pseudo-irreversible HSD-1 inhibitor Some pseudo-irreversible HSD-1 inhibitors are known and available in the art, including, but not limited to, SPI-62, ABT-384, MK-0736, MK-0916, BMS-823778, UE-2343, AMG-221, KR-67607, BI-187004, SAR-184481, Compound A, Compound B, Compound C, Compound D, BMS-823778, or a pharma- ceutically acceptable salt thereof. As will be understood by one of skill in the art, any pseudo-irreversible HSD-1 inhibitor described herein or known or available in the art may be used as described herein and is encompassed within the scope of the present disclosure.

[0035] The structures of some of the pseudoirreversible HSD-1 inhibitors described herein are set forth below. All structures and IUPAC names were generated using ChemDraw 20.0.

[0036] As used herein, "SPI-62" refers to 4-(5-(2-(4-chloro-2,6-difluorophenoxy)propan-2-yl)-4-methyl-4H-1,2,4-triazol-3-yl)-3-fluorobenzamide. [ka]

[0037] As used herein, "BMS-823778" refers to 2-(3-(l-(4-chlorophenyl)cyclopropyl)-[1,2,4]triazolo[4,3-a]pyridin-8-yl)propan-2-ol. [ka]

[0038] As used herein, "ABT-384" refers to (1s,3R,4r,5S,7s)-4-(2-methyl-2-(4-(5-(trifluoromethyl)pyridin-2-yl)piperazin-1-yl)propanamide)adamantane-1-carboxamide. [ka]

[0039] As used herein, "UE-2343" refers to (5-(1H-pyrazol-4-yl)thiophen-3-yl)((1R,3r,5S)-3-hydroxy-3-(pyrimidin-2-yl)-8-azabicyclo[3.2.1]octan-8-yl)methanone. [ka]

[0040] As used herein, "MK-0736" refers to 3-(4-(3-(ethylsulfonyl)propyl)bicyclo[2.2.2]octan-1-yl)-4-methyl-5-(2-(trifluoromethyl)phenyl)-4H-1,2,4-triazole. [ka]

[0041] As used herein, "AMG-221" refers to (S,E)-2-(((lS,2S,4R)-bicyclo[2.2.1]heptan-2-yl)imino)-5-isopropyl-5-methylthiazolidin-4-one. [ka]

[0042] As used herein, "MK-0916" refers to 3-((1s,3s)-l-(4-chlorophenyl)-3-fluorocyclobutyl)-4,5-dicyclopropyl-4H-1,2,4-triazole. [ka]

[0043] As used herein, "KR-67607" refers to (1s,3R,4s,5S,7s)-4-(2-(6-(2,6-dichloro-4-(trifluoromethyl)phenyl)-4-methyl-1,1-dioxide-1,2,6-thiadiazinan-2-yl)acetamide)adamantane-1-carboxamide. [ka]

[0044] As used herein, "BI-187004" refers to (4aR,9aS)-1-(1H-benzo[d]imidazole-6-carbonyl)-2,3,4,4a,9,9a-hexahydro-1H-indeno[2,1-b]pyridine-6-carbonitrile. [ka]

[0045] As used herein, "AZD4017" refers to (S)-2-(l-(5-(cyclohexylcarbamoyl)-6-(propylthio)pyridin-2-yl)piperidin-3-yl)acetic acid. [ka]

[0046] As used herein, "AZD8329" refers to 4-(4-(((lr,3r,5r,7r)-adamantan-2-yl)carbamoyl)-5-(tert-butyl)-1H-pyrazol-1-yl)benzoic acid. [ka]

[0047] As used herein, "BI-135585" refers to (S)-6-(2-hydroxy-2-methylpropyl)-3-((S)-1-(4-(l-methyl-2-oxo-1,2-dihydropyridin-4-yl)phenyl)ethyl)-6-phenyl-1,3-oxazinan-2-one. [ka]

[0048] As used herein, "SAR-184841" refers to 4-(5-(4-(tert-butyl)piperazin-l-yl)pyridin-2-yl)-N-((lR,3S,5s,7s)-5-carbamoyladamantan-2-yl)-3,4-dihydroquinoxaline-1(2H)-carboxamide. [ka]

[0049] As used herein, "Compound A" refers to (1s,3R,5S,7s)-4-(2-(4-methoxyphenoxy)-2-methylpropanamido)adamantane-1-carboxamide. [ka]

[0050] As used herein, "Compound B" refers to 3,4-dihydroquinolin-l(2H)-yl[4-(lH-imidazol-5-yl)piperidin-1-yl]methanone. [ka]

[0051] As used herein, "Compound C" refers to (5R)-2-[(2-fluorophenyl)amino]-5-(1-methylethyl)-1,3-thiazol-4(5H)-one. [ka]

[0052] As used herein, "Compound D" refers to 3-(2-fluoroethyl)-4-((4-[(2S)-1,1,1-trifluoro-2-hydroxypropan-2-yl]phenyl)sulfonyl)benzonitrile. [ka]

[0053] Symptoms of glucocorticoid excess Also provided is a method for treating or improving certain symptoms of patients with GC excess by administering pseudo-irreversible HSD-1 inhibitors.The symptoms of GC excess may vary from individual to individual, but common symptom domains may include, but are not limited to, cardiovascular, metabolic, immune, bone, muscle, dermatological, ophthalmic, mental, cognitive, circadian, and homeostasis.In some embodiments, brain-penetrating pseudo-irreversible HSD-1 inhibitors may be used to treat mood, cognition, and sleep-related symptoms.

[0054] In some embodiments, specific symptoms associated with GC excess may include, but are not limited to, weight gain and fatty tissue deposits around the midsection and upper back, face, and between the shoulders, pink or purple stretch marks on the skin of the abdomen, thighs, breasts, and arms, thin, fragile skin that bruises easily, fatigue, frequent illness, bruising and slow wound healing, weak bones, muscle weakness, high blood sugar, anxiety and depression, sleep problems, and difficulty concentrating, in some embodiments, prolonged high cortisol levels may lead to heart disease, osteoporosis, diabetes, and poor mental health.

[0055] In some embodiments, cardiovascular conditions associated with GC excess can include, but are not limited to, hypertension (including lack of nocturnal blood pressure dip), atherosclerosis, endothelial dysfunction, thrombotic conditions, coronary artery disease, heart failure, and stroke.

[0056] In some embodiments, metabolic conditions associated with GC excess can include, but are not limited to, obesity, glucose intolerance, insulin resistance, diabetes, and dyslipidemia (including hypercholesterolemia and hypertriglyceridemia).

[0057] In some embodiments, immunological conditions associated with GC excess can include, but are not limited to, infections (including opportunistic infections) and sepsis.

[0058] In some embodiments, bone conditions associated with GC excess can include, but are not limited to, osteoporosis, osteonecrosis, osteopenia, hypocalcemia (through decreased absorption or increased renal clearance or effects on vitamin D and PTH), impaired linear bone growth (height), and fractures (including low-impact or compression fractures).

[0059] In some embodiments, muscle symptoms associated with GC excess can include, but are not limited to, muscle atrophy and weakness.

[0060] In some embodiments, dermatological symptoms associated with GC excess can include, but are not limited to, impaired wound healing, thin or fragile skin, abnormal accumulation of subcutaneous fat, polycythemia, violet streaks, acanthosis nigricans, hyperpigmentation, and easy bruising.

[0061] In some embodiments, ocular conditions associated with GC excess can include, but are not limited to, increased intraocular pressure, glaucoma, exophthalmos, and cataracts.

[0062] In some embodiments, psychiatric symptoms associated with GC excess can include, but are not limited to, depression, anxiety, hypomania, mania, and psychosis.

[0063] In some embodiments, cognitive symptoms associated with GC excess can include, but are not limited to, impairments in memory, visuospatial processing, reasoning, verbal learning, and language performance.

[0064] In some embodiments, circadian symptoms associated with GC excess can include, but are not limited to, insomnia, daytime fatigue, sleep apnea, fragmented sleep, increased nocturnal motor activity, and abnormal REM sleep.

[0065] In some embodiments, homeostatic conditions associated with GC excess can include, but are not limited to, hypokalemia, hypernatremia, hypophosphatemia, hypercalciuria, growth hormone suppression, and thyroid disease (including hypothyroidism and hyperthyroidism).

[0066] Absence of Adipose Tachyphylaxis Also provided is a method for treating or ameliorating glucocorticoid excess or symptoms thereof in a patient by administration of a pseudo-irreversible HSD-1 inhibitor that does not show tachyphylaxis to human adipose HSD-1 inhibition. Competition with increased levels of HSD-1 substrates (inactive GCs) can cause adipose tachyphylaxis. GCs, whether active or inactive, are highly lipophilic and therefore accumulation of GCs would be expected in tissues of patients receiving HSD-1 inhibitors, particularly those with GC excess, and also in adipose tissue in particular, as described herein.

[0067] In some embodiments, the pseudo-irreversible HSD-1 inhibitor useful for the present disclosure may be any pseudo-irreversible HSD-1 inhibitor known or available in the art. Some exemplary pseudo-irreversible HSD-1 inhibitors include, but are not limited to, SPI-62, ABT-384, MK-0736, MK-0916, BMS-823778, UE-2343, AMG-221, KR-67607, BI-187004, SAR-184481, Compound A, Compound B, Compound C, Compound D, or a pharma- ceutically acceptable salt thereof. Those skilled in the art will understand that other pseudo-irreversible HSD-1 inhibitors may be used without departing from the scope of the present disclosure. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62, ABT-384, KR-67607, SAR-184481, Compound A, and Compound B, or a pharma- ceutically acceptable salt thereof. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from BMS-823778, MK-0916, Compound C, and Compound D, or a pharma- ceutically acceptable salt thereof. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62, ABT-384, MK-0736, MK-0916, BMS-823778, UE-2343, and AMG-221, or a pharma- ceutically acceptable salt thereof. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62, ABT-384, KR-67607, UE-2343, and BI-187004, or a pharma- ceutically acceptable salt thereof. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is selected from SPI-62 and ABT-384, or a pharma- ceutically acceptable salt thereof. In some embodiments, the pseudo-irreversible HSD-1 inhibitor is SPI-62, or a pharma- ceutically acceptable salt thereof.

