Methods for treating progressive familial intrahepatic cholestasis

Abstract

Methods for treating cholestasis in a subject with liver disease are provided. More specifically, the present invention relates to a method for treating progressive familial intrahepatic cholestasis (PFIC) in a subject, comprising administering malalixib to a subject in need thereof.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of and claims priority to U.S. Provisional Patent Application Nos. 63 / 418,589, filed October 23, 2022, 63 / 423,310, filed November 7, 2022, 63 / 471,291, filed June 6, 2023, and 63 / 522,355, filed June 21, 2023, which applications are incorporated herein by reference in their entireties. [Technical Field]

[0002] The present invention relates generally to methods for treating cholestasis in a subject with liver disease. More specifically, the present invention relates to a method for treating progressive familial intrahepatic cholestasis (PFIC) in a subject, comprising administering maralixibat to a subject in need thereof. [Background technology]

[0003] Progressive familial intrahepatic cholestasis (PFIC) is a rare autosomal recessive liver disorder characterized by intrahepatic cholestasis due to abnormalities in bile canalicular bile transport. There are four subtypes of PFIC classified based on different mutations. PFIC1, PFIC2, and PFIC3 are caused by mutations in the ATPase phospholipid transporter 8B1 (ATP8B1) gene, the ATP-binding cassette subfamily B member 11 (ABCB11) gene, and the ATP-binding cassette subfamily B member 4 (ABCB4) gene, respectively. All of these subtypes share the core clinical symptoms of cholestasis and pruritus. PFIC4 is caused by mutations in the tight junction protein 2 gene (TJP2), resulting in defective protein localization, disruption of tight junction structure, and severe cholestatic liver disease. In children, PFIC accounts for 10%–15% of cases of cholestasis and 10%–15% of indications for liver transplantation. PFIC2 is the most common subtype, diagnosed in approximately 50%–60% of PFIC patients, while PFIC1 (also known as Byler's disease) and PFIC3 account for approximately 10%–20% and 30%–40% of the PFIC population, respectively.

[0004] PFIC is associated with early mortality, morbidity, and a severe impact on patients' quality of life. Without surgery, PFIC1 and PFIC2 are highly aggressive, with only 10%–15% of PFIC1 and PFIC2 patients (depending on the variant) surviving to age 18 years. PFIC2 is associated with a continuous, progressive course of symptoms. While extrahepatic involvement, such as pancreatitis or diarrhea, can be characteristic of PFIC1, the initial symptoms and progression of disease in PFIC2 tend to be more severe than in PFIC1, with persistent jaundice occurring within the first month of life and rapid progression to cirrhosis and liver failure occurring within the first year of life. Interruption of the enterohepatic circulation of bile acids by partial external biliary diversion (PEBD) can produce promising results in terms of pruritus, jaundice, and histology in both PFIC1 and PFIC2 patients. Previous studies have reported dramatic 1-year outcomes in patients undergoing PEBD, with serum bile acid (sBA) and liver function normalized in 13 / 21 (62%) patients; however, other groups have reported an overall failure rate of up to 30%, with 30%–50% of patients requiring reoperation. Furthermore, for optimal benefit, PEBD must be performed before liver fibrosis and cirrhosis are established. For the majority of patients who do not undergo or respond to PEBD, liver transplantation may be the only treatment option. Given the clinical outcomes associated with PFIC, including the severe adverse impact on patient and caregiver quality of life, and the lack of approved treatments, there is a clear unmet medical need for novel therapies for this disease.

[0005] Maralixibat (as maralixibat chloride) is currently the only approved medication for treating pruritus in patients with Alagille syndrome. Maralixibat chloride is known to inhibit apical sodium-codependent bile acid transport (Patent Document 1). The synthesis of maralixibat chloride was previously disclosed in Patent Document 2. [Prior art documents] [Patent documents]

[0006] [Patent Document 1] U.S. Patent No. 5,994,391 [Patent Document 2] US Patent Application Publication No. 2003 / 0199515 Summary of the Invention [Means for solving the problem]

[0007] Various non-limiting aspects and embodiments of the present invention are described below.

[0008] In one aspect, the present invention provides a method for treating progressive familial intrahepatic cholestasis (PFIC) in a subject in need thereof, comprising administering maralixibat or a pharmaceutically acceptable salt thereof to the subject.

[0009] In one embodiment, the pharmaceutically acceptable salt of maralixibat is maralixibat chloride, maralixibat bromide, maralixibat acetate, or maralixibat mesylate. In one embodiment, the pharmaceutically acceptable salt of maralixibat is maralixibat chloride.

[0010] In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 10 μg / kg / day to about 1400 μg / kg / day. In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 300 μg / kg / day to about 1200 μg / kg / day. In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 600 μg / kg / day to about 1200 μg / kg / day. In one embodiment, the maralixibat or a pharmaceutically acceptable salt thereof is maralixibat chloride, and maralixibat chloride is administered in an amount of about 1200 μg / kg / day.

[0011] In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 0.5 mg / day to about 100 mg / day.

[0012] In one embodiment, the PFIC is PFIC1, PFIC2, PFIC3, PFIC4, PFIC5, or PFIC6. In one embodiment, the PFIC is PFIC1. In one embodiment, the PFIC is PFIC2. In one embodiment, the PFIC2 is non-truncated PFIC2. In one embodiment, the PFIC2 is truncated PFIC2. In one embodiment, the PFIC is PFIC3. In one embodiment, the PFIC is PFIC4. In one embodiment, the PFIC is PFIC5. In one embodiment, the PFIC is PFIC6.

[0013] In one embodiment, the PFIC is heterozygous. In one embodiment, the subject has intermittent cholestasis. In one embodiment, the subject has undergone biliary diversion surgery.

[0014] In some embodiments, the subject is a pediatric subject. In one embodiment, the subject is over 1 year old and under 18 years old. In one embodiment, the subject is under 12 months old.

[0015] In one embodiment, the subject has a mutation in a gene selected from the group consisting of ATP8B1, ABCB11, ABCB4, TJP2, NR1H4, and MYO5B.

[0016] In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered once daily (QD). In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered twice daily (BID).

[0017] In one embodiment, the maralixibat or a pharmaceutically acceptable salt thereof is maralixibat chloride, and the maralixibat chloride is administered at a total daily dose of 1200 μg / kg / day, at 600 μg / kg / day BID.

[0018] In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in PFIC symptoms or a change in a disease-relevant laboratory measure that is maintained for at least two months. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in PFIC symptoms or a change in a disease-relevant laboratory measure that is maintained for at least four months. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in PFIC symptoms or a change in a disease-relevant laboratory measure that is maintained for at least six months. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in PFIC symptoms or a change in a disease-relevant laboratory measure that is maintained for at least one year.

[0019] In one embodiment, symptom relief or change in disease-related laboratory values ​​is determined relative to baseline levels.

[0020] In one embodiment, the reduction in symptoms or change in disease-related laboratory values ​​comprises a decrease in sBA levels, a reduction in itching, a decrease in total bilirubin, a decrease in direct bilirubin, improved growth, or a combination thereof.

[0021] In one embodiment, administration of maralixibat reduces the intensity of pruritus, hi one embodiment, the reduction in pruritus intensity is a decrease in the ItchRO(Obs) score, the CSS score, or a combination thereof.

[0022] In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's ItchRO(Obs) score of at least 1.0 point compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's ItchRO(Obs) score of at least 1.2 point compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's ItchRO(Obs) score of at least 1.4 point compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's ItchRO(Obs) score of at least 1.6 point compared to baseline.

[0023] In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's CSS score of at least 1.0 point compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's CSS score of at least 1.2 points compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's CSS score of at least 1.4 points compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's CSS score of at least 1.6 points compared to baseline.

[0024] In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's sBA concentration of at least 50 μmol / L compared to baseline, hi one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's sBA concentration of at least 100 μmol / L compared to baseline.

[0025] In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin of at least 0.2 mg / dL compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin of at least 0.5 mg / dL compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin of at least 1.0 mg / dL compared to baseline.

[0026] In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in direct bilirubin. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in direct bilirubin of at least 0.2 mg / dL compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in direct bilirubin of at least 0.5 mg / dL compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in direct bilirubin of at least 1.0 mg / dL compared to baseline.

[0027] In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in an improvement in the subject's height Z-score or weight Z-score, or both, compared to baseline. In one embodiment, administration of maralixibat or a pharmaceutically acceptable salt thereof results in an increase in weight Z-score of at least 0.2 compared to baseline.

[0028] In one embodiment, the method further comprises administering a fat-soluble vitamin (LSV) to a subject with an LSV deficiency. In one embodiment, the LSV is selected from the group consisting of vitamin A, vitamin D, and vitamin E.

[0029] In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered before meals. In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered about 30 minutes before meals. In one embodiment, maralixibat or a pharmaceutically acceptable salt thereof is administered BID about 30 minutes before breakfast and about 30 minutes before dinner.

[0030] In one embodiment, maralixibat is administered in the form of a pharmaceutical composition comprising maralixibat or a pharmaceutically acceptable salt thereof, an antioxidant, and a preservative. In one embodiment, the pharmaceutical composition is a liquid composition for oral administration. In one embodiment, the liquid composition is an aqueous solution.

[0031] In one embodiment, maralixibat is present in an amount of about 2 mg / mL to about 100 mg / mL of the composition. In one embodiment, maralixibat is present in an amount of about 5 mg / mL to about 50 mg / mL of the composition. In one embodiment, maralixibat is present in an amount of about 8 mg / mL to about 20 mg / mL of the composition. In one embodiment, maralixibat is present in an amount of about 9.5 mg / mL to about 10 mg / mL of the composition.

[0032] In one embodiment, the preservative is an antimicrobial preservative. In one embodiment, the antimicrobial preservative is selected from the group consisting of propylene glycol, ethyl alcohol, glycerin, benzalkonium chloride, benzethonium chloride, benzoic acid, benzyl alcohol, butylparaben, cetrimide (cetyltrimethylammonium bromide), cetrimonium bromide, cetylpyridinium chloride, chlorhexidine, chlorobutanol, chlorocresol, cresol, ethylparaben, methylparaben, phenol, phenoxyethanol, phenylethyl alcohol, phenylmercuric acetate, phenylmercuric borate, phenylmercuric nitrate, propylparaben, sodium benzoate, sodium dehydroacetate, sodium propionate, sorbic acid, potassium sorbate, thimerosal, thymol, and combinations thereof. In one embodiment, the preservative is propylene glycol. In one embodiment, the preservative is present in an amount of about 30% to about 40% by weight of the composition. In one embodiment, the preservative is present in an amount of about 300 mg / mL to about 400 mg / mL of the composition.

[0033] In one embodiment, the antioxidant is selected from the group consisting of aminocarboxylic acids, aminopolycarboxylic acids, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, monothioglycerol, sodium ascorbate, sodium formaldehyde sulfoxylate, sodium metabisulfite, BHT, BHA, sodium bisulfite, vitamin E or a derivative thereof, propyl gallate, and combinations thereof.

[0034] In one embodiment, the antioxidant is an aminopolycarboxylic acid selected from EDTA (ethylenediaminetetraacetic acid), DTPA (diethylenetriaminepentaacetic acid), EGTA (ethylene glycol-bis(β-aminoethyl ether)-N,N,N',N'-tetraacetic acid), NTA (nitrilotriacetic acid), BAPTA (1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid), NOTA (2,2',2''-(1,4,7-triazonane-1,4,7-triyl)triacetic acid), DOTA (tetracarboxylic acid), and EDDHA (ethylenediamine-N,N'-bis(2-hydroxyphenylacetic acid). In one embodiment, the antioxidant is EDTA. In one embodiment, the antioxidant is present in an amount of about 0.01% (w / w) to 0.5% (w / w) of the composition.

[0035] In one embodiment, the pharmaceutical composition further comprises a sweetening agent, a taste-masking ingredient, or a combination thereof.

[0036] In one embodiment, the pharmaceutical composition comprises: a. About 8 mg / mL to about 20 mg / mL of maralixibat; b. about 330 mg / mL to about 380 mg / mL propylene glycol; c. Disodium EDTA, approximately 1 mg / mL; d. a sweetener, a taste-masking ingredient, or a combination thereof; and e water Includes:

[0037] These and other aspects of the present invention will become apparent to those skilled in the art after reading the following detailed description of the invention, including the appended claims. [Brief explanation of the drawings]

[0038] [Figure 1] A schematic diagram summarizing the physiological effects of maralixibat administration in patients is provided. IBAT = ileal bile acid transporter. [Figure 2]1 shows a schematic diagram providing an overview of the dosing regimen used in a Phase 3 open-label extension clinical trial of maralixibat in subjects with PFIC. The clinical trial investigated long-term exposure to maralixibat. [Figure 3] FIG. 1 shows a flow diagram depicting protocol recommendations for treatment of LSV deficiency and discontinuation due to exacerbation. [Figure 4] Figure 4A shows an overview of the MARCH-PFIC Phase 3 trial design. Figure 4B shows the efficacy endpoints. *Maralixibat 570 μg / kg is equivalent to maralixibat chloride 600 μg / kg. Abbreviations: AE = adverse event; BSEP = bile salt export pump; BL = baseline; ItchRO(Obs) = Itch-Reported Outcome (Observer); MMRM = mixed model repeated measure; R = randomization. [Figure 5] We describe 93 participants from the MARCH-PFIC trial. [Figure 6] Shown are the BSEP deficiency cohort (FIG. 6A) and the total PFIC cohort (FIG. 6B): mean change from baseline in itch severity score (ItchRO[Obs]). Abbreviations: LS = least squares; SE = standard error of the mean; CFB = change from baseline; CI = confidence interval. [Figure 7] The mean change from baseline in evening (Fig. 7A) and maximum daily (Fig. 7B) itch severity scores (ItchRO[Obs]) for the BSEP-deficient cohort is shown. [Figure 8] The mean change from baseline in evening (FIG. 8A) and maximum daily (FIG. 8B) itch severity scores (ItchRO[Obs]) for the entire PFIC cohort is shown. [Figure 9] The mean change from baseline in itch severity score (ItchRO[Obs]) for the FIC1 (FIG. 9A) and MDR3 (FIG. 9B) deficiency cohorts is shown. [Figure 10-1]10A shows the change from baseline in itch severity score (ItchRO[Obs]) over time for the BSEP deficiency (aka primary) cohort (FIG. 10A). [Figure 10-2] Shown is the change from baseline in itch severity score (ItchRO[Obs]) over time for the PFIC cohort (FIG. 10B). [Figure 10-3] Shown is the change from baseline in itch severity score (ItchRO[Obs]) over time for all study participants (FIG. 10C). [Figure 11] The Key Secondary Efficacy Endpoint: Mean change from baseline in sBA levels in the BSEP deficiency cohort (FIG. 11A) and the total PFIC cohort (FIG. 11B) is shown. Abbreviations: LS = least squares; SE = standard error of the mean; CFB = change from baseline; CI = confidence interval. [Figure 12] The mean change from baseline in sBA levels in the FIC1 cohort (FIG. 12A) and MDR3 cohort (FIG. 12B) is shown. [Figure 13] The percentage of pruritic responses (FIG. 13A) and sBA responses (FIG. 13B) by MARCH SAP for the BSEP deficiency cohort are shown. [Figure 14] The percentage of pruritus (FIG. 14A) and sBA (FIG. 14B) responses by MARCH SAP for the entire PFIC cohort are shown. [Figure 15-1] Shown is the change from baseline in sBA over time for the BSEP deficiency (aka primary) cohort (FIG. 15A). [Figure 15-2] The change from baseline in sBA over time for the PFIC cohort (FIG. 15B) and all study participants (FIG. 15C) is shown. [Figure 16] The proportion of pruritic responses with a rating of <1 in the BSEP deficiency cohort and the PFIC cohort is shown. The proportion of responders in the BSEP deficiency cohort is shown in Figure 16A; the proportion of responders in the total PFIC cohort is shown in Figure 16B. [Figure 17] The rates of pruritic responses of a rating of <1 or a decrease of >1 in the BSEP deficiency and PFIC cohorts are shown. The rate of responders in the BSEP deficiency cohort is shown in Figure 17A; the rate of responders in the total PFIC cohort is shown in Figure 17B. [Figure 18] Clinician scratch scores (or scratch scores) over time are shown for the BSEP deficiency (aka primary) cohort (FIG. 18A) and the PFIC cohort (FIG. 18B). [Figure 19] The mean change from baseline in Clinician Scratch Scale scores for the BSEP deficiency cohort (FIG. 19A) and the PFIC cohort (FIG. 19B) are shown. [Figure 20] The mean change from baseline in total bilirubin (mg / dL) for the BSEP deficiency cohort (FIG. 20A) and the PFIC cohort (FIG. 20B) is shown. [Figure 21] The change from baseline in total bilirubin (mg / dL) over time for the BSEP deficiency (aka primary) cohort (FIG. 21A) and the PFIC cohort (FIG. 21B) is shown. [Figure 22] The mean change from baseline in direct bilirubin (mg / dL) for the BSEP deficiency cohort (FIG. 22A) and the PFIC cohort (FIG. 22B) is shown. [Figure 23] Change from baseline in direct bilirubin (mg / dL) over time for the BSEP deficiency (aka primary) cohort (FIG. 23A) and the PFIC cohort (FIG. 23B) are shown. [Figure 24-1] Shown are changes from baseline in height Z-score over time for the BSEP-deficient (aka primary) cohort (FIG. 24A) and the PFIC cohort (FIG. 24B). [Figure 24-2] Figure 24C shows the change from baseline in height Z-score over time for the PFIC cohort (Figure 24C). [Figure 25-1] 25A shows the change from baseline in weight Z-score over time for the BSEP deficiency (aka primary) cohort (FIG. 25A). [Figure 25-2] The change from baseline in weight Z-score over time for the PFIC cohort (Figures 25B and 25C) is shown. [Figure 26] Changes from baseline in ALT in the entire PFIC cohort are shown. [Figure 27-1] Figure 27A shows a schematic providing an overview of the method. *ItchRO(Obs) score > 1.5; †Maralixibat 570 μg / kg corresponds to 600 μg / kg of maralixibat chloride. [Figure 27-2] Figure 27B shows that patients receiving maralixibat had significantly more days with minimal or no itch than patients receiving placebo. Error bars represent SE. Percentage values ​​represent the proportion of assessments from baseline to week 26. *Δ(95% CI). CI: confidence interval. SE is standard error. Figure 27C shows that patients receiving maralixibat had significant reductions in itch compared to placebo, regardless of when and how it was measured. [Figure 27-3] Figure 27D shows a significant improvement in change from baseline sleep as measured by EDQ(Obs) for maralixibat vs. placebo. *Δ(95% CI). Figure 27E shows that change in itch correlated strongly with change in sleep. Abbreviations: BL = Baseline; CSS = Clinician Scratch Scale; EDQ(Obs) = Exploratory Diary Questionnaire (Observer); ItchRO(Obs) = Itch-Reported Outcome (Observer); R = Randomization. [Figure 28] Figure 28 shows the incidence of gastrointestinal (GI) events. [Figure 29-1] Figure 29A shows a schematic providing the study design. [Figure 29-2] Figures 29B and 29C show that significant improvements in pruritus severity (Figure 29B) and serum bile acid (sBA) levels (Figure 29C) persisted in the MRX-MRX group. [Figure 29-3] Figures 29D and 29E show that newly obtained significant reductions in pruritus severity (Figure 29D) and sBA levels (Figure 29E) were observed in the PBO-MRX group. [Figure 30] Figure 30 shows a schematic diagram providing the study design. All patients received a weight-appropriate daily dose, with a maximum adult dose of 28.5 mg / d. bPre-16 years is defined as the last data point before the age of 16. Post-16 years is defined as the first data point after the age of 16. [Figure 31] Figures 31A and 31B show the change in ItchRO(Obs) (Figure 31A) and sBA (Figure 31B) for participants who initiated MRX treatment before age 16 (<16 years) (n=11). Of 11 participants, 9 had available ItchRO(Obs) scores at all measurement time points and were included in the analysis. b ItchRO(Obs) is on a 0-4 scale, with a decrease of ≥1 point considered clinically meaningful. Mean ItchRO(Obs) was rounded to one decimal place. Error bars represent standard error (SE). Significance was determined by Student's t-test. c Mean sBA was rounded to the nearest integer. Error bars represent standard error (SE). d Mean of the last two recordings before age 16. e Mean of the first two recordings after age 16. f Mean of the last two recordings. [Figure 32] Figures 32A and 32B show the change in ItchRO(Obs) (Figure 32A) and sBA (Figure 32B) for participants who initiated MRX treatment at age 16 years or older (≥16 years) (n=3). aItchRO(Obs) is on a 0-4 scale, with a reduction of ≥1 point considered clinically meaningful. bAverage of the last two recordings. [Figure 33] Figures 33A and 33B show the change in ItchRO(Obs) score by week in FIC1, MDR3, TJP2, and MYO5B. [Figure 34]Figures 34A and 34B show the change from baseline in serum bile acids for FIC1, MDR3, TJP2, and MYO5B. [Figure 35-1] Figures 35A and 35B show the weekly change in ItchRO(Obs) score and serum bile acids (sBA) in the entire study cohort. [Figure 35-2] Figures 35C and 35D show the weekly change in ItchRO(Obs) score and serum bile acids (sBA) in the no-variant-found cohort. [Figure 35-3] Figures 35E and 35F show the weekly change in ItchRO(Obs) score and serum bile acids (sBA) in the FIC1 cohort. [Figure 35-4] Figures 35G and 35H show the weekly change in ItchRO(Obs) score and serum bile acids (sBA) in MDR3. [Figure 36] Figures 36A and 36B show the change from baseline in total bilirubin (Figure 36A) and direct bilirubin (Figure 36B) in the entire PFIC cohort. [Figure 37] Figures 37A and 37B show the change from baseline in patients with abnormal total bilirubin (Figure 37A) and direct bilirubin (Figure 37B) at baseline. [Figure 38] Figures 38A and 38B show normalization of total bilirubin. [Figure 39] FIG. 39 shows normalization of direct bilirubin. [Figure 40] FIG. 40 shows the correlation between normalization of total bilirubin and changes in serum bile acids. [Figure 41-1]Figures 41A-41D show the change in morning itch severity over time for each patient, as measured by Itch-Reported Outcome (Observer). The change from baseline (baseline to week 26) in morning itch severity over time is shown for individual participants in the BSEP cohort (Figure 41A); and participants with FIC1, MDR3, TJP2, and MYO5B deficiencies (Figure 41B) (blue = maralixibat group; and red = placebo group). [Figure 41-2] Change from baseline (baseline to week 26) in morning pruritus severity over time is shown for individual participants without identified pathogenic variants (Figure 41C); and for participants with t-BSEP (BSEP3) deficiency (Figure 41D) (blue = maralixibat group; red = placebo group). BSEP is bile salt export pump, FIC1 is familial intrahepatic cholestasis-associated protein 1, MDR3 is multidrug resistance protein 3, MYO5B is myosin VB, t is truncated, and TJP2 is tight junction protein 2. [Figure 42-1] Figures 42A-42D show the change in BA levels over time for each patient. The change from baseline in sBA levels (baseline to week 26) for participants in the BSEP cohort (Figure 42A) is shown (blue = maralixibat and red = placebo group). [Figure 42-2]Changes from baseline in sBA levels (baseline to week 26) are shown for participants with FIC1, MDR3, TJP2, and MYO5B deficiencies (Figure 42B); participants without detected pathogenic variants (Figure 42C); and participants with truncated BSEP (BSEP3; Figure 42D) (blue = maralixibat; red = placebo). BSEP represents bile salt export pump, FIC1 represents familial intrahepatic cholestasis-associated protein 1, MDR3 represents multidrug resistance protein 3, MYO5B represents myosin VB, and t represents truncated. *Patients had a concomitant decrease in total bilirubin (from 3.85 mg / dL at baseline to 2.6 mg / dL at week 26) and ALT (from 320 U / L at baseline to 183 U / L at week 26). DETAILED DESCRIPTION OF THE INVENTION

[0039] Detailed embodiments of the present invention are disclosed herein; however, it should be understood that the disclosed embodiments are merely exemplary of the invention, which may be embodied in various forms. Furthermore, each of the examples given in connection with various embodiments of the present invention is intended to be illustrative, not limiting. Therefore, the specific structural and functional details disclosed herein should not be construed as limiting, but merely as a representative basis for teaching those skilled in the art to variously use the present invention.

[0040] Malalixibat is an inhibitor of IBAT, a transmembrane protein present in the terminal ileum and localized on the luminal surface of ileocytes. IBAT mediates the uptake of conjugated bile acids across the brush border membrane of enterocytes. Ninety-five percent of bile acids entering the intestinal lumen are recycled to the gallbladder, where they are stored for future release into the duodenum. Additional proteins and transporters transport bile acids across the enterocyte basolateral membrane into the bloodstream, where they circulate to the liver via the portal vein and are subsequently resecreted into the intestine, a process known as the enterohepatic circulation (Figure 1). Malalixibat-mediated blockade of intestinal reabsorption of bile acids by IBAT blocks the enterohepatic circulation, thereby increasing fBA excretion and decreasing sBA levels.

[0041] "Maralixibat" refers to 1-(4-((4-((4R,5R)-3,3-dibutyl-7-(dimethylamino)-4-hydroxy-1,1-dioxide-2,3,4,5-tetrahydrobenzo[b]thiepin-5-yl)phenoxy)methyl)benzyl)-1,4-diazabicyclo[2.2.2]octan-1-ium, which is the free form of maralixibat chloride. The structure of maralixibat is shown below: [ka]

[0042] "Maralixibat chloride" (also known as LUM-001, SHP625, or lopixibat chloride) refers to 1-(4-((4-((4R,5R)-3,3-dibutyl-7-(dimethylamino)-4-hydroxy-1,1-dioxide-2,3,4,5-tetrahydrobenzo[b]thiepin-5-yl)phenoxy)methyl)benzyl)-1,4-diazabicyclo[2.2.2]octan-1-ium chloride. The structure of maralixibat chloride is shown below: [ka]

[0043] IBAT is ideally suited for pharmacological modulation of bile acid transport with compounds that can be restricted to the intestinal lumen and do not require systemic exposure for activity. Malalixibat is designed to be minimally absorbed due to its large molecular weight (approximately 710 Da) and the presence of a positively charged quaternary nitrogen atom, thus maximizing local exposure of the molecule to its target and minimizing unwanted systemic exposure.

[0044] Because reduction in sBA concentrations after surgical interruption of the enterohepatic circulation has been shown to be associated with improved cholestasis and clinical outcome in some pediatric cholestatic liver diseases, pharmacological interruption of the enterohepatic circulation by IBAT inhibition represents a potential nonsurgical and easily reversible alternative to achieve a similar reduction in sBAs and therefore has the potential to improve outcomes in diseases such as PFIC, ALGS, and biliary atresia.

[0045] Bile acids / salts play an important role in the activation of digestive enzymes and the solubilization of fats and fat-soluble vitamins, and are involved in liver, bile duct, and intestinal diseases. Bile acids are synthesized in the liver through a multistep, multiorganellar pathway. Hydroxyl groups are added to specific sites on the steroid structure, the double bond in the B ring of cholesterol is reduced, the hydrocarbon chain is shortened by three carbon atoms, and a carboxyl group is attached to the end of the chain. The most common bile acids are cholic acid and chenodeoxycholic acid ("primary bile acids"). Before leaving hepatocytes to form bile, bile acids are conjugated to glycine (to produce glycocholic acid or glycochenodeoxycholic acid) or taurine (to produce taurocholic acid or taurochenodeoxycholic acid). Conjugated bile acids are called bile salts, and their amphiphilic nature makes them more efficient surfactants than bile acids. Bile salts, rather than bile acids, are found in bile.

[0046] Bile salts are excreted by hepatocytes into the bile canaliculi to form bile. The bile canaliculi empty into the left and right hepatic ducts, and bile flows to the gallbladder. Bile is released from the gallbladder and travels to the duodenum, where it contributes to fat metabolism and breakdown. Bile salts are reabsorbed in the terminal ileum and returned to the liver via the portal vein. Bile salts often undergo multiple enterohepatic circulations before being excreted in the feces. A small amount of bile salts can be reabsorbed in the proximal intestine by either passive or carrier-mediated transport. Most bile salts can be reabsorbed in the distal ileum by a sodium-dependent, apically located bile acid transporter called the apical sodium-dependent bile acid transporter (ASBT). At the basolateral surface of enterocytes, a truncated form of ASBT is involved in the vectorial transport of bile acids / salts into the portal circulation. Completion of the enterohepatic circulation occurs at the basolateral surface of hepatocytes through a transport process mediated primarily by sodium-dependent bile acid transporters. Intestinal bile acid transport plays a key role in the enterohepatic circulation of bile salts. Molecular analysis of this process has recently led to important advances in our understanding of the biology, physiology, and pathophysiology of intestinal bile acid transport.

[0047] In the intestinal lumen, bile acid concentrations fluctuate, with most of the reuptake occurring in the distal intestine. Described herein are specific compositions and methods for controlling the bile acid concentrations in the intestinal lumen, thereby controlling hepatocellular damage caused by bile acid accumulation in the liver.

[0048] General definition Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs.

[0049] As used in this specification and the appended claims, the singular forms "a," "an," and "the" include plural references unless the context clearly dictates otherwise. Thus, for example, reference to a "method" includes one or more methods, and / or steps of the type described herein and / or that will become apparent to those skilled in the art upon reading this disclosure.