[0068] In some embodiments, the pseudo-irreversible HSD-1 inhibitors described herein are administered to a patient or subject with elevated levels of glucocorticoids or urinary tetrahydrocortisol to reduce the levels of glucocorticoids or urinary tetrahydrocortisol in the patient or subject. In some embodiments, administration of the pseudo-irreversible HSD-1 inhibitor may be stopped or interrupted once the symptoms in the patient are reduced or eliminated, and may be resumed as needed if deemed appropriate by the clinician or physician. In some embodiments, the present disclosure provides chronic treatment of patients administered pseudo-irreversible HSD-1 inhibitors for chronic GC excess conditions without stopping or interrupting. In some embodiments, pseudo-irreversible inhibitors offer the advantage of retaining efficacy during short drug withdrawals (e.g., patients neglect to take their drug for days or even weeks).

[0069] In some embodiments, the dose of the pseudo-irreversible HSD-1 inhibitor described herein may be any dose deemed appropriate by the practitioner or clinician. In some embodiments, the pseudo-irreversible inhibitor is administered at a molar dose sufficient to occupy all of the HSD-1 in the body. In some embodiments, the pseudo-irreversible HSD-1 inhibitor achieves and maintains full target association at low doses. In some embodiments, the pseudo-irreversible HSD-1 inhibitor achieves and maintains full target association at sub-milligram doses.

[0070] In some embodiments, the pseudoirreversible HSD-1 inhibitor is administered in a single dose of about 1 mg to about 40 mg, e.g., 1 mg, 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 11 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg, 20 mg, 21 mg, 22 mg, 23 mg, 24 mg, 25 mg, 26 mg, 27 mg, 28 mg, 29 mg, 30 mg, 31 mg, 32 mg, 33 mg, 34 mg, 35 mg, 36 mg, 37 mg, 38 mg, 39 mg, 40 mg, etc. In some embodiments, a submilligram dose may be any dose that is approximately equal to or less than 1 mg, such as 0.05 mg, 0.1 mg, 0.15 mg, 0.2 mg, 0.25 mg, 0.3 mg, 0.35 mg, 0.4 mg, 0.45 mg, 0.5 mg, 0.55 mg, 0.6 mg, 0.65 mg, 0.7 mg, 0.75 mg, 0.8 mg, 0.85 mg, 0.9 mg, 0.95 mg, or 1 mg. In some embodiments, a single dose of pseudo-irreversible HSD-1 inhibitor may be appropriate for patients with chronic GC excess as described herein. In some embodiments, a single dose of pseudo-irreversible inhibitor is administered intravenously.

[0071] In some embodiments, the pseudo-irreversible HSD-1 inhibitor may be administered in multiple doses over a certain period of time. Multiple doses may refer to multiple doses within one day, or alternatively, to a single dose per day over a period of time that is deemed appropriate by the clinician or practitioner.

[0072] In some embodiments, the dose range for SPI-62 is about 0.2 mg to about 6 mg once daily. In some embodiments, the dose of SPI-62, ABT-384, MK-0736 or MK-0916 is about 10 mg or less. In some embodiments, the dose of UE-2343 is about 10 mg to about 35 mg. In some embodiments, the dose of BI-187004 is about 20 mg to about 240 mg.

[0073] In some embodiments, the duration of administration of the pseudo-irreversible HSD-1 inhibitor may be any duration, including, but not limited to, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, 28 days, 29 days, 30 days, etc. The duration according to the present disclosure may be any duration, for example, a duration of 1 to 14 days, or 7 to 14 days, or 7 to 10 days, or 10 to 14 days. In other embodiments, the duration of administration of the HSD-1 inhibitor may be 7 to 30 days, or 7 to 21 days, etc. In some embodiments, the duration of administration of the pseudo-irreversible HSD-1 inhibitor may be 1 day, 6 days, or 12 days. In some embodiments, the pseudo-irreversible HSD-1 inhibitor may be administered to patients on a continuous basis to control chronic GC excess. In some embodiments, the administration of the dose of the pseudo-irreversible HSD-1 inhibitor may take 1 month, or 2 months, or 3 months, or 4 months, or 5 months, or 6 months, or 7 months, or 8 months, or 9 months, or 10 months, or 11 months, or 12 months, or 15 months, or 18 months, or 24 months, or 36 months, or 48 months, or more. In some embodiments, the pseudo-irreversible HSD-1 inhibitor may be administered intravenously in a single high dose, for example, to control sepsis or prevent the development of side effects of steroid use, for example, in diabetic patients.

[0074] As described herein, pseudo-irreversible HSD-1 inhibitors (1) should not exhibit lipid tachyphylaxis, (2) should exhibit TMDD PK and PD, (3) should exhibit fast-on, slow-off kinetics, and (4) should be linked to NADPH in the active site. However, only one of these characteristics is necessary to indicate that a molecule is a pseudo-irreversible HSD-1 inhibitor.

[0075] In some embodiments, the pseudo-irreversible HSD-1 inhibitors described herein (e.g., SPI-62, ABT-384, etc.) are characterized by human pharmacokinetics consistent with target-mediated pharmacokinetics as described herein.

[0076] In some embodiments, the pseudo-irreversible HSD-1 inhibitor has a long pharmacodynamic half-life for human liver HSD-1 inhibition. In some embodiments, the pharmacodynamic half-life of the HSD-1 inhibitor for liver HSD-1 inhibition is extended compared to its pharmacokinetic half-life. In some embodiments, the half-life for human liver HSD-1 inhibition is at least 1 week, or 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks, or 6 weeks, etc.

[0077] In some embodiments, pseudo-irreversible HSD-1 inhibitors exhibit fast-on, slow-off binding kinetics to human HSD-1. In some embodiments, the residence time is an indication of fast-on, slow-off binding kinetics for HSD-1 inhibitors. Pseudo-irreversible HSD-1 inhibitors can be identified via in vitro enzyme kinetics evaluation, and are expected to exhibit longer enzyme residence times compared to other HSD-1 inhibitors. In some embodiments, the HSD-1 inhibitors described herein exhibit residence times of at least about 500 seconds. As will be appreciated by those skilled in the art, residence time thresholds may vary with different buffers, NADPH concentrations, or enzyme concentrations.

[0078] In some embodiments, the initial dose of the pseudo-irreversible HSD-1 inhibitor first binds to its target in the tissue and remains bound to it. In some embodiments, up to about 3 mg of the pseudo-irreversible HSD-1 inhibitor is sequestered from the central circulation. In some embodiments, the pseudo-irreversible HSD-1 inhibitor exhibits non-linear pharmacokinetics after a single dose ranging from submilligram to low milligram range, and exhibits dose-proportional exposure after multiple doses. In some embodiments, the plasma exposure of the HSD-1 inhibitor is less than dose-proportional after a single low dose, and is dose-proportional after multiple low doses. In some embodiments, the dose is 10 mg or less, for example, 10 mg, or 9 mg, or 8 mg, or 7 mg, or 6 mg, or 5 mg, or 4 mg, or 3 mg, or 2 mg, or 1 mg, or less than 1 mg. In some embodiments, the dose is 6 mg or less, or 4 mg or less.

[0079] In some embodiments, the pharmacokinetics of a pseudo-irreversible HSD-1 inhibitor, e.g., SPI-62, is characterized by a two-compartment TMDD population pharmacokinetic model with three pass absorption compartments and an estimated target capacity of about 2.5-3.6 mg. In some embodiments, the pseudo-irreversible HSD-1 inhibitor has a K i Lower K d In some embodiments, the pseudo-irreversible HSD-1 inhibitor has a K i At least 10 times lower than d In some embodiments, the pseudo-irreversible HSD-1 inhibitor has a K i At least 60 times lower than d In some embodiments, the pseudo-irreversible HSD-1 inhibitor has an in vivo IC of hepatic HSD-1 that is at least 50-fold lower than that measured in vitro. 50 In some embodiments, the pseudo-irreversible HSD-1 inhibitor has an in vivo IC of hepatic HSD-1 that is about 200-fold lower than that measured in vitro. 50 In some embodiments, pseudo-irreversible HSD-1 inhibitors have a lower IC20 of HSD-1 estimated in vivo affinity than HSD-1 inhibitors measured in vitro. 50In some embodiments, the pseudo-irreversible HSD-1 inhibitor has an in vivo lipid IC that is at least 100-fold lower than that measured in vitro. 50 In some embodiments, the pseudo-irreversible HSD-1 inhibitor has an in vivo lipid IC that is about 700-fold lower than that measured in vitro. 50 has.

[0080] In some embodiments, the pseudoirreversible HSD-1 inhibitor may be co-administered with a glucocorticoid drug. In some embodiments, the pseudoirreversible HSD-1 inhibitor and the glucocorticoid drug are co-administered in a fixed dose combination, co-packaged, or formulated separately. As described herein, the glucocorticoid drug may be any glucocorticoid known or available in the art, including, for example, but not limited to, prednisolone, methylprednisolone, dexamethasone, hydrocortisone, budesonide, deflazacort, beclomethasone, ciclesonide, fluticasone, mometasone, triamcinolone, flunisolide, clobetasol, betamethasone, fluocinonide, flurandrenolide, clocortolone, halobetasol, desoximetasone, desonide, halcinonide, prednicarbate, diflorasone, amcinonide, alclometasone, difluprednate, loteprednol, fluoromethalone, rimexolone, and medrysone. Ester prodrugs of glucocorticoids (e.g., prednisolone acetate and prednisolone hemisuccinate), or pharma- ceutically acceptable salts thereof, administered to extend the duration of pharmacological effects, are also suitable and are encompassed within the scope of the present disclosure. In some embodiments, the particular glucocorticoid drug may be varied as deemed appropriate by the practitioner or clinician. In some embodiments, the glucocorticoid drug may not be prednisone or cortisone, which are inactive prodrugs that require HSD-1 for activation.

[0081] In some embodiments, the pseudo-irreversible HSD-1 inhibitors described herein may be administered by any route deemed appropriate by the practitioner or clinician. Suitable routes of administration include, but are not limited to, oral, intravenous, intramuscular, subcutaneous, inhalation, intranasal, intraocular, and topical.

[0082] definition The definitions and methods provided define the present disclosure and guide one of ordinary skill in the art in practicing the disclosure. Unless otherwise specified, terms are to be understood according to conventional usage by those of ordinary skill in the relevant art.

[0083] As used herein, "brain penetrant" refers to a drug or compound that crosses the blood-brain barrier. In some embodiments, brain penetrant pseudo-irreversible HSD-1 inhibitors are used to treat symptoms of glucocorticoid excess related to mood, cognition, and sleep.

[0084] As used herein, "glucocorticoid excess" refers to a pathological or physiological state in an individual when the level of an active glucocorticoid, e.g., cortisol or synthetic glucocorticoid, is elevated relative to a reference patient or sample, or relative to a patient not experiencing glucocorticoid excess.