[0050] As used herein, the term "baseline" or "pre-administration baseline" refers to information collected at the beginning of a study or a known initial value used for comparison with subsequent data. A baseline is an initial measurement of a measurable condition obtained at an initial time point and used to compare over time to look for changes in the measurable condition. For example, a patient's serum bile acid concentration before drug administration (baseline) and after drug administration. A baseline is an observation or value representing a normal or starting level of a measurable quality used for comparison with values ​​representing a response to an intervention or environmental stimulus. A baseline is time "zero" before study participants receive an experimental drug or intervention or negative control. For example, "baseline" can, in some instances, refer to 1) the state of a measurable quantity immediately prior to the start of a clinical trial or 2) the state of a measurable quantity immediately prior to changing the dosage level or composition administered to a patient from a first dosage level or composition to a second dosage level or composition.

[0051] As used herein, the terms "level" and "concentration" are used interchangeably. For example, "high serum bilirubin level" can be replaced with "high serum bilirubin concentration."

[0052] As used herein, the term "normalized" or "normal range" refers to an age-specific value within a range appropriate for healthy individuals (i.e., a normal or normalized value). For example, the phrase "serum bilirubin concentration normalized within 3 weeks" means that the serum bilirubin concentration fell within a range known in the art to be appropriate for healthy individuals (i.e., within the normal range, not, for example, an elevated range) within 3 weeks. In various embodiments, a normalized serum bilirubin concentration is between about 0.1 mg / dL and about 1.2 mg / dL. In various embodiments, a normalized serum bile acid concentration is between about 0 μmol / L and about 25 μmol / L.

[0053] As used herein, the terms "ITCHRO(OBS)" and "ITCHRO" (or "ItchRO(Pt)") are used interchangeably, with the proviso that the ITCHRO(OBS) scale is used by caregivers to measure the severity of itch in all patients, and the ITCHRO scale is used to measure the severity of itch in adults aged 18 years and older. Therefore, when the ITCHRO(OBS) scale is referred to in relation to adult patients, the ITCHRO scale is the indicated scale. Similarly, when the ITCHRO scale is referred to in relation to pediatric patients, the ITCHRO(OBS) scale is usually the indicated scale. Some children aged 9 years and older reported their scores as the ITCHRO(Pt) score. For the ALGS and PFIC studies, the ITCHRO(Pt) was administered to patients aged 9 years and older, and the ITCHRO(OBS) was administered to patients younger than 9 years. The ITCHRO(OBS) scale ranges from 0 to 4, the ITCHRO(Pt) scale ranges from 0 to 4, and the ITCHRO scale ranges from 0 to 10.

[0054] As used herein, the terms "EDQ(Obs)," "EDQ(Pt)," and "EDQ" refer to the Exploratory Diary Questionnaire, used to assess pruritus in children under 18 years of age or adults 18 years of age or older. The EDQ is a caregiver / patient-reported outcome measure administered as a twice-daily electronic diary. The EDQ included a question about sleep related to pruritus: "Because of pruritus, your child had trouble staying asleep. 1-Never, 2-Rarely, 3-Sometimes, 4-Often, 5-Almost Always." Caregivers of all subjects under 9 years of age completed the observer tool: EDQ(Obs). Subjects 9 years of age or older completed the patient tool: EDQ(Pt). The EDQ includes questions about sleep disturbances related to pruritus.

[0055] As used herein, the term "bile acid(s)" includes steroid acids (and / or their carboxylate anions) and their salts found in animal (e.g., human) bile, including, but not limited to, cholic acid, cholate, deoxycholic acid, deoxycholate, hyodeoxycholic acid, hyodeoxycholate, glycocholic acid, glycocholate, taurocholic acid, taurocholate, chenodeoxycholic acid, ursodeoxycholic acid, ursodiol, tauroursodeoxycholic acid, glycoursodeoxycholic acid, 7-beta-methylcholic acid, methyllithocholic acid, chenodeoxycholate, lithocholic acid, lithocholate, and the like. Taurocholic acid and / or taurocholate are referred to herein as TCAs. As used herein, any reference to a bile acid includes a reference to a bile acid, one and only one bile acid, one or more bile acids, or at least one bile acid. Thus, the terms "bile acid," "bile salt," "bile acid / salt," "bile acids," "bile salts," and "bile acid / salts" are used interchangeably herein unless otherwise specified. Any reference to a bile acid as used herein includes a reference to a bile acid or its salt. Additionally, pharmaceutically acceptable bile acid esters are optionally utilized as "bile acids" herein, e.g., bile acids / salts conjugated to an amino acid (e.g., glycine or taurine). Other bile acid esters include, for example, substituted or unsubstituted alkyl esters, substituted or unsubstituted heteroalkyl esters, substituted or unsubstituted aryl esters, substituted or unsubstituted heteroaryl esters, and the like. For example, the term "bile acid" includes cholic acid conjugated with either glycine or taurine (glycocholic acid and taurocholic acid (and their salts), respectively). Any reference to a bile acid as used herein includes a reference to the same compound, whether naturally or synthetically prepared. Furthermore, any singular reference to a component (bile acid or otherwise) as used herein should be understood to include a reference to one and only one, one or more, or at least one of such components.Similarly, as used herein, a plurality of references to elements includes a reference to one and only one, one or more, or at least one of such elements unless otherwise specified.

[0056] The terms "subject," "patient," "participant," or "individual" are used interchangeably herein and refer to mammals and non-mammals, e.g., suffering from a disorder described herein. Examples of mammals include, but are not limited to, any member of the class Mammalia: humans, non-human primates such as chimpanzees, and other ape and monkey species; livestock animals such as cows, horses, sheep, goats, and pigs; domestic animals such as rabbits, dogs, and cats; and laboratory animals, including rodents such as rats, mice, and guinea pigs. Examples of non-mammals include, but are not limited to, birds, fish, and the like. In one embodiment of the methods and compositions provided herein, the mammal is a human.

[0057] As used herein, the term "about" includes any value within 10% of the stated value.

[0058] As used herein, the term "composition" includes disclosure of both compositions and compositions administered in the methods described herein. Furthermore, in some embodiments, the compositions of the present invention are or comprise a "formulation," an oral dosage form, or a rectal dosage form, as described herein.

[0059] The terms "treat," "treating," or "treatment," and other grammatical equivalents used herein, include alleviating, suppressing, or alleviating symptoms; reducing or inhibiting the severity of a disease or condition; reducing the occurrence of a disease or condition; reducing or inhibiting the recurrence of a disease or condition; delaying the onset of a disease or condition; delaying the recurrence of a disease or condition; alleviating or ameliorating a disease or condition; ameliorating the underlying cause of symptoms; inhibiting a disease or condition, e.g., arresting the progression of a disease or condition; relieving a disease or condition; causing regression of a disease or condition; alleviating symptoms caused by a disease or condition; or halting the symptoms of a disease or condition. These terms further include achieving a therapeutic benefit. A therapeutic benefit refers to eradication or amelioration of the underlying disease being treated and / or eradication or amelioration of one or more physiological symptoms associated with the underlying disease such that an improvement is observed in the patient.

[0060] As used herein, the term "effective amount" or "therapeutically effective amount" refers to a sufficient quantity of at least one agent (e.g., a therapeutically active substance) being administered to achieve a desired result in a subject or individual, such as alleviating to some extent one or more symptoms of the disease or condition being treated. In certain instances, the result is a reduction and / or alleviation of the signs, symptoms, or causes of a disease, or any other desired alteration of a biological system. In certain instances, an "effective amount" for therapeutic use is the amount of a composition comprising an agent described herein required to provide a clinically significant alleviation of the disease. The appropriate "effective" amount in any individual case is determined using any suitable technique, such as a dose escalation study. In some embodiments, a "therapeutically effective amount" or "effective amount" of ASBTI refers to an amount of ASBTI sufficient to treat cholestasis or cholestatic liver disease in a subject or individual.

[0061] As used herein, the terms "administer," "administering," "administration," and the like refer to methods that can be used to deliver an agent or composition to the site where a biological effect is desired. These methods include, but are not limited to, oral routes, intraduodenal routes, parenteral injection (including intravenous, subcutaneous, intraperitoneal, intramuscular, intravascular, or infusion), topical administration, and rectal administration. Administration techniques that may be used in the agents and methods described herein can be found, for example, in Goodman and Gilman, The Pharmacological Basis of Therapeutics, current ed.; Pergamon; and Remington's, Pharmaceutical Sciences (current edition), Mack Publishing Co., Easton, Pa., all of which are incorporated herein by reference in their entirety for all purposes. In certain embodiments, the agents and compositions described herein are administered orally.

[0062] The term "ASBT inhibitor" refers to a compound that inhibits apical sodium-dependent bile acid transport or any recuperative bile salt transport. The term "IBAT inhibitor" refers to a compound that inhibits ileal bile acid transport or any recuperative bile salt transport. The term apical sodium-dependent bile acid transporter (ASBT) is used interchangeably with the term ileal bile acid transporter (IBAT). The term "ASBT inhibitor" is used interchangeably with the term "IBAT inhibitor."

[0063] The phrase "pharmaceutically acceptable," when used in connection with compositions of the present invention, refers to molecular entities and other components of such compositions that are physiologically tolerated and typically do not produce adverse reactions when administered to a mammal (e.g., a human). Preferably, as used herein, the term "pharmaceutically acceptable" means approved by a federal or state regulatory agency or listed in the United States Pharmacopoeia or other generally recognized pharmacopoeias for use in mammals, more specifically, humans.

[0064] In various embodiments, pharmaceutically acceptable salts described herein include, by way of non-limiting example, nitrate, chloride, bromide, phosphate, sulfate, acetate, hexafluorophosphate, citrate, gluconate, benzoate, propionate, butyrate, salicylate, maleate, laurate, malate, fumarate, succinate, tartrate, amsonate, pamoate, p-toluenesulfonate, mesylate, etc. Additionally, pharmaceutically acceptable salts include, by way of non-limiting example, alkaline earth metal salts (e.g., calcium or magnesium), alkali metal salts (e.g., sodium or potassium), ammonium salts, etc.

[0065] bile acids Bile contains water, electrolytes, and numerous organic molecules, including bile acids, cholesterol, phospholipids, and bilirubin. It is secreted from the liver and stored in the gallbladder. When the gallbladder contracts due to the ingestion of a fatty meal, bile enters the intestine through the bile duct. Bile acids / salts are important for the digestion and absorption of fats and fat-soluble vitamins in the small intestine. Adults produce 400–800 mL of bile per day. Bile secretion can be thought of as occurring in two stages. First, hepatocytes secrete bile into the bile canaliculi, from which it flows into the bile ducts. This hepatic bile contains large amounts of bile acids, cholesterol, and other organic molecules. Second, as bile flows through the bile ducts, it is modified by the addition of a watery, bicarbonate-rich secretion from bile duct epithelial cells. Bile is typically concentrated fivefold during storage in the gallbladder.

[0066] Bile flow is lowest during fasting, with most of it directed to the gallbladder for concentration. When the chyme from a ingested meal enters the small intestine, acid and partially digested fat and protein stimulate the secretion of cholecystokinin and secretin, both of which are important for bile secretion and flow. Cholecystokinin (cholecyst = gallbladder and kinin = motor) is a hormone that stimulates contraction of the gallbladder and common bile duct, resulting in the delivery of bile to the intestine. The most potent stimulus for the release of cholecystokinin is the presence of fat in the duodenum. Secretin, a hormone secreted in response to acid in the duodenum, stimulates cholangiocytes to secrete bicarbonate and water, thereby increasing bile volume and its outflow to the intestine.

[0067] Bile acids / salts are derivatives of cholesterol. Cholesterol, either ingested as part of the diet or synthesized in the liver, is converted to bile acids / salts in hepatocytes. Examples of such bile acids / salts include cholic acid and chenodeoxycholic acid, which are then conjugated to amino acids (such as glycine or taurine) to produce conjugated forms that are actively secreted into the bile canaliculi. The most abundant bile salts in humans are cholate and deoxycholate, which are typically conjugated with either glycine or taurine to produce glycocholate or taurocholate, respectively.

[0068] Free cholesterol is virtually insoluble in aqueous solutions but becomes soluble in bile due to the presence of bile acids / salts and lipids. Hepatic synthesis of bile acids / salts accounts for the majority of cholesterol breakdown in the body. In humans, approximately 500 mg of cholesterol is converted to bile acids / salts and excreted in bile per day. Therefore, secretion into bile is the primary pathway for cholesterol elimination. Although a large amount of bile acids / salts is secreted into the intestine every day, relatively little is lost from the body. This is because approximately 95% of bile acids / salts delivered to the duodenum are absorbed back into the blood in the ileum through a process known as the "enterohepatic circulation."

[0069] Venous blood from the ileum enters the portal vein and thus passes through the hepatic sinusoids. Hepatocytes extract bile acids / salts from sinusoidal blood very efficiently, with very little escape into the systemic circulation from a healthy liver. The bile acids / salts are then transported across hepatocytes and re-secreted into the bile canaliculi. The net effect of this enterohepatic circulation is that each bile salt molecule is recycled approximately 20 times, often 2–3 times during a single digestive cycle. Bile biosynthesis represents the major metabolic fate of cholesterol and accounts for over half of the approximately 800 mg / day of cholesterol consumed by the average adult during metabolic processes. In contrast, steroid hormone biosynthesis consumes only approximately 50 mg of cholesterol per day. Much more than 400 mg of bile salts are required per day and secreted into the intestine, which is achieved by recycling bile salts. Most of the bile salts secreted into the upper region of the small intestine are absorbed at the lower end of the small intestine along with the dietary lipids they emulsify. They are separated from dietary lipids and returned to the liver for reuse, thus recycling allows 20–30 g of bile salts to be secreted into the small intestine each day.

[0070] Bile acids and salts are amphiphilic; cholesterol-derived moieties contain both hydrophobic (lipid-soluble) and polar (hydrophilic) moieties, whereas amino acid conjugates are generally polar and hydrophilic. This amphiphilic nature allows bile acids and salts to perform two important functions: emulsification of lipid aggregates and solubilization and transport of lipids into aqueous environments. Bile acids and salts have a detergent action on dietary fat particles, breaking down or emulsifying fat globules. Emulsification is important because it greatly increases the surface area of ​​fat available for digestion by lipases that cannot access the interior of lipid droplets. Furthermore, bile acids and salts are lipid carriers, capable of solubilizing many lipids by forming micelles, which are important for the transport and absorption of fat-soluble vitamins.

[0071] As used herein, the terms "non-systemic" or "minimally absorbed" refer to low systemic bioavailability and / or absorption of an administered compound. In some embodiments, a non-systemic compound is a compound that is not substantially systemically absorbed. In some embodiments, the ASBTI compositions described herein deliver ASBTI to the distal ileum, colon, and / or rectum and not systemically (e.g., a significant portion of ASBTI is not systemically absorbed). In some embodiments, the systemic absorption of the non-systemic compound is less than 0.1%, less than 0.3%, less than 0.5%, less than 0.6%, less than 0.7%, less than 0.8%, less than 0.9%, less than 1%, less than 1.5%, less than 2%, less than 3%, or less than 5% (wt % or mol %) of the administered dose. In some embodiments, the systemic absorption of the non-systemic compound is less than 10% of the administered dose. In some embodiments, the systemic absorption of the non-systemic compound is less than 15% of the administered dose. In some embodiments, the systemic absorption of the non-systemic compound is less than 25% of the administered dose. In an alternative approach, the non-systemic ASBTI (e.g., maralixibat) is a compound that has a lower systemic bioavailability compared to the systemic bioavailability of the systemic ASBTI. In some embodiments, the bioavailability of the non-systemic ASBTI (e.g., maralixibat) described herein is less than 30%, less than 40%, less than 50%, less than 60%, or less than 70% of the bioavailability of the systemic ASBTI.