[0085] As used herein, a "pseudo-irreversible HSD-1 inhibitor" refers to a compound, e.g., a small molecule compound, that binds to, interacts with, induces a conformational change in, or otherwise inhibits or eliminates the activity of HSD-1.

[0086] As used herein, "pseudo-irreversible inhibition" refers to hydrogen bonding or aromatic stacking interactions between HSD-1's NADPH cofactor and the inhibitor molecule, through which a ternary complex is formed that is more resistant (i.e., more strongly bound, not weaker) to dissociation compared to other HSD-1 inhibitors that form exclusively binary complexes with the enzyme.

[0087] As used herein, "tachyphylaxis" refers to a decreased response to successive doses of a drug, reducing the effectiveness of the drug. Tachyphylaxis refers to the manifestation of drug insensitivity.

[0088] As used herein, an "effective amount" of a compound refers to an amount that is sufficient to produce a desired response, e.g., to reduce or eliminate the signs or symptoms of a condition or disease. For example, as described herein, an effective amount may be the amount of pseudo-irreversible HSD-1 inhibitor required to treat glucocorticoid excess in a patient. An effective amount of a pseudo-irreversible HSD-1 inhibitor may be the amount required to improve or prevent symptoms of glucocorticoid excess in a patient, or to reduce the level of urinary tetrahydrocortisol in a patient. Generally, this amount will be sufficient to measurably reduce symptoms of glucocorticoid excess or to reduce the level of urinary tetrahydrocortisol in a patient. When administered to a subject, a dose is generally used that will achieve target tissue concentrations (e.g., in liver, adipose tissue, brain, bone, muscle, skin, eye) that have been shown to achieve acceptable levels of glucocorticoid or urinary tetrahydrocortisol, i.e., levels that do not cause symptoms of glucocorticoid excess in a patient. In some instances, an "effective amount" is one that treats one or more symptoms. In one instance, an effective amount is a therapeutically effective amount. In one instance, an effective amount is an amount that prevents or reverses one or more signs or symptoms of glucocorticoid excess.

[0089] As used herein, "reduce" or "reduced" refers to a decrease or lowering of the amount or level of, for example, one or more glucocorticoids or urinary tetrahydrocortisol in a patient relative to a reference sample or patient. As used herein, a decrease in the amount refers to lowering the level of a glucocorticoid or urinary tetrahydrocortisol to a level where physiological symptoms are not found or do not occur in the patient.

[0090] As used herein, a "reference sample" or a "reference patient" is a sample or patient to which a pseudo-irreversible HSD-1 inhibitor has not been administered as described herein, or a healthy patient.

[0091] As used herein, "subject" or "patient" refers to a human. A patient or subject according to the present disclosure has glucocorticoid excess. Unless otherwise indicated, the terms "patient" and "subject" are used interchangeably herein. In some embodiments, a patient or subject described herein has an ACTH or CRH secreting tumor. In some embodiments, a patient or subject has a cortisol secreting tumor.

[0092] As used herein, "tetrahydrocortisols" refers to urinary tetrahydrocortisol or cortol, the levels of which are altered by administration of an HSD-1 inhibitor.

[0093] The terms "treat" or "ameliorate" include the administration of a compound or agent to a patient to relieve or reverse the symptoms, or to arrest or inhibit further development, of a disease, condition, or disorder. Subjects in need of treatment include those already suffering from a disease or disorder or experiencing a symptom of a disease, condition, or disorder, e.g., patients with elevated levels of glucocorticoids or urinary tetrahydrocortisol.

[0094] Numbers expressing quantities of ingredients, properties, such as molecular weights, reaction conditions, and the like, used to describe and claim certain embodiments of the present disclosure should be understood in some instances as being modified by the term "about." In some embodiments, the term "about" is used to indicate that the values ​​include a measure of variability for the device or method being employed to determine the value. The numerical parameters set forth in the written description and accompanying claims are approximations that may vary depending on the desired properties sought to be obtained by a particular embodiment. The numerical parameters should be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. Notwithstanding that the numerical ranges and parameters setting forth certain embodiments of the present disclosure in broad terms are approximations, the numerical values ​​set forth in the specific examples are reported as precisely as practicable. The numerical values ​​presented in some embodiments of the present disclosure may necessarily contain certain errors resulting from the variability found in their respective testing measurements. The recitation of ranges of values ​​herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each separate value is incorporated herein as if it were individually set forth herein.

[0095] As used in the context of describing particular embodiments (particularly in the specific context of the claims below), "a," "an," and "the," and similar references, can be construed to encompass both the singular and the plural, unless specifically stated otherwise. The term "or," including the claims, is used inclusively as used herein, unless expressly stated to refer only to alternatives or unless the alternatives are mutually exclusive.

[0096] The terms "comprise," "have," and "include" are open-ended linking verbs. Any form or tense of one or more of these verbs, such as "comprises," "comprising," "has," "having," "includes," and "including," are also open-ended. For example, any method that "comprises," "has," or "includes" one or more steps is not limited to the processing of only those one or more steps, but may also include other unlisted steps. Similarly, any composition or apparatus that "comprises," "has," or "includes" one or more features is not limited to the processing of only those one or more features, but may also include other unlisted features.

[0097] All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples or representative language (e.g., "such as") provided in connection with specific embodiments herein is intended merely to more fully clarify the disclosure and does not pose a limitation on the scope of the disclosure as specifically claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the disclosure.

[0098] Groupings of alternative elements or embodiments of the disclosure disclosed herein are not to be construed as limiting. Each group member may be referenced or claimed individually or in any combination with other members of the group or other elements found herein. One or more members of a group may be included in, or removed from, a group for reasons of convenience or patentability.

[0099] The present disclosure has been described in detail, and it will be apparent that modifications, variations, and equivalent embodiments are possible without departing from the scope of the present disclosure, as defined in the appended claims. Moreover, it should be understood that all examples in this disclosure are provided as non-limiting examples. EXAMPLES

[0100] Working Example Examples of embodiments of the present disclosure are presented in the following examples. The following examples are presented solely by way of illustration and to assist those skilled in the art in using the present disclosure. The examples are not intended to limit the scope of the present disclosure in any way.

[0101] Example 1. Adipose HSD-1 inhibition by SPI-62 A paradoxical observation reported for three HSD-1 inhibitors, and considered potentially a class effect, is the tachyphylaxis of human adipose HSD-1 inhibition: the following HSD-1 inhibitors showed greater adipose HSD-1 inhibition after single doses compared to multiple doses, even though plasma drug levels increased to steady state with repeated dosing and hepatic HSD-1 inhibition was observed after both single and multiple doses:

[0102] In abdominally obese subjects, AZD4017 showed adipose HSD-1 inhibition after a single dose, but did not show sustained inhibitory effects after repeated dosing. AZD4017 also did not show skin HSD-1 inhibition after multiple doses, but in the same subjects, it was associated with maximal liver HSD-1 inhibition. Since there are no data after a single dose, it is unclear whether AZD4017 showed tachyphylaxis of skin HSD-1 inhibition or whether there could be another explanation. Clinical benefit in the skin (improved wound healing) was observed in subjects receiving AZD4017 compared to subjects receiving placebo. It is possible that the in vitro assay used to measure skin HSD-1 activity was not detailed.

[0103] In human adipose tissue, inhibition of HSD-1 activity was lost after repeated administration of AZD8329 compared with acute administration.

[0104] Median HSD-1 enzyme inhibition in human adipose tissue reached 90% after a single dose of BI-135585 but was low (≤31%) after 14 days of continuous treatment.

[0105] It was predicted that pseudo-irreversible HSD-1 inhibitors would not show the tachyphylaxis of human adipose HSD-1 inhibition. This was based on the hypothesis that adipose tachyphylaxis is the result of competition with increased levels of HSD-1 substrates (inactive GCs). Inactive GCs are highly lipophilic and would therefore be expected to accumulate in tissues, and thus especially in adipose tissue, of patients treated with HSD-1 inhibitors, especially those with GC excess.

[0106] BI-187004, which we have identified as a pseudo-irreversible HSD-1 inhibitor based on fast-on, slow-off in vitro enzyme kinetics, showed limited tachyphylaxis of human adipose HSD-1 inhibition. For example, the median HSD-1 enzyme inhibition in human adipose tissue associated with the 20 mg dose was 92.4% on day 2 and 78.1% on day 15. For the 240 mg dose, the median was 99.5% on day 2 and 93.1% on day 15. The difference between days 2 and 15 could be because adipose samples were obtained 10-45 min after dosing on day 2, and 24 h after dosing on days 15 and 14 for logistic reasons.

[0107] Cortisone has a K of 1.9 mM m and is an endogenous HSD-1 substrate with a logP of 1.25. Prednisone is a common GC drug that is a prodrug that requires HSD-1 for activation to prednisolone. It is also the major metabolite of prednisolone, another common GC drug. It has a K of 20.6 mM for human HSD-1. m and a logP of 1.5.

[0108] Increased tissue levels of cortisone, prednisone, or other lipophilic HSD-1 substrates are problematic for competitive inhibitors such as AZD4017, AZD8329, or Bl-135585. Substrates such as cortisone or prednisone accumulate in tissues because HSD-1 does not convert them to their active form, and thus may compete off the inhibitor. This is consistent with the observation that the three compounds inhibit adipose HSD-1 substantially after a single dose, but not significantly after multiple doses. This phenomenon may be advantageous in adipose (and possibly skin) compared to liver due to lower tissue blood flow, higher lipid content, and possibly other factors. In contrast, pseudoirreversible inhibitors would be much less susceptible to competition by substrate accumulation and would be much better able to maintain HSD-1 inhibition and its associated clinical benefits. Clinical trials verified this prediction.

[0109] Male and nonmenstruating female subjects with type 2 diabetes, aged 18-65 years and with a body mass index of 30.0-45.0, were administered SPI-62 daily for 14 days. SPI-62 was administered daily for at least 4 hours prior to and throughout the first, second, and fourteenth dosing intervals, with 1 μg / mL D8 cortisone ([2,2,4,6,6,9,12,12- 2 H 8 ]Cortisone, Millipore Sigma, Miamisburg OH) was continuously infused into subcutaneous abdominal adipose tissue at a rate of 1 μL / min via a microdialysis catheter (63 Microdialysis Catheter, MDialysis, Stockholm Sweden). Fat dialysates were collected over 2-h intervals (0–2, 2–4, 4–6, 6–8, 8–10, 20–22, and 22–24 h after SPI-62 administration) and analyzed for D8 cortisone and D8 cortisol. The mole percent fraction (MPF) of D8 cortisol was calculated as follows: ([2,2,4,6,6,9,12,12- 2 H8 ]Cortisol * 368.51) / ([2,2,4,6,6,9,12,12- 2 H 8 ]cortisone * 370.52), where 368.51 and 370.52 are the molar masses of D8 cortisone and D8 cortisol. Percent adipose HSD-1 inhibition was calculated as follows: 100 * (1-(MPF t / MPF baseline ).