[0072] In another alternative approach, the compositions described herein are formulated to deliver less than 10% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver less than 20% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver less than 30% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver less than 40% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver less than 50% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver less than 60% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver less than 70% of the administered dose of ASBTI systemically. In some embodiments, systemic absorption is determined in any suitable manner, including total circulating amount, amount cleared after administration, etc.

[0073] Classes of Cholestasis and Cholestatic Liver Disease As used herein, "cholestasis" refers to a disease or condition involving impaired bile formation and / or bile flow. As used herein, "cholestatic liver disease" refers to a liver disease associated with cholestasis. Cholestatic liver disease is often accompanied by jaundice, fatigue, and pruritus (itching). Biomarkers of cholestatic liver disease include elevated serum bile acid concentrations, elevated serum alkaline phosphatase (AP), elevated gamma-glutamyl transpeptidase (γGT), conjugated hyperbilirubinemia, and elevated serum cholesterol.

[0074] Cholestatic liver disease can be divided clinicopathologically into two major categories: obstructive, often extrahepatic, cholestasis and nonobstructive or intrahepatic cholestasis, in which cholestasis occurs when bile flow is mechanically blocked, such as by gallstones or tumors, or in extrahepatic biliary atresia.

[0075] The latter group, with nonobstructive intrahepatic cholestasis, is further divided into two major subgroups. In the first subgroup, cholestasis occurs when the processes of bile secretion and modification or bile component synthesis are secondary to hepatocellular injury so severe that nonspecific impairment of many functions, including those supporting bile formation, can be expected. In the second subgroup, no presumed cause of hepatocellular injury can be identified. Cholestasis in such patients appears to result from constitutive impairment of one of the steps in bile secretion or modification or bile component synthesis. Such cholestasis is considered primary.

[0076] Progressive familial intrahepatic cholestasis (PFIC) PFIC is a rare genetic disorder that causes progressive liver disease, typically resulting in liver failure. In people with PFIC, liver cells are less able to secrete bile. The resulting accumulation of bile causes liver disease in affected individuals. Signs and symptoms of PFIC typically begin in infancy. Patients experience severe itching, jaundice, failure to grow at the expected rate (failure to thrive), and increasing liver dysfunction (liver failure). The disease is estimated to affect 1 in 50,000 to 100,000 people in the United States and Europe. Six genetically identified forms of PFIC have been identified, all of which are similarly characterized by impaired bile flow and progressive liver disease.

[0077] Subtypes of PFIC include familial intrahepatic cholestasis-associated protein 1 (FIC1) deficiency (PFIC1), bile salt export pump (BSEP) deficiency (PFIC2), multidrug resistance 3 protein (MDR3) deficiency (PFIC3), tight junction protein 2 (TJP2) deficiency (PFIC4), farnesoid X receptor (FXR) deficiency (PFIC5), and myosin VB (MYO5B) deficiency (PFIC6), which are discussed in more detail below.

[0078] PFIC1 PFIC1 (also known as Byler disease or FIC1 deficiency) is associated with mutations in the ATP8B1 gene (also called FIC1). This gene, encoding a P-type ATPase, is located on human chromosome 18 and is also mutated in milder phenotypes, benign recurrent intrahepatic cholestasis type 1 (BRIO) and Greenland familial cholestasis. The FIC1 protein is located in the canalicular membrane of hepatocytes, but is primarily expressed in cholangiocytes within the liver. P-type ATPase appears to be an aminophospholipid transporter responsible for maintaining the enrichment of phosphatidylserine and phosphatidylethanolamine in the inner leaflet of the plasma membrane compared with the outer leaflet. In some cases, PFIC1 mutations are homozygous. In other cases, PFIC1 mutations are heterozygous. Asymmetric distribution of lipids in the membrane bilayer protects against high bile salt concentrations in the canalicular lumen. Abnormal protein function may indirectly interfere with biliary secretion of bile acids. Abnormal secretion of bile acids / salts leads to bile acid overload of hepatocytes.

[0079] PFIC1 typically presents in infants (e.g., 6-18 months of age). Infants may exhibit signs of pruritus, jaundice, abdominal distension, diarrhea, malnutrition, and short stature. Biochemically, individuals with PFIC1 have elevated serum transaminases, elevated bilirubin, elevated serum bile acid levels, and low γGT levels. Individuals may also have liver fibrosis. Individuals with PFIC1 typically lack bile duct proliferation. Most individuals with PFIC1 develop end-stage liver disease by the age of 10. No medical treatment has proven beneficial for the long-term treatment of PFIC1. Children are often given medium-chain triglycerides and fat-soluble vitamins to alleviate extrahepatic symptoms (e.g., malnutrition and growth failure). Ursodiol has not been shown to be effective in individuals with PFIC1.

[0080] PFIC2 PFIC2 (also known as Byler syndrome or BSEP deficiency) is associated with mutations in the ABCB11 gene (also called BSEP). The ABCB11 gene encodes the ATP-dependent canalicular bile salt export pump (BSEP) in the human liver and is located on human chromosome 2. The BSEP protein, expressed in the hepatocyte bile canalicular membrane, is the primary exporter (transporter) of primary bile acids / salts against extreme concentration gradients. Mutations in this protein are responsible for the reduced bile salt secretion described in affected patients, resulting in reduced bile flow and accumulation of bile salts within hepatocytes, causing ongoing severe hepatocellular damage. In some instances, PFIC2 mutations are homozygous. In other instances, PFIC2 mutations are heterozygous.

[0081] BSEP deficiency has previously been classified into three subtypes, designated BSEP1, BSEP2, and BSEP3, based on the type of mutation and the severity of the resulting deficiency. The BSEP1 genotype represents patients with at least one D482G or E297G mutation. Because the causative mutation still allows partial function of the BSEP protein, BSEP1 is considered the least severe genotype. The BSEP2 genotype represents patients with at least one missense mutation that is not a D482G or E297G mutation. The BSEP3 genotype is the most severe and represents patients with known or suspected mutations that result in a nonfunctional BSEP protein or lack of BSEP expression. BSEP3 is associated with a relatively high incidence of hepatocellular carcinoma (HCC). The severity of BSEP deficiency has also been shown to strongly predict long-term autologous liver survival.

[0082] PFIC2 typically presents in infants (e.g., 6-18 months of age). Infants may exhibit signs of pruritus. Biochemically, individuals with PFIC2 have elevated serum transaminases, elevated bilirubin, elevated serum bile acid levels, and low γGT levels. Individuals may also have portal vein inflammation and giant cell hepatitis. Furthermore, individuals often develop hepatocellular carcinoma. No medical treatment has proven beneficial for the long-term treatment of PFIC2. Children are often given medium-chain triglycerides and fat-soluble vitamins to alleviate extrahepatic symptoms (e.g., malnutrition and growth failure). PFIC2 patients account for approximately 60% of the PFIC population.

[0083] PFIC3 PFIC3 (also known as MDR3 deficiency) is caused by a genetic defect in the ABCB4 gene (also called MDR3) located on chromosome 7. Class III multidrug resistance (MDR3) P-glycoprotein (P-gp) is a phospholipid translocator involved in the export of bile phospholipids (phosphatidylcholine) across the bile canalicular membrane of hepatocytes. PFIC3 results from bile toxicity, in which detergent bile salts are not inactivated by phospholipids, causing damage to the bile canaliculi and bile duct epithelium.

[0084] PFIC3 also develops in early childhood. In contrast to PFIC1 and PFIC2, individuals have elevated γGT levels. Individuals also have portal vein inflammation, fibrosis, cirrhosis, and extensive bile duct proliferation. Individuals may also develop intrahepatic cholelithiasis. Ursodiol is effective in treating or ameliorating PFIC3.

[0085] PFIC4 PFIC4 (also known as TJP2 deficiency) is caused by a genetic defect in the TJP2 gene (also called zona occludens 2), located on chromosome 9. In the liver, tight junction protein 2 (TJP2) is involved in forming tight junctions by interacting with transmembrane tight junction proteins and the actin cytoskeleton. Tight junctions are essential in the liver because they help prevent leakage of bile components into the liver parenchyma. Normally, these proteins are localized to the bile canalicular membrane, but in TJP2 mutations, they fail to localize to the parenchyma, particularly in the hepatic lobule. These impaired tight junctions then allow cytotoxic bile salts to leak into the intercellular space, causing damage to surrounding hepatocytes and cholangiocytes.

[0086] PFIC4 presents with severe cholestasis and low γGT levels. Patients lack mutations in the ATP8B1 and ABCB11 genes, except for those diagnosed with PFIC1 and PFIC2. Extrahepatic manifestations, primarily in the nervous and respiratory systems, have been reported in some patients. There have been several reports of HCC development in patients with TJP2 deficiency.

[0087] PFIC5 PFIC5 (also known as FXR deficiency) is caused by a genetic defect in the NR1H4 gene (also called FXR) located on chromosome 12. The farnesoid X receptor (FXR) is a nuclear receptor activated by bile acids and directly involved in the expression of both BSEP and MDR3, proteins affected in PFIC2 and PFIC3, respectively. FXR is activated by elevated bile acid levels in the ileum and induces the expression of fibroblast growth factor 19 (FGF19). In the liver, FGF19 binds to the fibroblast growth factor receptor 4 / β-Klotho complex, which then inhibits cytochrome P450 7A1 (CYP7A1). Inhibition of this enzyme reduces de novo bile acid synthesis.

[0088] PFIC5 presents with neonatal onset of cholestasis with normal γGT, elevated serum bilirubin, elevated serum AFP levels, undetectable bile duct expression of BSEP, and vitamin K-independent coagulopathy. This vitamin K-independent coagulopathy is unique to PFIC5 and has been shown to be a direct result of FXR mutations. Three fibrinogen genes, as well as several coagulation factors, have been associated with FXR-dependent induction, but this does not occur in PFIC5 patients. NR1H4 / FXR-related PFIC is extremely rare; only eight cases have been reported in the literature.

[0089] PFIC6 PFIC6 (also known as MYO5B deficiency) is caused by a genetic defect in the MYO5B gene located on chromosome 18. The interaction between myosin 5B (MYO5B) and RAS-related GTP-binding protein 11A (RAB11A) is essential for epithelial cell polarization and the localization of BSEP to the bile canalicular membrane. Reduced activity of the MYO5B / RAB11A recycling endosomal pathway is associated with disrupted BSEP localization. Mutations in this gene are associated with microvillus inclusion disease (MVID), which affects enterocytes and results in diarrhea and malabsorption. Mislocalized apical brush border proteins, villous atrophy, and the presence of microvillus inclusions are all associated with MVID. Total parenteral nutrition (TPN), although required lifelong, is associated with a high risk of sepsis and small bowel transplantation.

[0090] MVID is likely associated with cholestatic liver disease resulting from TPN. Indeed, genetic mutations in MYO5B may account for 20% of idiopathic low-gamma GT-associated cholestasis in pediatric patients. This cholestasis manifests as low-to-normal gamma GT levels, jaundice, pruritus, mildly elevated alanine transaminase and aspartate transaminase, elevated serum BS levels, hepatomegaly, portal and lobular fibrosis, and giant cell transformation.

[0091] Other PFIC subtypes The phenotypic presentation of PFIC types, which have yet to be genetically characterized, often exhibits clinical symptoms similar to those of the other PFIC subtypes described herein. These phenotypes may include jaundice, cholestasis manifested by elevated serum bile acids, elevated liver enzymes, and other symptoms associated with cholestasis, including pruritus, growth retardation, and poor quality of life. New phenotypes associated with mutations in each gene are still emerging.

[0092] Intermittent cholestasis or elevated serum bile acids may be present in patients with BSEP deficiency or other genetic subtypes. Symptoms associated with intermittent elevated sBa include pruritus and poor quality of life, which can affect both children and adults. Elevated liver enzymes may be present spontaneously or continuously in patients.

[0093] Patients who undergo bile diversion surgery to divert bile acids may still experience symptoms associated with PFIC, including pruritus, poor quality of life, and poor growth and nutrition. Surgical diversion, while often successful in lowering bile acids and improving symptoms, may lose effectiveness in some patients with recurrent elevated serum bile acids and recurrent pruritus, as well as other associated elevated liver enzymes or symptoms of cholestasis.

[0094] In some examples, PFIC mutations can be heterozygous. PFIC1, PFIC2, PFIC3, PFIC4, PFIC5, PFIC6 or other PFIC subtypes can be heterozygous. As a non-limiting example, a subject can have heterozygous non-truncated PFIC2. In another example, a subject can have heterozygous PFIC1. In one embodiment, a subject can have heterozygous ABCB11 mutation. In another embodiment, a subject can have heterozygous ATP8B1 mutation.

[0095] ASBT inhibitors In various embodiments of the methods of the present invention, an ASBT inhibitor is administered to a subject. In some embodiments, the ASBTI inhibitor is maralixibat or a pharmaceutically acceptable salt thereof. In some embodiments, the ASBTI inhibitor is maralixibat chloride. ASBT inhibitors (ASBTI) reduce or inhibit bile acid recycling in the distal gastrointestinal tract (GI), including the distal ileum, colon, and / or rectum. Inhibition of apical sodium-dependent bile acid transport blocks the enterohepatic circulation of bile acids, resulting in more bile acids being excreted in the feces (see FIG. 1), resulting in lower levels of bile acids systemically, thereby reducing bile acid-mediated liver injury and associated effects and complications. In certain embodiments, the ASBTI is systemically absorbed. In certain embodiments, the ASBTI is not systemically absorbed. In one embodiment, maralixibat is a non-systemically absorbed ASBTI. In some embodiments, the ASBTI used in the methods or compositions of the present invention is [ka] or a pharmaceutically acceptable salt thereof.

[0096] In one embodiment, the ASBTI used in the methods or compositions of the invention is [ka] is.

[0097] In one embodiment, the ASBTI used in the methods or compositions of the invention is [ka] is.

[0098] In one embodiment, the ASBTI used in the methods or compositions of the invention is [ka] is.

[0099] In one embodiment, the ASBTI used in the methods or compositions of the invention is [ka] is.

[0100] Methods for treating cholestasis Provided herein is a method for treating cholestasis in a subject with liver disease. The method comprises administering to a subject in need thereof an apical sodium-dependent bile acid transporter inhibitor (ASBTI). The ASBTI is maralixibat, maralixibat chloride, or an alternative pharmaceutically acceptable salt thereof. The ASBTI is administered in an amount of about 140 μg / kg / day to about 1400 μg / kg / day.

[0101] In various embodiments, liver disease is cholestatic liver disease.In some embodiments, liver disease is PFIC, ALGS, PSC, biliary atresia, intrahepatic cholestasis of pregnancy, PBC, any of the above-mentioned cholestatic liver diseases or various combinations thereof.In some embodiments, liver disease is PFIC.