[0110] The time of sample (t) was considered to be the midpoint of the collection interval. Assay sensitivity limited quantification of adipose HSD-1 inhibition to approximately 90-95%, depending on the D8 cortisol value, as D8 cortisol values ​​below the lower limit of quantification were assigned as the lower limit of quantification. Data shown are the median inhibition observed in two subjects receiving a daily dose of 6 mg SPI-62.

[0111] As shown in Figure 1, adipose HSD-1 inhibition was detectable 2-4 hours after a single dose, reached maximum measurable levels during the second dosing interval, and was nearly identical during the second and fourteenth dosing intervals. In additional subjects receiving SPI-62 doses of 1, 2, 3, or 10 mg, maximum measurable adipose HSD-1 inhibition was observed after multiple dosing, even though no or limited adipose HSD-1 inhibition was associated with the lower single SPI-62 doses.

[0112] Example 2. Pseudo-irreversible HSD-1 inhibitors identified by human pharmacokinetics Pseudoirreversible HSD-1 inhibitors can be identified through human pharmacokinetic data. When an initial dose of pseudoirreversible HSD-1 inhibitor first binds and remains bound to its target in tissue, up to about 3 mg can be sequestered from the central circulation. Thus, there is a dose-proportional exposure after multiple doses, along with a remarkably consistent nonlinearity in pharmacokinetics after a single dose in the sub-mg to low mg range. Based on human pharmacokinetic data, the following have been identified as pseudoirreversible HSD-1 inhibitors:

[0113] Substantial nonlinearity in plasma exposure was observed following administration of single SPI-62 (previously ASP3662) doses; single doses of 0.7 to 3 mg were associated with much lower dose-normalized plasma levels than higher single doses. Plasma levels 14 days after administration were roughly dose-proportional for SPI-62 doses of 0.2 to 50 mg (a 3 mg loading dose was administered prior to daily administration of 0.2 mg). The pharmacokinetics of single and multiple doses of SPI-62 were well characterized by a two-compartment TMDD population pharmacokinetic model with three pass absorption compartments and an estimated target capacity of approximately 2.5 mg of SPI-62, which was well-fitted in the dose range where pharmacokinetic nonlinearity was prominent.

[0114] Substantial nonlinearity in plasma exposure was noted following administration of single ABT-384 doses; single doses of 1-4 mg were associated with much lower dose-normalized plasma levels than higher single doses. Plasma levels 14 days after administration were roughly dose-proportional for ABT-384 doses of 1-100 mg. The pharmacokinetics of single and multiple doses of ABT-384 were well characterized by a two-compartment TMDD population pharmacokinetic model with three pass absorption compartments and an estimated targeting ability of SPI-62 of approximately 1 mg, which was well-fitted in the dose range where pharmacokinetic nonlinearity was pronounced and may be a low estimate since data from sub-mg doses were not available. ABT-384 was reported to be retained in the cynomolgus monkey liver for at least 77 days.

[0115] SPI-62 and ABT-384 are i Approximately 60 times lower than d Share remarkable and unexpected properties of

[0116] MK-0736 exhibited a nonlinear saturation distribution PK resulting in a decreasing half-life with increasing dose and dose-dependent accumulation. The population pharmacokinetics of MK-0736 was described by a two-compartment model with first-order absorption, linear elimination, and saturation distribution. As the administered dose range was 1.2-200 mg, the saturation distribution was similarly observed at doses similar to SPI-62 and ABT-384, consistent with precedent for the HSD-1 inhibitor TMDD. The authors, who are clinical pharmacology experts from Merck, were apparently unaware of TMDD and therefore used a model structure that was less suitable to model MK-0736 pharmacokinetics.

[0117] Substantial nonlinearity of plasma exposure was observed after administration of a single MK-0916 dose; single doses of 0.2 to 3.16 mg were associated with much lower dose-normalized plasma levels than higher single doses. Plasma levels 14 or 28 days after administration were roughly dose-proportional for MK-0916 doses of 0.2 to 50 mg. Pharmacokinetic data were fitted to a two-compartment saturation distribution model. The dose range in which pharmacokinetic linearity was observed was similar to that of SPI-62, suggesting that MK-0916 also follows TMDD mediated by HSD-1. The authors, who are clinical pharmacology experts from Merck, were apparently unaware of TMDD and therefore used a model structure that was less suitable to model MK-0916 pharmacokinetics. The estimated ability of the saturation distribution of approximately 3 mg of MK-0916 was a good fit in the dose range in which pharmacokinetic nonlinearity was prominent, and the targeting ability for SPI-62 is evaluated using the TMDD model.

[0118] BMS-823778 plasma levels were not detectable after single doses of 0.1 mg or 0.5 mg and were lower than dose-proportional plasma levels after a single dose of 2 mg. Steady-state exposure was dose-proportional from 0.5 mg daily. These observations are consistent with the TMDD clinical pharmacokinetic behavior of HSD-1 inhibitors, best characterized by SPI-62 and ABT-384. Physiologically based pharmacokinetic models over-predicted exposure after the first dose at low levels. The authors, clinical pharmacology experts from BMS, attributed the weakness of their models to an unknown mechanism, due to the apparent lack of knowledge of HSD-1-mediated TMDD.

[0119] UE2343 plasma levels were below the level of quantitation after single doses of 2 mg and 5 mg. Exposure increased in a greater than dose-proportional manner after single doses of 10 to 35 mg. The figure shows that the measured mean maximum plasma concentration after a single dose of 10 mg (40.4 ng / mL) was substantially higher than the assay limit of quantitation (by visual inference, approximately 5 ng / mL or less). No multiple dose data were reported for doses <10 mg. No population pharmacokinetic model was reported. TMDD due to pseudo-irreversible HSD-1 inhibition by UE2343 is the most likely explanation for the data.

[0120] AMG-221 demonstrated nonlinear pharmacokinetics, with dose-normalized exposure reduced after a single dose of 3 mg compared with a single dose of 30 mg or 100 mg. Plasma level data were characterized by a two-compartment open model with linear elimination from the central compartment with slightly overestimated exposure associated with higher doses. AMG-221 appears to exhibit human pharmacokinetics consistent with TMDD, but in the absence of data after repeated dosing, inferences are less clear than for other HSD-1 inhibitors based on pharmacokinetic evidence alone.

[0121] Dose-normalized plasma levels of BI-187004 were substantially below after a single dose of 2.5 mg, below after a single dose of 5 mg, and associated with single doses of 10 mg and above. No multiple dose data below 10 mg were reported. No population pharmacokinetic model was reported. TMDD due to pseudo-irreversible HSD-1 inhibition by BI-187004 is the most likely explanation for the data.

[0122] Example 3. Pseudo-irreversible HSD-1 inhibitors identified by human pharmacodynamics Pseudoirreversible HSD-1 inhibitors can be identified through human pharmacodynamic data. Because the inhibitor slowly dissociates from the enzyme, the following are characteristic of pseudoirreversible HSD-1 inhibitors:

[0123] HSD-1 inhibition will be observed for long periods after cessation of treatment, especially in the liver where HSD-1 protein concentrations are highest and may further promote long-term interactions. With high HSD-1 concentrations in the endoplasmic reticulum, an inhibitor molecule that dissociates from one enzyme molecule theoretically has a higher probability of binding to another before distributing out of the endoplasmic reticulum.

[0124] Target inhibition may be associated with very low plasma levels. If circulating pseudo-irreversible HSD-1 inhibitor molecules are not bound to the enzyme, they may be cleared by similar pathways at rates similar to other HSD-1 inhibitors, whereas prolonged binding to intracellular enzymes results in compartments where pseudo-irreversible HSD-1 inhibitors simply re-enter the circulation very slowly. Even with highly sensitive assays, HSD-1 inhibition may result in plasma drug levels near or below the limit of quantification, and the molecular K for human HSD-1. i or IC 50 This may relate to unbound (ie, tissue accessible) levels well below .

[0125] After a single dose, hysteresis and concentration independence will be observed for HSD-1 inhibition. When pseudo-irreversible HSD-1 inhibitor is absorbed from the gastrointestinal tract, it will first be distributed to the liver, which contains the highest concentration of HSD-1, where the drug can bind and remain bound without entering the central circulation. At low doses, substantial HSD-1 inhibition can be observed before the drug achieves plasma levels above the limit of quantification. Hepatic HSD-1 inhibition may not change so much that drug plasma levels increase and then decrease after a single dose of pseudo-irreversible HSD-1 inhibitor, especially if the dose is sufficient to saturate hepatic HSD-1 (with a maximum capacity of about 3 mg of drug in healthy adults).

[0126] In hepatocytes, 5-steroid reductase and 3-steroid reductase metabolize cortisol (HSD-1 product) to tetrahydrocortisol and allotetrahydrocortisol, and cortisone (HSD-1 substrate) to tetrahydrocortisone over time. The tetrahydro metabolites are rapidly and extensively excreted in the urine. Therefore, the urinary ratio (tetrahydrocortisol + allotetrahydrocortisol) / tetrahydrocortisone is a biomarker of liver enzyme activity. Continued adrenal synthesis provides a circulating pool of cortisol, of which (about 5%) is the free fraction that enters the cells. It prevents the urinary HSD-1 ratio from falling below about 0.1. Therefore, values ​​within that range are considered to indicate maximal inhibition of hepatic HSD-1.

[0127] Hepatic HSD-1 inhibition, as assessed by urinary HSD-1 ratio, is durable after cessation of SPI-62 administration. In healthy adults, recovery of urinary HSD-1 ratio to baseline was incomplete for more than 2 weeks after the last dose. For example, 16±2 days after cessation of a daily dose of 0.7 mg SPI-62, the mean urinary HSD-1 ratio had declined 55% from baseline compared to an 84% decline from baseline on the day of the last dose. Similar data were observed following both lower (Figure 2) and higher daily doses of SPI-62. In patients with painful diabetic peripheral nephropathy administered a daily dose of 10 mg SPI-62 for 6 weeks, the mean urinary HSD-1 ratio was 1.06 before dosing, 0.13 on the day of the last dose, and 0.33 2 weeks after the last dose.

[0128] HSD-1 specific PET ligand [ 11 Brain HSD-1 occupancy after a single 3 mg dose of SPI-62, assessed by competition with [C]AS2471907, was 84-90% at 3.3-25 h, 56-83% at 42-46 h, 36-45% at 139 h, and 26% at 189 h. The pharmacological half-life of SPI-62 in the brain is, as expected, shorter than in the liver. See Figure 3.

[0129] The lowest dose of SPI-62 administered clinically to date, 0.2 mg per day for 14 days, was associated with a mean maximum plasma drug concentration (C max ) <1 ng / mL was associated with a mean 87% decrease from baseline in urinary HSD-1 ratios on the last day of treatment, which is consistent with the K i and IC of 17 nM 50 This corresponds to an unbound concentration of <0.25 nM, well below the C value. Throughout the dose range of 0.2 to 50 mg of SPI-62, the mean urinary HSD-1 ratios ranged from 0.09 to 0.17 in each dose group. The final urinary HSD-1 ratios were concentration-independent; the corresponding C max Means ranged from <1 to 835 ng / mL. A single 1 mg dose of SPI-62 reduced urinary HSD-1 rates by a mean of 51% compared to placebo and reduced mean Cmax <0.05 ng / mL (unbound concentration <0.012 nM). Mean urinary HSD-1 ratios were 0.11-0.18 after single doses of 6-60 mg of SPI-62; corresponding C max Means ranged from 28 to 595 ng / mL.

[0130] Following administration of a single dose of SPI-62, the expected hysteresis pattern was observed. Urinary HSD-1 ratios in urine collections were plotted at 0–6 h (○), 6–12 h (◇), 12–24 h (+), 24–48 h (●), and 48–72 h (

number

[0131] During the first 6 h after dosing, partial hepatic HSD-1 was observed without a monotonic concentration-response relationship. This is likely due to between-group variability in the duration of the early distribution phase, during which little or no HSD-1 inhibition was observed. In the interval following the initial distribution phase, similar mean urinary HSD-1 ratios of 0.1 to 0.2 were associated with plasma drug concentrations of <2 to >300 ng / mL, and throughout the time interval spanning 6 to 72 h after dosing. Hysteresis plots are not shown for a single 1 mg dose of SPI-62, since all of the drug concentrations were below the LLOQ (0.1 ng / mL). The mean urinary HSD-1 ratios after the 1 mg dose were 0.694, 0.471, 0.472, 0.522, and 0.618, indicating partial hepatic HSD-1 inhibition in urine collections 0-6 hours, 6-12 hours, 12-24 hours, 24-48 hours, and 48-72 hours after dosing, respectively.

[0132] ABT-384 has also been reported to exhibit prolonged HSD-1 inhibition in vivo. Similar hepatic HSD-1 inhibition was measured in healthy adults after 7-day doses of 1 to 100 mg of ABT-384, with corresponding mean C max In a phase 1 clinical trial, complete brain HSD-1 inhibition was observed up to 40 hours after cessation of daily ABT-384 administration to healthy adults.

[0133] Following administration of a single oral dose of 3 mg of AMG-221, the expected hysteresis pattern was observed. These data add credence to AMG-221 being a pseudo-irreversible HSD-1 inhibitor.

[0134] Example 4. Pseudo-irreversible HSD-1 inhibitors identified by in vitro enzyme kinetics Pseudo-irreversible HSD-1 inhibitors can be identified through in vitro enzyme kinetic assessment, where they are expected to exhibit longer enzyme residence times compared to other HSD-1 inhibitors. Surface plasmon resonance (SPR) is the resonant oscillation of conduction electrons at an interface between a negative and a positive dielectric constant material that is stimulated by incident light. Once a protein is bound to a surface, SPR can be used to detect ligand binding to the protein.

[0135] It has previously been reported that in vitro ABT-384 rapidly forms a tight enzyme-inhibitor complex with the HSD-1 enzyme, but has a very slow dissociation rate.

[0136] The binding affinity and kinetics of 19 HSD-1 inhibitors were characterized using SPR. Each compound was tested by the ABA method using a parallel experimental design in 50 mM Tris, 150 mM NaCl, 2% DMSO, pH 7.4 at a flow rate of 30 μL / min. The enzyme was exposed to 300 μM NADPH in 50 mM Tris, 150 mM NaCl, 2% DMSO, pH 7.4 for 90 s (step A), then to 300 μM NADPH and test compound in buffer for 150 s (step B), then to 300 μM NADPH in buffer for 300 s to 370 s (step A). ​​Throughout the experiment, the association and dissociation of the test compound was monitored in the presence of 300 μM NADPH. Four concentrations of test compounds were prepared by two-fold serial dilution in 50 mM Tris, 150 mM NaCl, 2% DMSO, pH 7.4 with 300 μM NADPH. The residence times (the inverse of the dissociation rate constant) for each compound are shown in Table 1 below.

[0137] [Table 1]

[0138] Based on these results, ABT-384, BI-187004, UE-2343, SPI-62, and KR-67607 are identified as potential pseudoirreversible HSD-1 inhibitors.

[0139] The rationale for classifying only them as such is as follows:

[0140] Although no clinical pharmacokinetic or pharmacodynamic data have been published for KR-67607, it had a residence time in the enzyme very similar to that of SPI-62, which has also been established as a pseudo-irreversible HSD-1 inhibitor by clinical pharmacokinetic and pharmacodynamic results. KR-67607 also shares important chemophores with another established pseudo-irreversible HSD-1 inhibitor, ABT-384, and appears to share a binding mode for human HSD-1 with both SPI-62 and ABT-384 (see below).

[0141] The ABT-384 acid metabolite is only 19% as potent as ABT-384 as an HSD-1 inhibitor in vitro. Furthermore, there is a structural basis for considering the ABT-384 acid metabolite as not a pseudo-irreversible HSD-1 inhibitor.

[0142] SPI-09 demonstrated dose-proportional pharmacokinetics in cynomolgus monkeys across a wide range of single doses that would not be expected for a pseudo-irreversible HSD-1 inhibitor. The pharmacokinetic behavior of ABT-384 in cynomolgus monkeys was similar to that in humans and elsewhere. The Pro-Cys motif (see below), important for allosteric regulation of human HSD-1, is shared by cynomolgus monkeys, further supporting it as a suitable species for characterizing pseudo-irreversible HSD-1 inhibitors.

[0143] Thus, the ABT-384 acid metabolite SPI-09, and other HSD-1 inhibitors with shorter enzymatic residence times, are not classified as pseudoirreversible inhibitors by in vitro enzyme kinetics.

[0144] Inhibitors that showed tachyphylaxis upon adipose HSD-1 inhibition (Bl-135585, AZD4017, AZD8329) are not classified as pseudo-irreversible inhibitors by in vitro enzyme kinetics.

[0145] However, some compounds (MK-0916, BMS-823778) that show clinical pharmacokinetics consistent with pseudo-irreversible inhibition are not classified as such by in vitro enzyme kinetics. A possible limitation of SPR is that the allosteric conformation of human HSD-1 in vivo (see below) is not maintained under experimental conditions. To the extent that the binding mode of pseudo-irreversible HSD-1 inhibitors depends on the native allosteric conformation of the enzyme, SPR may show long residence times only for some pseudo-irreversible HSD-1 inhibitors. BMS-823778 has a different binding mode to human HSD-1 compared to SPI-62, ABT-384, and KR-67607 (see below). MK-0916 has chemical structure similarity to BMS-823778; the two molecules may bind to human HSD-1 similarly.

[0146] Example 5. Pseudo-irreversible HSD-1 inhibitors identified by enzyme-inhibitor structure Human HSD-1 appears to function as a tetramer. A primate-specific C-terminal proline (P)271-cysteine ​​(C)272 motif is localized in the center of the tetramer and forms a reversible enzyme disulfide that modifies the enzyme activity. Conformational flexibility at the tetramerization interface suggests that the central P271-C272 motif may modulate the enzyme activity, coupled to structural changes at the enzyme active site. The two dimers associate through complementary interactions between pairs of carboxyl termini of the enzymes that are oriented in an antiparallel direction. Each carboxyl terminus in the HSD-1 tetramer moves roughly perpendicular to the dimer 2-fold axis. This arrangement of the termini results in a 30 Å long, four-helix bundle-like structure that localizes adjacent enzyme active sites at the top and bottom of the structure (Figure 5). Substrate (eg, cortisone) binding induces a conformational change in the tetramer that confers enzyme specificity, protects the active site from bulk movement, and facilitates hydride transfer.

[0147] We present two structure-based models for HSD-1 membrane interactions and subunit assembly in the ER lumen (Figure 6). The highly invaginated membrane structure of the ER is consistent with a model in which a tetramer spanning two lipid bilayers forms a chamber in which pseudoirreversible inhibitors, after gradual dissociation from HSD-1, can rapidly reassociate with HSD-1 within the same tetramer to achieve sustained inhibition.

[0148] HSD-1 belongs to the family of short-chain dehydrogenase / reductase (SDR) enzymes with a common reaction mechanism in which the active site tyrosine (Y) functions as a catalytic acid to protonate the reactive keto oxygen of bound substrates. The active site serine (S) stabilizes the orientation of the bound substrate. The conserved lysine (K) forms a hydrogen bond with the nicotinamide ribose of NADPH and lowers the pK of the Y hydroxyl to facilitate proton transfer. a In HSD-1, the catalytic triad is S170-Y183-K187. Many HSD-1 inhibitors interact with the catalytic triad, particularly S170 and Y183. Some HSD-1 inhibitors interact instead with the α-helical backbone near the catalytic triad.

[0149] It was hypothesized that the formation of a ternary complex with the HSD-1 protein and the NADPH cofactor is a general feature of pseudo-irreversible inhibitors. Among the 39 HSD-1 inhibitors whose structures bound to HSD-1 have been deposited in the Protein Data Bank, a small number appear to form such ternary complexes directly with NADPH. They can be further classified according to three types of interactions: (1) hydrogen bonds between the amide nitrogen and NADPH pyrophosphate (amide); (2) hydrogen bonds between the aromatic nitrogen and NADPH pyrophosphate (aromatic); and (3) aromatic stacking interactions with the NADPH nicotinamide ring (stack). The catalytic triad and interactions with nearby scaffolds are also summarized in Table 2 below.