[0102] In certain embodiments, the cholestatic liver disease is progressive familial intrahepatic cholestasis (PFIC), PFIC type 1, PFIC type 2, PFIC type 3, PFIC type 4, PFIC type 5, PFIC type 6, Alagille syndrome, Dubin-Johnson syndrome, biliary atresia, post-Kasai biliary atresia, post-liver transplant biliary atresia, post-liver transplant cholestasis, post-liver transplant associated liver disease, intestinal failure associated liver disease, The cholestatic liver disease is a pediatric type of liver disease. In some embodiments, the cholestatic liver disease is a pediatric type of liver disease. In some embodiments, the subject has intrahepatic cholestasis of pregnancy (ICP).

[0103] In certain embodiments, the cholestatic liver disease is progressive familial intrahepatic cholestasis (PFIC). In certain embodiments, the cholestatic liver disease is PFIC1, PFIC2, PFIC3, PFIC4, PFIC5, or PFIC6. In some embodiments, the cholestatic liver disease is PFIC1. In some embodiments, the cholestatic liver disease is PFIC2. In one embodiment, the cholestatic liver disease is PFIC3. In some embodiments, the cholestatic liver disease is PFIC4. In some embodiments, the cholestatic liver disease is PFIC5. In some embodiments, the cholestatic liver disease is PFIC6.

[0104] In one embodiment, the cholestatic liver disease is non-truncated PFIC2. In one embodiment, the cholestatic liver disease is truncated PFIC2.

[0105] In some embodiments, the cholestatic liver disease is heterozygous PFIC.

[0106] In certain embodiments, the cholestatic liver disease is characterized by one or more symptoms selected from jaundice, pruritus, cirrhosis, hypercholesterolemia, neonatal respiratory distress syndrome, pneumonia, elevated serum concentrations of bile acids, elevated hepatic concentrations of bile acids, elevated serum concentrations of bilirubin, hepatocellular injury, hepatic scarring, liver failure, hepatomegaly, xanthomas, malabsorption, splenomegaly, diarrhea, pancreatitis, hepatocellular necrosis, giant cell formation, hepatocellular carcinoma, gastrointestinal bleeding, portal hypertension, hearing loss, fatigue, loss of appetite, anorexia, characteristic odor, dark urine, pale stools, steatorrhea, failure to thrive, and / or renal failure.

[0107] In various embodiments, the liver disease is PFIC1, and the subject has a mutation in the ATP8B1 gene. In various embodiments, the mutation in the ATP8B1 gene is a missense mutation. In various embodiments, the mutation in the ATP8B1 gene is a nonsense mutation. In various embodiments, the mutation can be selected from one of the mutations listed in Klomp, et al., "Characterization of mutations in ATP8B1 associated with hereditary cholestasis," Hepatology, 40:27-38 (2004), which is incorporated herein by reference in its entirety for all purposes.

[0108] In various embodiments, the liver disease is PFIC2, and the subject has a non-truncating mutation in the ABCB11 gene. In various embodiments, the non-truncating mutation in the ABCB11 gene is a missense mutation. In various embodiments, the missense mutation may be selected from one of the mutations listed in Byrne, et al., "Missense Mutations and Single Nucleotide Polymorphisms in ABCB11 Impair Bile Salt Export Pump Processing and Function or Disrupt Pre-Messenger RNA Splicing," Hepatology, 49:553-567 (2009), which is incorporated herein by reference in its entirety for all purposes.

[0109] In various embodiments, the liver disease is PFIC3, and the subject has a mutation in the ABCB4 gene. In various embodiments, the mutation in the ABCB4 gene is a missense mutation. In various embodiments, the mutation in the ABCB4 gene is a nonsense mutation. In various embodiments, the mutation may be selected from one of the mutations listed in Degiorgio, et al., "Molecular characterization and structural implications of 25 new ABCB4 mutations in progressive familial intrahepatic cholestasis type 3 (PFIC 3)," Eur J Hum Genet, 15:1230-1238 (2007), which is incorporated herein by reference in its entirety for all purposes.

[0110] In various embodiments, the liver disease is PFIC4, and the subject has a truncating mutation in the TJP2 gene. In various embodiments, the truncating mutation in the TJP2 gene may be selected from the mutations listed in Sambrotta, et al., "Mutations in TJP2 cause progressive cholestatic liver disease," Nat Genet, 46:326-328 (2014), which is incorporated herein by reference in its entirety for all purposes.

[0111] In various embodiments, the liver disease is PFIC5, and the subject has a mutation in the NR1H4 gene. In various embodiments, the mutation in the NR1H4 gene is a nonsense mutation. In various embodiments, the mutation may be selected from one of the mutations listed in Gomez-Ospina, et al., "Mutations in the nuclear bile acid receptor FXR cause progressive familial intrahepatic cholestasis," Nat Commun, 7:1-8 (2016), which is incorporated herein by reference in its entirety for all purposes.

[0112] In various embodiments, the liver disease is PFIC6, and the subject has a non-truncating mutation in the MYO5B gene. In various embodiments, the non-truncating mutation in the MYO5B gene is a missense mutation. In various embodiments, the missense mutation may be selected from one of the mutations listed in Overeem, et al., "A Molecular Mechanism Underlying Genotype-Specific Intrahepatic Cholestasis Resulting From MYO5B Mutations," Hepatology, 72:213-229 (2020), which is incorporated herein by reference in its entirety for all purposes.

[0113] In various embodiments, the subject has a condition associated with, caused by, or partially caused by BSEP deficiency. In certain embodiments, the condition associated with, caused by, or partially caused by BSEP deficiency is PFIC1, PFIC2, PFIC3, PFIC4, PFIC5, PFIC6, or a combination thereof. In certain embodiments, the BSEP deficiency is BSEP1, BSEP2, or BSEP3 as defined herein and in van Wessel, et al. "Genotype Correlates with the Natural History of Severe Bile Salt Export Pump Deficiency." Journal of Hepatology, 73(1):84-93 (2020) (incorporated herein by reference in its entirety for all purposes). In various embodiments, the subject has heterozygous PFIC. In some embodiments, the subject has PFIC characterized by intermittent cholestasis. In some embodiments, the subject with PFIC has undergone bile diversion surgery.

[0114] In various embodiments, the patient is a pediatric patient aged 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, or 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, or 18 years. In certain embodiments, the pediatric subject is a newborn, premature infant, infant, toddler, preschooler, school-age child, pre-adolescent child, post-adolescent child, adolescent, or teenager under 18 years of age. In some embodiments, the pediatric subject is a newborn, premature infant, infant, toddler, preschooler, or school-age child. In some embodiments, the pediatric subject is a newborn, premature infant, infant, toddler, or preschooler. In some embodiments, the pediatric subject is a newborn, premature infant, infant, or toddler. In some embodiments, the pediatric subject is a newborn, premature infant, or infant. In some embodiments, the pediatric subject is a newborn. In some embodiments, the pediatric subject is an infant. In some embodiments, the pediatric subject is a toddler. In various embodiments, the pediatric patient has PFIC1, PFIC2, PFIC3, PFIC4, PFIC5, or PFIC6. In various embodiments, the pediatric patient has heterozygous PFIC, or PFIC associated with intermittent cholestasis, or the pediatric PFIC subject has undergone bile diversion surgery. In some embodiments, the patient is an adult over 18, 20, 30, 40, 50, 60, or 70 years of age.

[0115] In certain embodiments, the methods of the invention involve non-systemic administration of a therapeutically effective amount of maralixibat or maralixibat chloride. In certain embodiments, the methods involve contacting the gastrointestinal tract, including the distal ileum and / or colon and / or rectum, of an individual in need thereof with maralixibat or maralixibat chloride. In various embodiments, the methods of the invention result in a reduction of bile acids in intraenterocytes or a reduction in damage to hepatocytes or intestinal structures caused by cholestasis or cholestatic liver disease.

[0116] In various embodiments, the methods of the present invention comprise delivering a therapeutically effective amount of maralixibat or maralixibat chloride to the ileum or colon of an individual.

[0117] In various embodiments, the methods of the invention involve reducing damage to hepatocytes or intestinal structures or cells due to cholestasis or cholestatic liver disease, comprising administering a therapeutically effective amount of maralixibat or maralixibat chloride. In certain embodiments, the methods of the invention involve reducing bile acids / salts in intestinal cells by administering a therapeutically effective amount of maralixibat or maralixibat chloride to an individual in need thereof.

[0118] In some embodiments, the methods of the present invention provide for inhibition of bile salt recycling by administering any of the compounds described herein to an individual. In some embodiments, maralixibat or maralixibat chloride is not systemically absorbed. In some embodiments, maralixibat or maralixibat chloride is orally administered to an individual. In some embodiments, maralixibat or maralixibat chloride is delivered and / or released to the distal ileum of an individual.

[0119] In various embodiments, contacting an individual's distal ileum with an ASBTI (e.g., malalixibat or malalixibat chloride) inhibits bile acid reuptake and increases bile acid / salt concentrations in the vicinity of L-cells in the distal ileum and / or colon and / or rectum, thereby depleting enterocyte bile acids, lowering serum and / or hepatic bile acid levels, reducing total serum bile acid load, and / or reducing damage to ileal structure caused by cholestasis or cholestatic liver disease. Without being limited to any particular theory, reducing serum and / or hepatic bile acid levels ameliorates hypercholesterolemia and / or cholestatic disease.

[0120] Administration of the compounds described herein can be achieved by any suitable method, including, but not limited to, oral, enteral, parenteral (e.g., intravenous, subcutaneous, intramuscular), intranasal, buccal, topical, rectal, or transdermal routes of administration. Any compound or composition described herein can be administered in a manner or formulation suitable for treating newborns or infants. Any compound or composition described herein can be administered in an oral formulation (e.g., solid or liquid) for treating newborns or infants. Any compound or composition described herein can be administered before, with, or after food intake.

[0121] In certain embodiments, the compound described herein or the composition comprising the compound is administered for preventive and / or therapeutic treatment.In therapeutic application, the composition is administered to the individual who has already suffered from disease or condition in an amount sufficient to cure or at least partially stop the symptoms of disease or condition.In various cases, the amount that is effective for this use depends on the severity and course of disease or condition, previous treatment, individual health condition, weight and response to drug, and the judgment of the treating physician.

[0122] In prophylactic applications, the compounds described herein or compositions containing the compounds can be administered to individuals susceptible to or at risk of a particular disease, disorder, or condition. In certain embodiments of this use, the exact amount of compound administered will depend on the individual's health, weight, etc. Furthermore, in some cases, when the compounds or compositions described herein are administered to an individual, the effective amount for this use will depend on the severity and course of the disease, disorder, or condition, previous treatments, the individual's health and response to the drugs, and the judgment of the treating physician.

[0123] In certain embodiments of the methods of the present invention, if an individual's condition does not improve after administration of a selected dose of a compound or composition described herein, at the physician's discretion, the compound or composition described herein is optionally administered chronically, i.e., administered for an extended period of time, including for the duration of the individual's life, to ameliorate or otherwise control or limit the symptoms of the individual's disorder, disease, or condition.

[0124] In certain embodiments of the methods of the present invention, the effective amount of a given agent will vary depending on one or more of several factors, such as the specific compound, the disease or condition and its severity, the personality (e.g., weight) of the subject or host requiring treatment, and will be determined according to the specific circumstances surrounding the case, such as the specific agent being administered, the route of administration, the condition being treated, and the subject or host being treated. In some embodiments, the administered dose will include a dose up to the maximum tolerated dose. In some embodiments, the administered dose will include a dose up to the maximum tolerated dose by a newborn or infant.

[0125] In various embodiments of the methods of the present invention, the desired dose is conveniently provided in a single dose or in divided doses administered simultaneously (or over a short period of time) or at appropriate intervals, for example, as two, three, four or more subdoses per day. In various embodiments, a single dose of ASBTI is administered every 6 hours, 12 hours, 24 hours, 48 ​​hours, 72 hours, 96 hours, 5 days, 6 days, or once a week. In some embodiments, the total single dose of maralixibat or maralixibat chloride is within the ranges described below.

[0126] In various embodiments of the methods of the present invention, if the patient's condition improves, at the physician's discretion, maralixibat or maralixibat chloride is optionally administered continuously; alternatively, the administered dose of drug is temporarily reduced or temporarily suspended for a specified period of time (i.e., a "drug holiday"). The length of the drug holiday optionally varies from 2 days to 1 year, and includes, by way of example only, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 10 days, 12 days, 15 days, 20 days, 28 days, 35 days, 50 days, 70 days, 100 days, 120 days, 150 days, 180 days, 200 days, 250 days, 280 days, 300 days, 320 days, 350 days, or 365 days. Dose reductions during drug holidays include 10% to 100% of the original dose, and by way of example only, include 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% of the original dose. In some embodiments, the total single dose of ASBTI is within the ranges set forth below.

[0127] Once improvement of the patient's condition occurs, a maintenance dose is administered as needed. Thereafter, the dosage or frequency of administration, or both, is reduced as a function of symptoms to a level at which the improved disease, disorder, or condition is maintained. In some embodiments, patients require intermittent treatment on a long-term basis upon recurrence of symptoms.

[0128] In certain instances, there are numerous variables regarding individual treatment regimens, and considerable deviation from these recommendations is contemplated within the ranges set forth herein. The dosages set forth herein are optionally varied depending on many variables, including, by way of non-limiting example, the activity of the compound being used, the disease or condition being treated, the mode of administration, the requirements of the individual subject, the severity of the disease or condition being treated, and the judgment of the practitioner.

[0129] Dosage In various embodiments, the ASBTI is maralixibat or a pharmaceutically acceptable salt thereof.

[0130] In various embodiments, the efficacy and safety of ASBTI administration to patients is monitored by measuring serum levels of 7α-hydroxy-4-cholesten-3-one (7αC4), sBA concentration, the ratio of 7αC4 to sBA (7αC4:sBA), serum conjugated bilirubin concentration, serum autotaxin concentration, serum fibroblast growth factor (FGF-19) concentration, serum bilirubin concentration, serum total cholesterol concentration, serum LDL-C concentration, serum ALT concentration, serum AST concentration, or a combination thereof. In various embodiments, the efficacy of ASBTI administration is measured by monitoring observer-reported itch outcome (ITCHRO (OBS)) score, HRQoL (e.g., PedsQL) score, CSS score, xanthomas score, height Z score, weight Z score, or various combinations thereof. In various embodiments, the method includes monitoring serum levels of 7α-hydroxy-4-cholesten-3-one (7αC4), sBA concentration, the ratio of 7αC4 to sBA (7αC4:sBA), serum conjugated bilirubin concentration, serum total cholesterol concentration, serum LDL-C concentration, serum autotaxin concentration, serum bilirubin concentration, serum ALT concentration, serum AST concentration, or a combination thereof. In various embodiments, the method includes monitoring observer-reported itch-reported outcomes (ITCHRO(OBS)) score, weight Z-score, HRQoL (e.g., PedsQL) score, xanthomas score, CSS score, height Z-score, or various combinations thereof.