[0150] [Table 2]

[0151] The association of one of these drugs with HSD-1 would be a bimolecular reaction, whereas dissociation would be a process in which the interactions of both the drug and the catalytic cofactor NADPH with HSD-1 contribute to the activation energy barrier to dissociation, and in a way, the binding energy of NADPH to HSD-1 would hold the inhibitor to HSD-1, resulting in the fast-on, slow-off kinetic characteristics of pseudo-irreversible inhibitors.

[0152] Of the other 33 inhibitors for which HSD-1 bound structures are available, including AZD4017 (PDB record 4hfr) and AZD8329 (PDB record 4p38), both of which show tachyphylaxis upon lipid HSD-1 inhibition and do not form ternary complexes with NADPH or do so exclusively via water molecules. Here, it is not predicted that a complex between an HSD-1 inhibitor and NADPH in the human HSD-1 active site via water molecules would confer the same advantages as amide, aromatic, and stack interactions, since water molecules may be sufficiently mobile in the active site.

[0153] Compound A [(1s,3R,5S,7s)-4-(2-(4-methoxyphenoxy)-2-methylpropanamido)adamantane-l-carboxamide)], shown in Figure 7, is useful because the part of the molecule that interacts with NADPH and the catalytic triad is the same as in ABT-384 and KR-67607. Using molecular docking techniques, modeling of the binding of SPI-62, ABT-384, and KR-67607 to HSD-1 was performed. The model shows that these inhibitors naturally form a ternary complex with the amide class and NADPH in the active site. They, together with SAR-184841 and compound A, are classified as pseudo-irreversible HSD-1 inhibitors.

[0154] SPI-62 exhibits different but similar interactions compared to other class members. For example, (a) the benzamide, not the adamantane carboxamide, interacts with the pyrophosphate of NADPH; (b) the triazine ring, not the amide keto, interacts with S170 and Y183 (Figure 10). Also, BMS-823778 and other HSD-1 inhibitors exhibit such triazine interactions with S170 and Y183.

[0155] Molecular docking models of the acid metabolites of SPI-62 and ABT-384 suggest that the metabolites bind in the reverse orientation with benzoic acid or adamantane carboxylic acid, pointing away from NADPH pyrophosphate, providing the structural basis for why the acid metabolites are substantially less potent HSD-1 inhibitors compared to the parent drugs.

[0156] The triazine ring of MK-0916 and BMS-823778 interacts with NADPH, S170, and the nicotinamide ring of Y183, which is the structural basis for them as pseudo-irreversible HSD-1 inhibitors. Figure 9 shows the established binding of BMS-823778. Using molecular docking techniques, modeling of the binding of MK-0916 was performed to determine whether the binding mode is similar to that of BMS-823778. The model showed that this inhibitor naturally forms a ternary complex with stack class and NADPH in the active site. Compound C and compound D (PDB records 2rbe and 3oql, Table 2) may also be pseudo-irreversible HSD-1 inhibitors. Compounds that form aromatic class ternary complexes with NAPDH in the HSD-1 active site (e.g., compound B; PDB record 3qqp) may be pseudo-irreversible inhibitors.

[0157] Example 6. Evidence for HSD-1 inhibitors as potential treatments for glucocorticoid excess The therapeutic hypothesis for HSD-1 inhibitors for patients with glucocorticoid excess, whether endogenous (Cushing's syndrome and ACS) or exogenous (GC drugs), is that HSD-1 binds to intracellular GC and mineralocorticoid receptors, as well as non-genomic receptors, forming a large amount of excess intracellular GC that may cause symptoms. HSD-1 inhibition may reduce the intracellular GC, and therefore potentially reduce symptoms in patients with Cushing's syndrome or ACS. It may also prevent or reverse many of the adverse effects associated with GC drug use, particularly in patients who rely on long-term use of GC drugs to control autoimmune diseases and other conditions.

[0158] Several lines of independent clinical and non-clinical evidence support the potential of HSD-1 inhibitors for the treatment of Cushing's syndrome or ACS, or as adjunctive therapy to GC in patients in need of such drugs.

[0159] HSD-1 activity is increased in patients with Cushing's syndrome. The urinary HSD-1 ratio, a biomarker for hepatic HSD-1 activity, was 1.74 ± 0.24 in patients with Cushing's disease, 3.95 ± 0.69 in patients with ectopic ACTH secretion, and 1.7 (median) in patients with adrenal Cushing's syndrome, in contrast to 1.21 ± 0.06 in healthy adults. The increase in the HSD-1 ratio is thought to be the result of HSD-1 induction by cortisol.

[0160] Patients with Cushing's syndrome and constitutionally low HSD-1 activity did not show symptoms associated with hypercortisolemia, even with very high 24-hour urinary free cortisol. For example, a 20-year-old woman presented with amenorrhea, an androgenic symptom of Cushing's syndrome, but did not show sequelae of hypercortisolemia. Her urinary free cortisol was 831 and 1049 nmol / 24 hours on separate occasions, and her urinary HSD-1 ratio was 0.66. After transsphenoidal pituitary adenomactomy, she began menstruating, and her circulating and urinary cortisol levels returned to normal. In another example, a 55-year-old woman presented with an incidentally discovered adrenal tumor. She did not show physical signs of Cushing's syndrome, insulin resistance, hypertension, or dyslipidemia. Her urinary free cortisol was 1149 nmol / 24 hours, and her urinary HSD-1 ratios ranged from 0.61 to 0.66 on separate occasions. After adrenalectomy, high-dose glucocorticoid therapy was initially required to prevent adrenal insufficiency.

[0161] A pilot open-label clinical trial of an HSD-1 inhibitor (S-707106) in patients with hypercortisolism (11 with ACS, 4 with Cushing's syndrome) showed positive trends for glycemic control and body habitus. At 24 weeks, subjects showed a mean weight loss of 1.6 kg, a decrease in body fat percentage of 2.5%, and an increase in body muscle percentage of 2.4%. The area under the glucose curve after an oral glucose tolerance test was reduced primarily in obese subjects.

[0162] In a cohort of healthy adult men, those receiving 20 mg prednisolone for 7 days along with an HSD-1 inhibitor (AZD4017) demonstrated resistance to decreased insulin sensitivity, increased triglycerides, increased nocturnal blood pressure, decreased bone formation biomarkers, and increased bone resorption biomarkers during a euglycemic clamp compared to those receiving prednisolone alone.

[0163] Clinical trial results with various HSD-1 inhibitors, including INCB-13739 for diabetes, RO5093151 for non-alcoholic fatty liver disease, and AZD4017 for impaired wound healing, support efficacy for the treatment of certain common chronic diseases and disorders that correspond to the prevalence of GC excess. HSD-1 inhibitors in some clinical trials have also been associated with a weight loss of 1-2 kg at 12 weeks compared to placebo. Other clinical trials of HSD-1 inhibitors, such as ABT-384 for dementia, have shown a lack of efficacy, even in the case of adequate dose administration and positive results for active controls. Furthermore, other clinical trials of HSD-1 inhibitors, such as BI-187004 for diabetes, have shown a lack of efficacy, possibly due to reasons such as insufficient treatment duration or exclusion of patients with GC excess. Diabetes, non-alcoholic fatty liver disease, impaired wound healing, obesity, and dementia are complex pathologies where cortisol excess is only one of several pathogenic factors and is not present in all patients. HSD-1 inhibitors may be expected to be particularly beneficial in patients with GC excess where such treatment is specifically targeted to the primary cause of the morbidity they suffer from, which may further be the situation of morbidity (e.g., cognitive impairment) where previous clinical trials of HSD-1 inhibitors have been negative.

[0164] HSD-1 knockout mice are resistant to multiple adverse effects of exogenously administered corticosterone (CORT; the mouse equivalent of cortisol). CORT also suppressed HPA axis activity, as evidenced by adrenal atrophy in both knockout and control mice. In contrast to control mice, knockout mice essentially did not exhibit the effects of corticosterone on blood pressure and hepatic steatosis, and substantially reduced the effects of CORT on insulin resistance, steatosis, muscle wasting, and skin atrophy. Knockout mice were almost completely resistant to the adverse effects of CORT on trabecular bone structure.

[0165] HSD-1 inhibitors have shown the ability to block or reverse exogenously administered GCs in animal models. Abbott's HSD-1 inhibitors blocked the adverse effects of GC administration to rat bone. Femoral head necrosis induced by mycotoxins patulin and prednisolone was ameliorated by administration of HSD-1 inhibitors, showing improved bone microarchitecture and density. Carbenoxolone and PF-915275 each prevented GC-induced wound healing impairment in mice. Glycyrrhizin partially prevented intraocular pressure increases associated with intravitreal triamcinolone in rabbits.

[0166] Example 7. Supporting evidence specific to SPI-62 Clinical and non-clinical evidence supports the specific potential of SPI-62 for the treatment of Cushing's syndrome or ACS, or as an adjunctive therapy to GC in patients in need of such drugs.

[0167] In patients with painful diabetic peripheral neuropathy, after daily administration of SPI-62 or placebo, analyses of covariance were performed to evaluate the effect of SPI-62 on total cholesterol (TC), glucose, glycated hemoglobin (HbA1c), and triglycerides (TG) on baseline values ​​compared with the covariates and baseline values. * Analyzed as a treatment interaction term.Data were obtained from Study 3662-CL-0049, a Phase 2 randomized, double-blind, placebo- and active-controlled clinical trial of the safety and efficacy of SPI-62 in subjects with painful diabetic peripheral neuropathy.

[0168] SPI-62 was associated with lower baseline-adjusted values ​​compared with placebo for TC, glucose, HbA1c, and TG at Week 6 / end of study (EOT). The magnitude of the differences decreased for 2 weeks after discontinuation of study drug administration (Week 8 / end of study (EOS)) for TC, glucose, and TG, but increased for HbA1c. At Week 6 / EOT, treatment-related differences for TC and HbA1c *A baseline interaction was observed, such that patients with higher baseline values ​​showed a larger average difference between SPI-62 and placebo, but not glucose or TG (Figure 11). Thus, overall, SPI-62 was associated with favorable changes in TC, glucose, HbA1c, and TG in patients with PDPN. These analyses increase confidence that SPI-62 has the potential to control hyperglycemia and dyslipidemia. Patients with higher TC or HbA1c values ​​may especially benefit from SPI-62 therapy.

[0169] The magnitude of the effect of the pseudoirreversible HSD-1 inhibitor SPI-62 on HbA1c, TC, and TG (Table 3) was numerically larger than that reported for other HSD-1 inhibitors in other clinical trials.