[0131] In some embodiments, ASBTI is about or at least about 0.5 μg / kg, 1 μg / kg, 2 μg / kg, 3 μg / kg, 4 μg / kg, 5 μg / kg, 6 μg / kg, 7 μg / kg, 8 μg / kg, 9 μg / kg, 10 μg / kg, 15 μg / kg, 20 μg / kg, 25 μg / kg, 30 μg / kg, 35 μg / kg, 40 μg / kg, 45 μg / kg, 50 μg / kg, 55 μg / kg, 60 μg / kg, 65 μg / kg, 70 μg / kg, 75 μg / kg, 80 μg / kg, 85 μg / kg, 90 μg / kg, 100 μg / kg, 140 μg / kg, 150 μg / kg It is administered at a dose of 200 μg / kg, 240 μg / kg, 280 μg / kg, 300 μg / kg, 250 μg / kg, 280 μg / kg, 300 μg / kg, 400 μg / kg, 500 μg / kg, 560 μg / kg, 600 μg / kg, 700 μg / kg, 800 μg / kg, 900 μg / kg, 1,000 μg / kg, 1,100 μg / kg, 1,200 μg / kg, 1,300 μg / kg, 1,400 μg / kg, 1,500 μg / kg, 1,600 μg / kg, 1,700 μg / kg, 1,800 μg / kg, 1,900 μg / kg, or 2,000 μg / kg.In various embodiments, the ASBTI is about 1 μg / kg, 2 μg / kg, 3 μg / kg, 4 μg / kg, 5 μg / kg, 6 μg / kg, 7 μg / kg, 8 μg / kg, 9 μg / kg, 10 μg / kg, 15 μg / kg, 20 μg / kg, 25 μg / kg, 30 μg / kg, 35 μg / kg kg, 40μg / kg, 45μg / kg, 50μg / kg, 55μg / kg, 60μg / kg, 65μg / kg, 70μg / kg, 75μg / kg, 80μg / kg, 85μg / kg, 90μg / kg, 100μg / kg, 140μg / kg, 150μg / kg, 200μg / kg, 24 Administered at a dose not exceeding 0 μg / kg, 280 μg / kg, 300 μg / kg, 250 μg / kg, 280 μg / kg, 300 μg / kg, 400 μg / kg, 500 μg / kg, 560 μg / kg, 600 μg / kg, 700 μg / kg, 800 μg / kg, 900 μg / kg, 1,000 μg / kg, 1,100 μg / kg, 1,200 μg / kg, 1,300 μg / kg, 1,400 μg / kg, 1,500 μg / kg, 1,600 μg / kg, 1,700 μg / kg, 1,800 μg / kg, 1,900 μg / kg, 2,000, or 2,100 μg / kg. In various embodiments, ASBTI is administered at a dose of about or at least about 0.5 mg / day, 1 mg / day, 2 mg / day, 3 mg / day, 4 mg / day, 5 mg / day, 6 mg / day, 7 mg / day, 8 mg / day, 9 mg / day, 10 mg / day, 11 mg / day, 12 mg / day, 13 mg / day, 14 mg / day, 15 mg / day, 16 mg / day, 17 mg / day, 18 mg / day , 19mg / day, 20mg / day, 30mg / day, 40mg / day, 50mg / day, 60mg / day, 70mg / day, 80mg / day, 90mg / day, 100mg / day, 150mg / day, 200mg / day, 300mg / day, 500mg / day, 600mg / day, 700mg / day, 800mg / day, 900mg / day, 1000mg / day.In various embodiments, ASBTI is about 1 mg / day or less, 2 mg / day or less, 3 mg / day or less, 4 mg / day or less, 5 mg / day or less, 6 mg / day or less, 7 mg / day or less, 8 mg / day or less, 9 mg / day or less, 10 mg / day or less, 11 mg / day or less, 12 mg / day or less, 13 mg / day or less, 14 mg / day or less, 15 mg / day or less, 16 mg / day or less, 17 mg / day or less, 18 mg / day or less, 19 mg / day or less, 20 mg / day or less It is administered at doses of 30mg / day or less, 40mg / day or less, 50mg / day or less, 60mg / day or less, 70mg / day or less, 80mg / day or less, 90mg / day or less, 100mg / day, 150mg / day or less, 200mg / day or less, 300mg / day or less, 500mg / day or less, 600mg / day or less, 700mg / day or less, 800mg / day or less, 900mg / day or less, 1,000mg / day or less, and 1,100mg / day or less.

[0132] In some embodiments, maralixibat is administered at a dose of about 140 μg / kg / day to about 1400 μg / kg / day. In various embodiments, maralixibat is administered at a dose of about or at least about 0.5 μg / kg / day, 1 μg / kg / day, 2 μg / kg / day, 3 μg / kg / day, 4 μg / kg / day, 5 μg / kg / day, 6 μg / kg / day, 7 μg / kg / day, 8 μg / kg / day, 9 μg / kg / day, 10 μg / kg / day, 15 μg / kg / day, 20 μg / kg / day, 25 μg / kg / day, 30 μg / kg / day, 35 μg / kg / day, 40 μg / kg / day, 45 μg / kg / day, 50 μg / kg / day, 100 μg / kg / day g / day, 140 μg / kg / day, 150 μg / kg / day, 200 μg / kg / day, 240 μg / kg / day, 250 μg / kg / day, 280 μg / kg / day, 300 μg / kg / day, 400 μg / kg / day, 500 μg / kg / day, 560 μg / kg / day, 600 μg / kg / day, 700 μg / kg / day, 800 μg / kg / day, 900 μg / kg / day, 1000 μg / kg / day, 1100 μg / kg / day, 1200 μg / kg / day, or 1300 μg / kg / day. In various embodiments, maralixibat is administered at a dose of about 1 μg / kg / day, 2 μg / kg / day, 3 μg / kg / day, 4 μg / kg / day, 5 μg / kg / day, 6 μg / kg / day, 7 μg / kg / day, 8 μg / kg / day, 9 μg / kg / day, 10 μg / kg / day, 15 μg / kg / day, 20 μg / kg / day, 25 μg / kg / day, 30 μg / kg / day, 35 μg / kg / day, 40 μg / kg / day, 45 μg / kg / day, 50 μg / kg / day, 100 μg / kg / day, 140 μg / kg / day, 150 μg / kg / day, 200 μg / kg / day, 300 μg / kg / day, 350 μg / kg / day, 400 μg / kg / day, 450 μg / kg / day, 500 μg / kg / day, 1000 μg / kg / day, 1400 μg / kg / day, 1500 μg / kg / day, 2000 μg / kg / day, 3000 μg / kg / day, 3500 μg / kg / day, 4000 μg / kg / day, 4500 μg / kg / day, 50 ... g / kg / day, 240 μg / kg / day, 280 μg / kg / day, 300 μg / kg / day, 250 μg / kg / day, 280 μg / kg / day, 300 μg / kg / day, 400 μg / kg / day, 500 μg / kg / day, 560 μg / kg / day, 600 μg / kg / day, 700 μg / kg / day, 800 μg / kg / day, 900 μg / kg / day, 1,000 μg / kg / day, 1,100 μg / kg / day, 1,200 μg / kg / day, 1,300 μg / kg / day, or 1,400 μg / kg / day.In various embodiments, maralixibat is administered at a dose of about 0.5 μg / kg / day to about 500 μg / kg / day, about 0.5 μg / kg / day to about 250 μg / kg / day, about 1 μg / kg / day to about 100 μg / kg / day, about 10 μg / kg / day to about 50 μg / kg / day, about 10 μg / kg / day to about 100 μg / kg / day, about 0.5 μg / kg / day to about 2000 μg / kg / day, about 280 μg / kg / day to about 1400 μg / kg / day, about 420 μg / kg / day kg / day~about 1400μg / kg / day, about 250~about 550μg / kg / day, about 560μg / kg / day~about 1400μg / kg / day, 700μg / kg / day~about 1400μg / kg / day, about 560μg / kg / day~about 1200μg / kg / day, about 700μg / kg / day to about 1200μg / kg / day, about 560μg / kg / day to about 1000μg / kg / day, about 700μg / kg / day to about 1000μg / kg / day, about 800μg / kg / day ~Approx. 1000μg / kg / day, approx. 200μg / kg / day ~ approx. 600μg / kg / day, approx. 300μg / kg / day ~ approx. 600μg / kg / day, approx. 400μg / kg / day ~ approx. 500μg / kg / day, approx. 400μg / kg / day ~about 600μg / kg / day, about 400μg / kg / day to about 700μg / kg / day, about 400μg / kg / day to about 800μg / kg / day, about 500μg / kg / day to about 800μg / kg / day, about 500μg / kg / day to about The dose is administered at a dose of 900 μg / kg / day, about 600 μg / kg / day to about 900 μg / kg / day, about 700 μg / kg / day to about 900 μg / kg / day, about 200 μg / kg / day to about 600 μg / kg / day, about 800 μg / kg / day to about 900 μg / kg / day, about 100 μg / kg / day to about 1500 μg / kg / day, about 300 μg / kg / day to about 2,000 μg / kg / day, or about 400 μg / kg / day to about 2000 μg / kg / day.

[0133] In some embodiments, maralixibat is administered at a dose of about 30 μg / kg to about 1400 μg / kg per dose. In some embodiments, maralixibat is administered at a dose of about 0.5 μg / kg to about 2000 μg / kg per dose, about 0.5 μg / kg to about 1500 μg / kg per dose, about 100 μg / kg to about 700 μg / kg per dose, about 5 μg / kg to about 100 μg / kg per dose, about 10 μg / kg to about 500 μg / kg per dose, about 50 μg / kg to about 1400 μg / kg per dose, about 300 μg / kg to about 2000 μg / kg per dose, about 60 μg / kg to about 1200 μg / kg per dose, about 70 μg / kg to about 1000 μg / kg per dose, The dose is administered at a rate of about 70 μg / kg to about 700 μg / kg per dose, 80 μg / kg to about 1000 μg / kg per dose, 80 μg / kg to about 800 μg / kg per dose, 100 μg / kg to about 800 μg / kg per dose, 100 μg / kg to about 600 μg / kg per dose, 150 μg / kg to about 700 μg / kg per dose, 150 μg / kg to about 500 μg / kg per dose, 200 μg / kg to about 400 μg / kg per dose, 200 μg / kg to about 300 μg / kg per dose, or 300 μg / kg to about 400 μg / kg per dose.

[0134] In some embodiments, maralixibat is administered at a dose of about 0.5 mg / day to about 550 mg / day. In various embodiments, maralixibat is administered at a dose of about 1 mg / day to about 500 mg / day, about 1 mg / day to about 300 mg / day, about 1 mg / day to about 200 mg / day, about 2 mg / day to about 300 mg / day, about 2 mg / day to about 200 mg / day, about 4 mg / day to about 300 mg / day, about 4 mg / day to about 200 mg / day, about 4 mg / day to about 150 mg / day, about 5 mg / day to about 150 mg / day, about 5 mg / day to about 100 mg / day, about 5 mg / day to about 80 mg / day, about 5 mg / day to about 50 mg / day, or about 5 mg / day to about 40 mg / day. / day, about 5mg / day to about 30mg / day, about 5mg / day to about 20mg / day, about 5mg / day to about 15mg / day, about 10mg / day to about 100mg / day, about 10mg / day to about 80mg / day, about 10mg / day to about 50mg / day, about 10mg / day to about 40mg / day, about 10mg / day to about 20mg / day, about 20mg / day to about 100mg / day, about 20mg / day to about 80mg / day, about 20mg / day to about 50mg / day, or about 20mg / day to about 40mg / day, or about 20mg / day to about 30mg / day.

[0135] In some embodiments, maralixibat is administered twice daily (BID) in an amount of about 150 μg / kg to about 600 μg / kg per dose. In some embodiments, maralixibat is administered in an amount of about 280 μg / kg / day to about 1400 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 400 μg / kg / day to about 800 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 20 mg / day to about 50 mg / day. In some embodiments, maralixibat is administered in an amount of about 5 mg / day to about 15 mg / day. In some embodiments, maralixibat is administered in an amount of about 560 μg / kg / day to about 1400 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 700 μg / kg / day to about 1400 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 400 μg / kg / day to about 800 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 700 μg / kg / day to about 900 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 560 μg / kg / day to about 1400 μg / kg / day. In some embodiments, maralixibat is administered in an amount of 700 μg / kg / day to about 1400 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 200 μg / kg / day to about 600 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 400 μg / kg / day to about 600 μg / kg / day. In some embodiments, maralixibat is administered in an amount of about 1100 μg / kg / day to about 1200 μg / kg / day. In some embodiments, maralixibat is administered twice daily (BID) in an amount of about 570 μg / kg / day of maralixibat, based on maralixibat free base, which is equivalent to about 600 μg / kg / day of maralixibat chloride.

[0136] In various embodiments, the dose of maralixibat is at a first dose level. In various embodiments, the dose of maralixibat is at a second dose level. In various embodiments, the dose of maralixibat is at a third dose level. In various embodiments, the dose of maralixibat is at a fourth dose level. In some embodiments, the second dose level is higher than the first dose level. In some embodiments, the second dose level is about or at least about 1.5-fold, 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold, 8-fold, 9-fold, 10-fold, 15-fold, 20-fold, 30-fold, 40-fold, 50-fold, 60-fold, 70-fold, 80-fold, 90-fold, or 100-fold the first dose level. In some embodiments, the second dose level is not more than about 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, 100, or 150 times the first dose level. In some embodiments, the third dose level is higher than the second dose level. In some embodiments, the third dose level is about or at least about 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, or 100 times the second dose level. In some embodiments, the third dose level is not more than about 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, 100, or 150 times the second dose level. In some embodiments, the fourth dose level is higher than the third dose level. In some embodiments, the fourth dose level is about or at least about 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, or 100 times the third dose level. In some embodiments, the fourth dose level is no more than about 1.5x, 2x, 3x, 4x, 5x, 6x, 7x, 8x, 9x, 10x, 15x, 20x, 30x, 40x, 50x, 60x, 70x, 80x, 90x, 100x, or 150x the third dose level.

[0137] In various embodiments, maralixibat is administered once daily (QD) at one of the doses or within one of the dose ranges above. In various embodiments, maralixibat is administered twice daily (BID) at one of the doses or within one of the dose ranges above. In various embodiments, the dose of ASBTI is administered daily, every other day, twice a week, or once a week.

[0138] In various embodiments, maralixibat is administered periodically for a period of about or at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 48, 50, 75, 100, 150, 200, 250, 300, 350, 400, 450, 500, 600, 700, or 800 weeks. In various embodiments, maralixibat is administered for a period not exceeding about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 48, 50, 75, 100, 150, 200, 250, 300, 350, 400, 450, 500, 600, 700, 800, or 1000 weeks. In various embodiments, maralixibat is administered periodically for a period of about or at least about 0.5, 1, 1.5, 2, 3, 4, 5, 6, 7, 8, 9, or 10 years. In various embodiments, maralixibat is administered periodically for a period of not more than about 0.5, 1, 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 15 years.