[0170] [Table 3]

[0171] To demonstrate mitigation of corticosterone (CORT) adverse effects in mice by SPI-62, C57BL / 6 male mice (7 weeks old; n=14 per group) were administered CORT (100 mg / mL in drinking water) and SPI-62 (by gavage in 0.5% HPMC; 0, 1, or 10 mg / kg / day or 10 mg / kg twice daily) for 35 days. Control groups did not receive CORT or SPI-62. Body weight was assessed daily and food intake twice weekly. On days 0, 14, and 28, whole body muscle and fat mass were measured using an EchoMRI-130H body composition analyzer. On days 1 (pre-dosing), 15, 29, and 35, blood samples for fasting glucose and insulin were obtained. On day 22, an open field test was performed. On day 28, a grip strength test was performed. After sacrifice on day 36, the gonadal, subcutaneous, retroperitoneal, and mesenteric fat, quadriceps, and anterior tibial bone were dissected and weighed, and the skin was fixed in formalin and embedded in paraffin.

[0172] CORT increased food intake and seemed to be normalized by SPI-62. CORT-treated mice showed reduced weight gain over 2 weeks, followed by accelerated weight gain. SPI-62 prevented the accelerated weight gain. CORT effects on skin thickness and structure were less pronounced in mice that also received SPI-62. No effect of CORT or SPI-62 was observed in the open field test. SPI-62 prevented the adverse effects of CORT of insulin resistance, increased adiposity, skeletal muscle atrophy, and reduced grip strength. SPI-62 prevented some of the adverse effects of CORT in mice, indicating that blocking local intracellular glucocorticoid activation by HSD-1 inhibitors in target tissues can reduce glucocorticoid toxicity. See Tables 4 to 9 and Figures 12 and 13.

[0173] [Table 4]

[0174] [Table 5]

[0175] [Table 6]

[0176] [Table 7]

[0177] [Table 8]

[0178] [Table 9]

[0179] Example 8. PK-Adipose PD Model Development Male and nonmenstruating female subjects with type 2 diabetes, age 18-65 years, with a body mass index of 30.0-45.0, were administered SPI-62 daily for 14 days. In addition to the six subjects described in Example 1 who received 1, 3, or 6 mg of SPI-62 for 14 days, six additional subjects received 1, 2, 3, or 10 mg of SPI-62 for 5-8 days. Subjects were administered 1 μg / mL of D8 cortisone ([2,2,4,6,6,9,12,12- 2 H 8 ]Cortisone, Millipore Sigma, Miamisburg OH) was continuously infused into subcutaneous abdominal adipose tissue at a rate of 1 μL / min via a microdialysis catheter (63 Microdialysis Catheter, MDialysis, Stockholm Sweden). Fat dialysates were collected over 2-h intervals (0–2, 2–4, 4–6, 6–8, 8–10, 20–22, and 22–24 h after SPI-62 administration) and analyzed for D8 cortisone and D8 cortisol. The mole percent fraction (MPF) of D8 cortisol was calculated as follows: ([2,2,4,6,6,9,12,12- 2 H 8 ]Cortisol * 368.51) / ([2,2,4,6,6,9,12,12- 2 H 8 ]cortisone * 370.52), where 368.51 and 370.52 are the molar masses of D8 cortisone and D8 cortisol. Percent adipose HSD-1 inhibition was calculated as follows: 100 * (1-(MPF t / MPF baseline ). Sample time (t) was considered to be the midpoint of the collection interval. Use of a more sensitive assay for D8 cortisol allows quantification of >95% adipose HSD-1 inhibition.

[0180] The data were fitted to a target-mediated pharmacokinetic (TMDD) model, as shown in Figure 14. SPI-62 exhibited a first-order absorption rate constant (K a ) and the central compartment (C p ,V central After reaching the peripheral compartment (C t ,V peripheral ) and the second-order association rate constant (k on ) or can bind to a target site (R) to form the SPI-62-R complex. This complex has a first-order dissociation rate constant (k off ) into free drug and free target. In addition, there are three consecutive and equivalent first-pass rate constants (K TR ) was used to characterize the movement of SPI-62 from the absorption site (i.e., the depot compartment) to the central compartment. The model further incorporates the adipose interstitial fluid compartment and the adipose tissue cell compartment, where the transport of SPI-62 molecules between the two compartments is determined by their permeability (PS). Furthermore, a TMDD process occurs in adipose tissue: SPI-62 molecules in the adipose tissue cell compartment are transported by the second-order association rate constant (k on ) at the target site (i.e., HSD-1, R expressed in adipocytes). TA ) to form the SPI-62-R complex. The SPI-62 concentration in the lipid dialysate was collected using microdialysis and was the unbound concentration, so this was accounted for by incorporating the unbound fraction (fu) into the model. Finally, the complete PK / PD model structure was developed using an inhibitor I to relate lipid SPI-62 concentration to lipid HSD-1 activity. max Includes models.

[0181] Key parameter estimates from the model include: association rate constant (k on ) 1.44nM -1 h -1 , dissociation rate constant (k off )0.264h -1 , the total target volume in the central compartment (R TOT ) 7840 nM, total target amount in the fat compartment (R TA ) 671 nM, 50% HSD-1 inhibition (IC 50) to achieve a lipid free concentration of 23.4 pM, and a Hill coefficient (γ) of 1.42.

[0182] Estimated K d (k off / k on ) is the measured K of 12.6 nM for SPI-62 against human HSD-1 expressed in CHO cells. i and a K of 5.3 nM for purified human HSD-1, both 69-fold lower than that of SPI-62. i The estimated IC 50 The measured IC of 17 nM for SPI-62 against purified human HSD-1 50 Both of these differences unexpectedly indicate high potency of SPI-62 against HSD-1 in human adipose tissue, consistent with the lack of adipose tachyphylaxis due to the highly potent competitive binding of SPI-62 to HSD-1 versus accumulated cortisone (i.e., the HSD-1 substrate).

[0183] Estimated total target amount (R TOT +R TA ) corresponds to 3.6 mg of SPI-62, well within the dose range in which nonlinear PK was observed following a single SPI-62 dose. The Hill coefficients indicate moderate positive cooperativity for binding of SPI-62 to human HSD-1.

[0184] Example 9. Potential benefits of pseudo-irreversible HSD-1 inhibitors The key finding described herein is that SPI-62 does not exhibit tachyphylaxis upon adipose HSD-1 inhibition. Such tachyphylaxis has been previously reported for three other HSD-1 inhibitors (AZD4017, AZD8329, BI-135585) and was potentially considered a class effect. BI-187004, identified as a pseudo-irreversible HSD-1 inhibitor based on fast-on, slow-off in vitro enzyme kinetics, only exhibited limited tachyphylaxis upon adipose HSD-1 inhibition. SPI-62 is the first HSD-1 inhibitor for which a lack of adipose tachyphylaxis has been demonstrated. A structural model in which SPI-62 and certain other HSD-1 inhibitors form a ternary complex with NADPH in the human HSD-1 active site predicts that members of this genus of pseudo-irreversible HSD-1 inhibitors will not exhibit tachyphylaxis upon adipose HSD-1 inhibition. Based on the relative importance of adipose HSD-1 in regulating cardiac metabolic processes corresponding to the morbidity of GC excess, pseudo-irreversible inhibitors may be expected to show clinical advantages over other HSD-1 inhibitors on domains such as glycemic and lipid control, especially in patients with GC excess. For example, animal model data for BI-187004 shows glucose dependency that reduces efficacy for sustained >90% inhibition of adipose HSD-1. Evidence supporting the contention also comes from SPI-62, which is associated with the maximum reported effects on HbA1c, cholesterol, and triglycerides for HSD-1 inhibitors, subject to limitations including different durations of administration in separate clinical trials.

[0185] Pseudo-irreversible HSD-1 inhibitors may have additional advantages over other HSD-1 inhibitors. For example, in the case of sustained pharmacological effects, pseudo-irreversible HSD-1 inhibitors are more amenable to smaller daily doses, including depot formulations, and are less likely to show efficacy loss due to poor patient compliance. In addition, HSD-1 in the human body is likely to become fully occupied with approximately 3 mg of potent small molecule inhibitors. Low chronic doses are possible because pseudo-irreversible inhibitors simply distribute slowly away from HSD-1 once bound. Some pseudo-irreversible HSD-1 inhibitors, such as SPI-62, ABT-384, MK-0736, and MK-0916, have effective dose ranges of less than 10 mg per day. In contrast, other HSD-1 inhibitors, such as S-707106, AZD4017, INCB-13739, and RO5093151, require daily doses of 100 mg or more to show efficacy. At higher doses, the probability of certain types of side effects (eg, liver toxicity, which has been documented with AZD4017) may become more likely.

[0186] In summary, the present disclosure describes the discovery of a genus of HSD-1 inhibitors that have certain shared properties that are likely to be clinically beneficial, particularly in patients with GC excess.

[0187] The various embodiments described above can be combined to provide further embodiments. All U.S. patents, U.S. patent application publications, U.S. patent applications, foreign patents, foreign patent applications, and non-patent publications referenced herein and / or listed in the Application Data Sheets are incorporated herein by reference in their entirety. Aspects of the embodiments can be modified as necessary to utilize concepts from various patents, applications, and publications to provide further embodiments.

[0188] These and other variations to the embodiments can be made in light of the above detailed description. In general, in the following claims, the terms used should not be construed to limit the scope of the claims to the specific embodiments disclosed in the specification and claims, but should be construed to include all possible embodiments, along with the full scope of equivalents to which such claims are entitled. Thus, the claims are not limited by this disclosure.

Claims

1. A method for treating glucocorticoid excess in a patient in need thereof, comprising administering to said patient a pseudoirreversible HSD-1 inhibitor.

2. A method for ameliorating or preventing symptoms of glucocorticoid excess in a patient in need thereof, comprising administering to said patient a pseudoirreversible HSD-1 inhibitor.

3. 1. A method of reducing urinary tetrahydrocortisol levels in a patient having glucocorticoid excess, the method comprising administering a pseudoirreversible HSD-1 inhibitor to the patient, wherein the urinary tetrahydrocortisol levels are elevated compared to an asymptomatic patient.

4. 3. The method of claim 2, wherein the symptoms of glucocorticoid excess include cardiovascular, metabolic, immunological, bone, muscular, dermatological, ophthalmic, psychiatric, cognitive, circadian, or homeostatic symptoms.

5. 5. The method of claim 4, wherein the cardiovascular condition is selected from hypertension (including lack of nocturnal blood pressure dip), atherosclerosis, endothelial dysfunction, thrombotic conditions, coronary artery disease, heart failure, and stroke.

6. 5. The method of claim 4, wherein the metabolic condition is selected from obesity, glucose intolerance, insulin resistance, diabetes, and dyslipidemia (including hypercholesterolemia and hypertriglyceridemia).

7. 5. The method of claim 4, wherein the immunological condition is selected from infection (including opportunistic infection) and sepsis.

8. 5. The method of claim 4, wherein the bone condition is selected from osteoporosis, osteonecrosis, osteopenia, hypocalcemia (through decreased absorption or increased renal clearance or effects on vitamin D and PTH), linear bone growth (height), and fractures (including low impact or compression fractures).

9. 5. The method of claim 4, wherein the muscle symptom is selected from muscle atrophy and muscle weakness.

10. 5. The method of claim 4, wherein the dermatological condition is selected from impaired wound healing, thin or fragile skin, abnormal accumulation of subcutaneous fat, plethora, violet streaks, acanthosis nigricans, hyperpigmentation, and easy bruising.

11. 5. The method of claim 4, wherein the ocular condition is selected from increased intraocular pressure, glaucoma, exophthalmos, and cataracts.

12. 5. The method of claim 4, wherein the psychiatric condition is selected from depression, anxiety, hypomania, mania, and psychosis.

13. 5. The method of claim 4, wherein the cognitive symptoms are selected from impairments in memory, visuospatial processing, reasoning, verbal learning, and language performance.

14. 5. The method of claim 4, wherein the circadian symptom is selected from insomnia, daytime fatigue, sleep apnea, fragmented sleep, increased nocturnal motor activity, and abnormal REM sleep.

15. 5. The method of claim 4, wherein the homeostatic condition is selected from hypokalemia, hypernatremia, hypophosphatemia, hypercalciuria, growth hormone suppression, and thyroid disease (including hypothyroidism and hyperthyroidism).

16. The method according to any one of claims 1 to 15, wherein said pseudo-irreversible HSD-1 inhibitor does not exhibit tachyphylaxis to human adipose HSD-1 inhibition.

17. 17. The method of claim 16, wherein the HSD-1 inhibitor is selected from SPI-62 and BI-187004 or a pharma- ceutically acceptable salt thereof.

18. The method of any one of claims 1 to 15, wherein said HSD-1 inhibitor is characterized by human pharmacokinetics consistent with target-mediated pharmacokinetics.

19. 19. The method of claim 18, wherein the HSD-1 inhibitor is selected from SPI-62, ABT-384, MK-0736, MK-0916, BMS-823778, UE-2343, BI-187004, and AMG-221, or a pharma- ceutically acceptable salt thereof.

20. 19. The method of claim 18, wherein the plasma exposure of the HSD-1 inhibitor is less than dose-proportional after a single low dose and is dose-proportional after multiple low doses.

21. 21. The method of claim 20, wherein the dose is 10 mg or less.

22. 22. The method of claim 21 , wherein the dose is 6 mg or less.

23. 22. The method of claim 21 , wherein the dose is 4 mg or less.

24. The method of any one of claims 1 to 15, wherein said HSD-1 inhibitor is characterized by human pharmacodynamics consistent with target-mediated pharmacokinetics.

25. 25. The method of claim 24, wherein the HSD-1 inhibitor is selected from SPI-62 and ABT-384, or a pharma- ceutically acceptable salt thereof.

26. 25. The method of claim 24, wherein the pharmacodynamic half-life of the HSD-1 inhibitor for hepatic HSD-1 inhibition is extended compared to its pharmacokinetic half-life.

27. 27. The method of claim 26, wherein the HSD-1 inhibitor has a pharmacodynamic half-life for human hepatic HSD-1 inhibition of at least 1 week.

28. 28. The method of claim 27, wherein the pharmacodynamic half-life is at least 2 weeks.

29. 28. The method of claim 27, wherein the pharmacodynamic half-life is at least 4 weeks.

30. The method of any one of claims 1 to 15, wherein the HSD-1 inhibitor is characterized by fast-on, slow-off binding kinetics to human HSD-1.

31. 31. The method of claim 30, wherein the residence time of the HSD-1 inhibitor is at least about 500 seconds.

32. 31. The method of claim 30, wherein the HSD-1 inhibitor is selected from SPI-62, ABT-384, KR-67607, UE-2343, and BI-187004, or a pharma- ceutically acceptable salt thereof.

33. The method of any one of claims 1 to 15, wherein the HSD-1 inhibitor forms a hydrogen bond with the pyrophosphate of NADPH in the human HSD-1 active site.

34. 34. The method of claim 33, wherein the HSD-1 inhibitor is selected from SPI-62, ABT-384, KR-67607, SAR-184841, Compound A, and Compound B, or a pharma- ceutically acceptable salt thereof.

35. 16. The method of any one of claims 1 to 15, wherein the HSD-1 inhibitor forms an aromatic stacking interaction with NADPH in the human HSD-1 active site.

36. 36. The method of claim 35, wherein the HSD-1 inhibitor is selected from BMS-823778, MK-0916, Compound C, Compound D, or a pharma- ceutically acceptable salt thereof.

37. A method for ameliorating or preventing symptoms of glucocorticoid excess in a patient in need thereof, the method comprising administering a brain penetrant pseudoirreversible HSD-1 inhibitor to said patient. A method for ameliorating or preventing symptoms of glucocorticoid excess in a patient in need thereof, the method comprising administering a brain penetrant pseudoirreversible HSD-1 inhibitor to said patient.

38. 38. The method of claim 37, wherein the symptom is selected from a psychiatric symptom, a cognitive symptom, or a circadian symptom.

39. the psychiatric condition is selected from depression, anxiety, hypomania, mania, and psychosis; or the cognitive symptom is selected from impairments in memory, visuospatial processing, reasoning, verbal learning, and language performance; or The circadian symptoms are selected from insomnia, daytime fatigue, sleep apnea, fragmented sleep, increased nocturnal motor activity, and abnormal REM sleep.

39. The method of claim 38.

40. 38. The method of claim 37, wherein the pseudoirreversible HSD-1 inhibitor does not exhibit tachyphylaxis to human adipose HSD-1 inhibition.

41. 41. The method of claim 40, wherein the HSD-1 inhibitor is SPI-62.

42. 38. The method of claim 37, wherein the HSD-1 inhibitor exhibits human pharmacokinetics consistent with target-mediated pharmacokinetics.

43. 43. The method of claim 42, wherein the HSD-1 inhibitor is selected from SPI-62, ABT-384, and UE-2343, or a pharma- ceutically acceptable salt thereof.

44. 38. The method of claim 37, wherein said HSD-1 inhibitor is characterized by human pharmacodynamics consistent with target-mediated pharmacokinetics.

45. 45. The method of claim 44, wherein the HSD-1 inhibitor is selected from SPI-62 and ABT-384, or a pharma- ceutically acceptable salt thereof.

46. 38. The method of claim 37, wherein the HSD-1 inhibitor exhibits fast-on, slow-off binding kinetics to human HSD-1.

47. 47. The method of claim 46, wherein the HSD-1 inhibitor is selected from SPI-62, ABT-384, and UE-2343, or a pharma- ceutically acceptable salt thereof.

48. 38. The method of claim 37, wherein the HSD-1 inhibitor forms a hydrogen bond with the pyrophosphate of NADPH in the human HSD-1 active site.

49. 49. The method of claim 48, wherein the HSD-1 inhibitor is selected from SPI-62 and ABT-384, or a pharma- ceutically acceptable salt thereof.

50. 38. The method of claim 37, wherein the HSD-1 inhibitor forms an aromatic stacking interaction with NADPH in the human HSD-1 active site.

51. 51. The method of any one of claims 1 to 50, further comprising administering to the patient a glucocorticoid drug.

52. 52. The method of claim 51, wherein the HSD-1 inhibitor is administered in a fixed dose combination with the glucocorticoid drug.

53. 52. The method of claim 51, wherein the HSD-1 inhibitor and the glucocorticoid drug are co-packaged for separate administration.

54. 52. The method of claim 51, wherein the HSD-1 inhibitor is administered and packaged separately from the glucocorticoid drug.

55. 55. The method of any one of claims 51 to 54, wherein the glucocorticoid drug is selected from prednisolone, methylprednisolone, dexamethasone, hydrocortisone, budesonide, deflazacort, beclomethasone, ciclesonide, fluticasone, mometasone, triamcinolone, flunisolide, clobetasol, betamethasone, fluocinonide, flurandrenolide, clocortolone, halobetasol, desoximetasone, desonide, halcinonide, prednicarbate, diflorasone, amcinonide, alclometasone, difluprednate, loteprednol, fluorometholone, rimexolone, and medrysone, or a pharma- ceutically acceptable salt or ester derivative thereof.

56. The method of any one of claims 1 to 50, wherein the patient has an ACTH or CRH secreting tumor.

57. The method of any one of claims 1 to 50, wherein the patient has a cortisol-secreting tumor.

58. 58. The method of any one of claims 1 to 57, wherein the HSD-1 inhibitor is SPI-62, or a pharma- ceutically acceptable salt thereof.

59. 59. The method of any one of claims 1 to 58, wherein the HSD-1 inhibitor is administered orally.

60. 59. The method of any one of claims 1 to 58, wherein the HSD-1 inhibitor is administered intravenously.

61. 59. The method of any one of claims 1 to 58, wherein the HSD-1 inhibitor is administered intramuscularly or subcutaneously.

62. 59. The method of any one of claims 1 to 58, wherein the HSD-1 inhibitor is administered by inhalation or intranasally.

63. 59. The method of any one of claims 1 to 58, wherein the HSD-1 inhibitor is administered intraocularly.

64. 59. The method of any one of claims 1 to 58, wherein the HSD-1 inhibitor is administered locally.

65. The HSD-1 inhibitor is ｉ Lower K ｄ The method according to any one of claims 1 to 15, comprising:

66. The HSD-1 inhibitor is ｉ At least 60 times lower than ｄ 66. The method of claim 65, having the following structure:

67. The HSD-1 inhibitor has a lower IC20 measured in vivo than in vitro. ５０ The method according to any one of claims 1 to 15, comprising:

68. The estimated in vivo adipose IC ５０ is at least 700-fold lower than when measured in vitro.

69. 69. The method of any one of claims 65 to 68, wherein the HSD-1 inhibitor is SPI-62, or a pharma- ceutically acceptable salt thereof.

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