[0139] Relief of symptoms of cholestatic liver disease or changes in disease-related laboratory values In various embodiments of the above methods of the invention, administration of maralixibat or maralixibat chloride results in a reduction in symptoms of cholestatic liver disease or a change in a disease-relevant laboratory measure (i.e., an improvement in the patient's condition) that occurs within about or at least about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 6 months, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, 53 weeks, 54 weeks, 55 weeks, 56 weeks, 57 weeks, 58 weeks, 59 weeks, 60 weeks, 61 weeks, 62 weeks, 63 weeks, 64 weeks, 65 weeks, 66 weeks, 67 weeks, 68 weeks, 69 weeks, 70 weeks, 71 weeks, 72 weeks, 73 weeks, 74 weeks, 75 weeks, 76 weeks, 77 weeks, 78 weeks, 79 weeks, 80 weeks, 81 weeks, 82 weeks, 83 weeks, 84 weeks, 8 Maintained for 5 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, 1 year, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, 5.5 years, 6 years, 6.5 years, 7 years, 8 years, 9 years, or 10 years. In various embodiments, the symptom reduction or disease-related laboratory value change includes a decrease in sBA concentration, an increase in serum 7αC4 concentration, an increase in the 7αC4:sBA ratio, an increase in fBA excretion, a decrease in itching, a decrease in serum total cholesterol concentration, a decrease in serum LDL-C cholesterol concentration, a decrease in ALT level, an increase in quality of life inventory score, an increase in fatigue-related quality of life scale score, a decrease in xanthomas score, a decrease in serum autotaxin concentration, an increase in growth, or a combination thereof.In various embodiments, the symptom reduction or disease-related laboratory value change includes a decrease in sBA concentration, a decrease in itching, a decrease in total bilirubin, a decrease in direct bilirubin, an increase in growth, or a combination thereof.In various embodiments, the symptom reduction or disease-related laboratory value change is determined compared to baseline levels.That is, the symptom reduction or change in disease-related laboratory value is determined relative to the symptom measurement or change in disease-related laboratory value 1) before a change in the dose level of ASBTI administered to the patient, 2) before a change in the dosing regimen followed by the patient, 3) before initiation of administration of ASBTI, or 4) before any other change made to reduce the symptom or change the disease-related laboratory value in the patient. In various embodiments, the symptom reduction or change in disease-related laboratory value is a statistically significant reduction.

[0140] In various embodiments, the reduction in cholestatic liver disease symptoms or change in disease-related laboratory values ​​occurs within about or at least about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 6 months, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks. This is measured as a progressive reduction in symptoms or change in disease-related laboratory values ​​over a period of 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, 1 year, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, 5.5 years, 6 years, 6.5 years, 7 years, 8 years, 9 years, or 10 years.

[0141] In some embodiments, the patient is a pediatric patient, and the reduction in symptoms or change in disease-related laboratory values ​​comprises an increase or improvement in growth. In some embodiments, the increase in growth is measured compared to baseline. In various embodiments, the increase in growth is measured as an increase in height Z-score or weight Z-score. In various embodiments, the increase in height Z-score or weight Z-score is statistically significant. In various embodiments, the increase in height Z-score, weight Z-score, or both is at least 0.1, 0.11, 0.12, 0.13, 0.14, 0.15, 0.16, 0.17, 0.18, 0.19, 0.2, 0.21, 0.22, 0.23, 0.24, 0.25, 0.26, 0.27, 0.28, 0.29, 0.3, 0.31, 0.32, 0.33, 0.34, 0.35, 0.36, 0.37, 0.38, 0.39, 0.40, 0.41, 0.42, 0.43, 0.44, 0.45, 0.46, 0.47, 0.48, 0.49, 0.50, 0.51, 0.52, 0.53, 0.54, 0.55, 0.56, 0.57, 0.58, 0.59, 0.60, 0.61, 0.62, 0.63, 0.64, 0.65, 0.66, 0.67, 0.68, 0.69, 0.70, 0.71, 0.72, 0.73, 0.74, 0 0.32, 0.33, 0.34, 0.35, 0.36, 0.37, 0.38, 0.39, 0.4, 0.41, 0.42, 0.43, 0.44, 0.45, 0.46, 0.47, 0.48, 0.49, 0.5, 0.51, 0.52, 0.53, 0.54, 0.55, 0.56, 0.57, 0.58, 0.59, 0.6, 0.7, 0.8, or 0.9. In some embodiments, the height Z-score, weight Z-score, or both increase progressively during administration of ASBTI over a period of about or at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 48, 50, 60, 70, or 72 weeks.

[0142] In various embodiments, administration of ASBTI results in an increase in serum 7αC4 concentration. In various embodiments, serum 7αC4 concentration is increased by about or at least about 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, 100, 200, 300, 400, or 500 times compared to baseline. In various embodiments, serum 7αC4 concentration is increased by about or at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 150%, 200%, 300%, 400%, 500%, 600%, 700%, 800%, 900%, 1,000%, or 10,000%.

[0143] In various embodiments, administration of ASBTI results in a decrease in total bilirubin. In various embodiments, total bilirubin is decreased by about or at least about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, or 0.9 times compared to baseline. In various embodiments, total bilirubin is decreased by about or at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100% compared to baseline. In various embodiments, total bilirubin is reduced by about or at least about 0.1 mg / dL, 0.2 mg / dL, 0.3 mg / dL, 0.4 mg / dL, 0.5 mg / dL, 0.6 mg / dL, 0.7 mg / dL, 0.8 mg / dL, 0.9 mg / dL, 1.0 mg / dL, 1.1 mg / dL, or 1.2 mg / dL compared to baseline.

[0144] In various embodiments, administration of ASBTI results in a decrease in direct bilirubin. In various embodiments, direct bilirubin is decreased by about or at least about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, or 0.9 times compared to baseline. In various embodiments, direct bilirubin is decreased by about or at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100% compared to baseline. In various embodiments, direct bilirubin is reduced by about or at least about 0.1 mg / dL, 0.2 mg / dL, 0.3 mg / dL, 0.4 mg / dL, 0.5 mg / dL, 0.6 mg / dL, 0.7 mg / dL, 0.8 mg / dL, 0.9 mg / dL, 1.0 mg / dL, 1.1 mg / dL, or 1.2 mg / dL compared to baseline.

[0145] In various embodiments, administration of ASBTI results in an increase in the 7αC4:sBA ratio of about or at least about 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 75, 100, 150, 200, 300, 500, 750, 1,000, 2,000, 3,000, 4,000, 5,000, or 10,000 fold relative to baseline.

[0146] In various embodiments, administration of ASBTI results in an increase in fBA excretion. In some embodiments, administration of ASBTI results in an increase in fBA excretion of about or at least about 100%, 110%, 115%, 120%, 130%, 150%, 200%, 250%, 275%, 300%, 400%, 500%, 600%, 700%, 800%, 1,000%, 5,000%, 10,000%, or 15,000% relative to baseline. In various embodiments, fBA excretion is increased by about or at least about 1, 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50, 60, 70, 80, 90, or 100-fold relative to baseline. In some embodiments, fBA excretion is increased by about or at least about 100 μmol, 150 μmol, 200 μmol, 250 μmol, 300 μmol, 400 μmol, 500 μmol, 600 μmol, 700 μmol, 800 μmol, 900 μmol, 1,000 μmol, or 1,500 μmol compared to baseline. In various embodiments, administration of ASBTI results in a dose-dependent increase in fBA excretion, with administration of higher doses of ASBTI resulting in correspondingly higher levels of fBA excretion. In various embodiments, ASBTI is administered at a dose sufficient to result in an increase in bile acid secretion of at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50, 60, 70, 80, 90, or 100-fold compared to baseline.

[0147] In various embodiments, administration of ASBTI results in a reduction in sBA concentrations of about or at least about 5%, 10%, 15%, 20%, 25%, 30%, 31%, 35%, 40%, 45%, 50%, 55%, 57%, 60%, 65%, 70%, 75%, 80%, 85%, 90% or 95% relative to baseline.

[0148] In some embodiments, administration of ASBTI results in a reduction in the severity of pruritus. In various embodiments, the severity of pruritus is measured using the ITCHRO (OBS) score, the ITCHRO score, the CSS score, or a combination thereof. In various embodiments, administration of ASBTI results in a reduction in the ITCHRO (OBS) score on a scale of 1 to 4 of about or at least about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2.25, 2.5, or 3 compared to baseline. In various embodiments, administration of ASBTI results in a decrease in the ITCHRO score on a scale of 1 to 10 of about or at least about 0.1, 0.2, 0.3, 0.4, 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In various embodiments, administration of ASBTI reduces the ITCHRO(OBS) score, the ITCHRO score, or both to zero. In various embodiments, administration of ASBTI reduces the ITCHRO(OBS) score or the ITCHRO score to 1.0 or less. In various embodiments, administration of ASBTI results in a decrease in CSS score compared to baseline of at least about 0.1, 0.2, 0.3, 0.4, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2.25, 2.5, or 3. In various embodiments, administration of ASBTI results in a reduction in CSS score to zero. In various embodiments, administration of ASBTI reduces the CSS score, ITCHRO(OBS) score, ITCHRO score, or a combination thereof by about or at least about 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% relative to baseline.In various embodiments, a decrease in the CSS score, ITCHRO(OBS) score, ITCHRO score, or a combination thereof compared to baseline is observed in 10%, 20%, 30%, 40%, 50%, 60%, 70%, 75%, 80%, 85%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% of days.

[0149] In some embodiments, patients with higher baseline ITCHRO (OBS) scores exhibit greater symptom relief or disease-related laboratory changes than patients with lower baseline ITCHRO (OBS) scores. In some embodiments, patients with a baseline ITCHRO (OBS) score of at least 2, 3, or 4 or an ITCHRO score of at least 4, 5, 6, 7, 8, 9, or 10 have greater symptom relief or greater change in disease-related laboratory values ​​relative to baseline, compared to smaller reductions in patients with lower baseline severity of pruritus scores. In various embodiments, patients with PSC and a baseline ITCHRO score of at least 4 exhibit greater symptom relief or disease-related laboratory changes than patients with a baseline ITCHRO score of less than 4. In various embodiments, the method includes predicting that a patient will have greater symptom relief or disease-related laboratory changes if the patient's baseline ITCHRO score is at least 4, compared to patients with a baseline ITCHRO score of less than 4. In various embodiments, the smaller reduction is about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, or 60% or less of the larger reduction. In various embodiments, the difference in symptom relief or disease-related laboratory change (i.e., the difference between the greater and lesser reduction) between patients with an ITCHRO score of at least 4 at baseline and patients with an ITCHRO score of less than 4 at baseline is about or at least about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 6 months, 25 weeks, 26 weeks, 27 weeks, 28 weeks after the initial administration of ASBTI at the first dose or the second dose.Measured after 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, 1 year, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, 5.5 years, 6 years, 6.5 years, 7 years, 8 years, 9 years, or 10 years.

[0150] In various embodiments, the reduction in the severity of pruritus resulting from administration of ASBTI to a patient is positively correlated with a decrease in the concentration of sBA in the patient, hi various embodiments, a greater decrease in the concentration of sBA in the patient is correlated with a corresponding greater reduction in the severity of pruritus.

[0151] In various embodiments, administration of ASBTI results in a reduction in serum LDL-C concentrations compared to baseline, hi some embodiments, serum LDL-C concentrations are reduced by about or at least about 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, or 80% relative to baseline.

[0152] In some embodiments, administration of ASBTI results in a decrease in serum total cholesterol concentration compared to baseline. In some embodiments, administration of ASBTI results in a decrease in serum LDL-C levels compared to baseline. In some embodiments, serum total cholesterol concentration, serum LDL-C level, or both are reduced by about or at least about 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, or 80% relative to baseline. In various embodiments, administration of ASBTI results in a reduction in serum total cholesterol concentration, serum LDL-C levels, or both, of about or at least about 1 mg / dL, 2 mg / dL, 3 mg / dL, 4 mg / dL, 5 mg / dL, 10 mg / dL, 12.5 mg / dL, 15 mg / dL, 20 mg / dL, 30 mg / dL, 40 mg / dL, or 50 mg / dL compared to baseline.

[0153] In various embodiments, administering ASBTI causes serum autotaxin concentration to decrease.In some embodiments, administering ASBTI causes the autotaxin concentration to decrease by about or at least about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or 80% compared to baseline.

[0154] In various embodiments, administration of ASBTI results in improved sleep. In some embodiments, sleep is assessed using the Exploratory Diary Questionnaire (EDQ(Obs)). In some embodiments, the mean morning EDQ(Obs) sleep disturbance score is reduced by about or at least about 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, or 80% relative to baseline.

[0155] In some embodiments, administration of ASBTI results in improved sleep as measured by a decrease in the subject's EDQ(Obs) or EDQ(Pt) score of at least 1.0 compared to baseline. In some embodiments, administration of ASBTI results in improved sleep as measured by a decrease in the subject's EDQ(Obs) or EDQ(Pt) score of at least 1.2 compared to baseline. In some embodiments, administration of ASBTI results in improved sleep as measured by a decrease in the subject's EDQ(Obs) or EDQ(Pt) score of at least 1.4 compared to baseline. In some embodiments, administration of ASBTI results in improved sleep as measured by a decrease in the subject's EDQ(Obs) or EDQ(Pt) score of at least 1.6 compared to baseline.

[0156] In various embodiments, administration of ASBTI results in an increase in a quality of life scale score or a fatigue-related quality of life scale score. The quality of life scale score can be a health-related quality of life (HRQoL) score. In some embodiments, the HRQoL score is a PedsQL score. In various embodiments, administration of ASBTI results in an increase in the PedsQL score or fatigue-related PedsQL score of about or at least about 5%, 10%, 15%, 20%, 25%, 30%, 45%, or 50% relative to baseline.

[0157] In various embodiments, administration of ASBTI results in a reduction in xanthomas score compared to baseline. In some embodiments, the xanthomas score is reduced by about or at least about 2.5%, 5%, 10%, 15%, 20%, 35%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to baseline.

[0158] In various embodiments, administration of ASBTI is for only about 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, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks. Result in a reduction in symptoms or a change in disease-related laboratory values ​​by 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, or 1 year.

[0159] In various embodiments, the serum bilirubin concentration is at normal levels at about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 1 month, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 2 months, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 4 months, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, and 36 weeks. Pre-dose baseline or normal levels at or by 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 weeks, or 1 year

[0160] In various embodiments, the serum ALT concentration is at normal levels at about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 4 months, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, and 38 weeks. Pre-administration baseline or normal levels at or by 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, or 1 year. In some embodiments, administration of ASBTI results in a reduction in ALT levels of about or at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, or 15% relative to baseline.

[0161] In various embodiments, the serum ALT concentration, serum AST concentration, serum bilirubin concentration, serum conjugated bilirubin concentration, or various combinations thereof, is increased or decreased at about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 4 months, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks. Within the normal range or pre-administration baseline levels at or by 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, or 1 year. In various embodiments, administration of ASBTI is for at least about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 4 months, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, or 29 weeks. does not result in a statistically significant change from baseline in serum bilirubin concentration, serum AST concentration, serum ALT concentration, serum alkaline phosphatase concentration, or any combination thereof, for a period of 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, or 1 year. In various embodiments, for adult patients with an ITCHRO score of at least 4 at baseline, administration of ASBTI is continued for at least about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 4 months, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, or 31 weeks.does not result in a significant change from baseline in serum conjugated bilirubin concentrations for a period of 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 ​​weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, or 1 year.

[0162] Dose adjustment In various embodiments, the method includes adjusting the dosage of maralixibat administered to the patient. In some embodiments, adjusting the dosage of maralixibat can include escalating the dosage of maralixibat. In some embodiments, the adjustment includes administering a first dose level of maralixibat to the patient for a first week. If the patient tolerates the first dose level, the dose level is increased to a second dose level for a second week. If the patient tolerates the second dose level, the dose level is increased to a third dose level for a third week. If the patient tolerates the third dose level, the dose level is increased to a fourth dose level for the remainder of the treatment trial.

[0163] In some embodiments, the method includes a dose escalation period. In one non-limiting embodiment, the dose escalation period includes the following weekly steps: a) Dose Level 1: 150 μg / kg maralixibat BID for 1 week; b) Dose Level 2: 300 μg / kg maralixibat BID for 1 week; c) Dose Level 3: 450 μg / kg maralixibat BID for 1 week; d) Dose Level 4: 600 μg / kg maralixibat BID for the remainder of the administration period. In another non-limiting embodiment, the dose escalation steps may be delayed or reversed to improve tolerability.

[0164] Pharmaceutical Composition In some embodiments, maralixibat is administered as a pharmaceutical composition comprising maralixibat or maralixibat chloride. Any of the compositions described herein can be formulated for delivery to the ileum, rectum, and / or colon. In more specific embodiments, the composition is formulated for non-systemic or local delivery to the rectum and / or colon. As used herein, delivery to the colon is understood to include delivery to the sigmoid colon, transverse colon, and / or ascending colon. In even more specific embodiments, the composition is formulated for non-systemic or local delivery to the rectum and / or colon and administered rectally. In other specific embodiments, the composition is formulated for non-systemic or local delivery to the rectum and / or colon and administered orally.

[0165] In certain embodiments, provided herein is a pharmaceutical composition comprising a therapeutically effective amount of any compound described herein. In certain examples, the pharmaceutical composition comprises an ASBT inhibitor (e.g., maralixibat or maralixibat chloride).

[0166] In certain embodiments, pharmaceutical compositions are formulated in a conventional manner using one or more physiologically acceptable carriers, including, for example, excipients and auxiliaries that facilitate the processing of active compounds into preparations suitable for pharmaceutical use.In certain embodiments, suitable formulations depend on the route of administration selected.Summary of pharmaceutical compositions described herein can be found in, for example, Remington: The Science and Practice of Pharmacy, Nineteenth Edition (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, HA and Lachman, L., Eds., Pharmaceutical Dosage Forms, Mareel Decker, New York, NY, 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Edition (Lippincott Williams & Wilkins 1999), all of which are incorporated herein in their entirety for all purposes.

[0167] As used herein, a pharmaceutical composition refers to a mixture of a compound described herein with other chemical components, such as a carrier, stabilizer, diluent, dispersant, suspending agent, thickener, and / or excipient. In certain instances, the pharmaceutical composition facilitates administration of the compound to an individual or cell. In certain embodiments of practicing the methods of treatment or use provided herein, a therapeutically effective amount of a compound described herein is administered in a pharmaceutical composition to an individual having a disease, disorder, or condition to be treated. In certain embodiments, the individual is a human. As discussed herein, the compounds described herein are utilized alone or in combination with one or more additional therapeutic agents.

[0168] In certain embodiments, the pharmaceutical formulations described herein are administered to an individual by any method, including one or more of a variety of routes of administration, such as, but not limited to, oral, parenteral (e.g., intravenous, subcutaneous, intramuscular), intranasal, buccal, topical, rectal, or transdermal routes of administration.

[0169] In certain embodiments, the pharmaceutical compositions described herein contain one or more compounds described herein as active ingredients in the form of a free acid or free base, or in the form of a pharmaceutically acceptable salt. In some embodiments, the compounds described herein are utilized as N-oxides or in crystalline or amorphous form (i.e., polymorphs). In some situations, the compounds described herein exist as tautomers. All tautomers are included within the scope of the compounds presented herein. In certain embodiments, the compounds described herein exist in unsolvated or solvated forms, where solvated forms include any pharmaceutically acceptable solvent, such as water, ethanol, etc. Solvated forms of the compounds presented herein are also considered to be described herein.

[0170] "Carriers," in some embodiments, comprise pharmaceutically acceptable excipients and are selected based on compatibility with a compound described herein, such as a compound of any of Formulas I-VI, and the release profile characteristics of the desired dosage form. Exemplary carrier materials include, for example, binders, suspending agents, disintegrants, fillers, surfactants, solubilizers, stabilizers, lubricants, wetting agents, diluents, and the like. See, e.g., Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, H.A. and Lachman, L., Eds., Pharmaceutical Dosage Forms, Mareel Decker, New York, NY, 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999); all of which are incorporated herein in their entirety for all purposes.

[0171] Furthermore, in certain embodiments, the pharmaceutical compositions described herein are formulated as dosage forms.Therefore, in some embodiments, the dosage forms provided herein are suitable for administration to individuals and comprise the compounds described herein.In certain embodiments, suitable dosage forms include, but are not limited to, aqueous oral dispersions, liquids, gels, syrups, elixirs, slurries, suspensions, solid oral dosage forms, aerosols, controlled release (or sustained release) formulations, fast dissolving formulations, effervescent formulations, lyophilized formulations, tablets, powders, pills, dragees, capsules, delayed release formulations, sustained release formulations, pulsed release formulations, multiparticulate formulations, and mixed immediate release and controlled release formulations.

[0172] Route of administration, dosage form, and dosing regimen In some embodiments, the compositions described herein and compositions administered in the methods described herein are formulated to inhibit bile acid reuptake or reduce serum or hepatic bile acid levels. In certain embodiments, the compositions described herein are formulated for rectal or oral administration. In some embodiments, such formulations are administered rectally or orally, respectively. In some embodiments, the compositions described herein are combined with a device for local delivery of the composition to the rectum and / or colon (sigmoid colon, transverse colon, or ascending colon). In certain embodiments, for rectal administration, the compositions described herein are formulated as enemas, rectal gels, enema foams, rectal aerosols, suppositories, jelly suppositories, or retention enemas. In some embodiments, for oral administration, the compositions described herein are formulated for oral administration and enteral delivery to the colon.

[0173] In certain embodiments, the compositions or methods described herein are non-systemic. In some embodiments, the compositions described herein deliver ASBTI to the distal ileum, colon, and / or rectum, but not systemically (e.g., a substantial portion of the enteroendocrine peptide secretagogue is not systemically absorbed). In some embodiments, the oral compositions described herein deliver ASBTI to the distal ileum, colon, and / or rectum, but not systemically (e.g., a substantial portion of the enteroendocrine peptide secretagogue is not systemically absorbed). In some embodiments, the rectal compositions described herein deliver ASBTI to the distal ileum, colon, and / or rectum, but not systemically (e.g., a substantial portion of the enteroendocrine peptide secretagogue is not systemically absorbed). In certain embodiments, the non-systemic compositions described herein deliver less than 90% by weight (% w / w) of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 80% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 70% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 60% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 50% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 40% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 30% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 25% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 20% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 15% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 10% w / w of ASBTI systemically. In certain embodiments, the non-systemic compositions described herein deliver less than 5% w / w of ASBTI systemically.In some embodiments, systemic absorption is determined by any suitable method, including total circulating amount, amount cleared after administration, etc.

[0174] In certain embodiments, the compositions and / or formulations described herein are administered at least once a day. In certain embodiments, the formulations comprising ASBTI are administered at least twice a day, and in other embodiments, the formulations comprising ASBTI are administered at least three times a day. In certain embodiments, the formulations comprising ASBTI are administered at most five times a day. It should be understood that in certain embodiments, the dosage regimen of the compositions comprising ASBTI described herein is determined by considering various factors such as the patient's age, sex, and diet.

[0175] The concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 1 M. In certain embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 750 mM. In certain embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 500 mM. In certain embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 5 mM to about 500 mM. In certain embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 10 mM to about 500 mM. In certain embodiments, the concentration administered in the formulations described herein ranges from about 25 mM to about 500 mM. In certain embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 50 mM to about 500 mM. In certain embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 100 mM to about 500 mM. In certain embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 200 mM to about 500 mM.

[0176] In certain embodiments, by targeting the distal gastrointestinal tract (e.g., the distal ileum, colon, and / or rectum), the compositions and methods described herein provide efficacy (e.g., efficacy in reducing microbial growth and / or alleviating symptoms of cholestasis or cholestatic liver disease) at reduced doses of enteroendocrine peptide secretagogue (e.g., compared to oral doses that do not target the distal gastrointestinal tract).

[0177] Liquid dosage form Liquid pharmaceutical dosage forms of the present invention can be prepared according to techniques well known in the art of pharmacy.

[0178] A solution refers to a liquid pharmaceutical formulation in which the active ingredient is dissolved in a liquid. Pharmaceutical solutions of the present invention include syrups and elixirs. A suspension refers to a liquid pharmaceutical formulation in which the active ingredient is in a precipitate in a liquid.

[0179] It is desirable for liquid dosage forms to have a specific pH and / or be maintained within a specific pH range. An appropriate buffer system can be used to control the pH. Furthermore, the buffer system must have sufficient capacity to maintain the desired pH range. Examples of buffer systems useful in the present invention include, but are not limited to, citrate buffer, phosphate buffer, or any other suitable buffer known in the art. Preferably, the buffer system includes sodium citrate, potassium citrate, sodium bicarbonate, potassium bicarbonate, sodium dihydrogen phosphate, potassium dihydrogen phosphate, etc. The concentration of the buffer system in the final suspension will vary depending on factors such as the strength and pH range of the buffer system required for the liquid dosage form. In one embodiment, the concentration is within the range of 0.005-0.5 w / v% in the final liquid dosage form.

[0180] Pharmaceutical compositions, including liquid dosage forms of the present invention, may also contain suspending / stabilizing agents to prevent settling of the active substance. Over time, settling can cause the active substance to cake on the inner walls of the product pack, making redispersion and accurate dispensing difficult. Suitable stabilizers include, but are not limited to, polysaccharide stabilizers such as xanthan, guar, and tragacanth gum, as well as cellulose derivatives HPMC (hydroxypropylmethylcellulose), methylcellulose, and Avicel RC-591 (microcrystalline cellulose / sodium carboxymethylcellulose). In another embodiment, polyvinylpyrrolidone (PVP) can also be used as a stabilizer.

[0181] In addition to the aforementioned ingredients, the ASBTI oral suspension formulation may optionally contain alternative solvents, taste masking agents, antioxidants, bulking agents, acidifying agents, enzyme inhibitors, and other additives as described in Handbook of Pharmaceutical Excipients, Rowe et al., Eds., 4 th Edition, Pharmaceutical Press (2003), which is incorporated herein by reference in its entirety for all purposes.

[0182] The addition of an alternative solvent can help to increase the solubility of the active ingredient in the liquid dosage form, thereby increasing its absorption and bioavailability in the subject's body. Preferably, the alternative solvent includes methanol, ethanol, propylene glycol, etc.

[0183] In another aspect, the present invention provides a process for preparing a liquid dosage form. This process comprises mixing maralixibat or a pharmaceutically acceptable salt thereof with ingredients including glycerol or syrup or a mixture thereof, preservatives, a buffer system, and suspending / stabilizing agents in a liquid medium. Generally, the liquid dosage form is prepared by uniformly and homogeneously mixing these various ingredients in the liquid medium. For example, ingredients such as glycerol or syrup or a mixture thereof, preservatives, a buffer system, and suspending / stabilizing agents can be dissolved in water to form an aqueous solution, and then the active ingredient can be dispersed in the aqueous solution to form a suspension.

[0184] In some embodiments, the liquid dosage forms provided herein can have a volume of about 5 ml to about 50 ml. In some embodiments, the liquid dosage forms provided herein can have a volume of about 5 ml to about 40 ml. In some embodiments, the liquid dosage forms provided herein can have a volume of about 5 ml to about 30 ml. In some embodiments, the liquid dosage forms provided herein can have a volume of about 5 ml to about 20 ml. In some embodiments, the liquid dosage forms provided herein can have a volume of about 10 ml to about 30 ml. In some embodiments, the liquid dosage forms provided herein can have a volume of about 20 ml. In some embodiments, the maralixibat can be present in an amount ranging from about 0.001% to about 90% of the total volume. In some embodiments, the maralixibat can be present in an amount ranging from about 0.01% to about 80% of the total volume. In some embodiments, the maralixibat can be present in an amount ranging from about 0.1% to about 70% of the total volume. In some embodiments, the maralixibat can be present in an amount ranging from about 1% to about 60% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 1% to about 50% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 1% to about 40% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 1% to about 30% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 1% to about 20% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 1% to about 10% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 5% to about 70% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 5% to about 60% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 5% to about 50% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 5% to about 40% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 5% to about 30% of the total volume.In some embodiments, maralixibat may be present in an amount ranging from about 5% to about 20% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 5% to about 10% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 10% to about 50% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 10% to about 40% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 10% to about 30% of the total volume. In some embodiments, maralixibat may be present in an amount ranging from about 10% to about 20% of the total volume. In one embodiment, the resulting liquid dosage form has a liquid volume of 10 ml to 30 ml, preferably 20 ml, and the active ingredient is present in an amount ranging from about 0.001 mg / ml to about 25 mg / ml, or from about 0.025 mg / ml to about 8 mg / ml, or from about 0.1 mg / ml to about 4 mg / ml, or about 0.25 mg / ml, or about 0.5 mg / ml, or about 1 mg / ml, or about 2 mg / ml, or about 4 mg / ml, or about 5 mg / ml, or about 8 mg / ml, or about 10 mg / ml, or about 12 mg / ml, or about 14 mg / ml, or about 16 mg / ml, or about 18 mg / ml, or about 20 mg / ml, or about 25 mg / ml. In one embodiment, the active ingredient is maralixibat present in an amount of 9.5 mg / ml. In one embodiment, the active ingredient is maralixibat chloride present in an amount of 10 mg / ml.

[0185] Oral solution In some embodiments, the pharmaceutical composition is formulated as an oral solution comprising maralixibat chloride, a preservative, an antioxidant, a flavoring agent, a sweetener, and water.

[0186] preservatives In certain embodiments, the compositions of the present invention comprise a preservative, hi certain embodiments, the preservative is an antimicrobial preservative.

[0187] In certain embodiments, the antimicrobial preservative is selected from the group consisting of propylene glycol, ethyl alcohol, glycerin, benzalkonium chloride, benzethonium chloride, benzoic acid, benzyl alcohol, butylparaben, cetrimide (cetyltrimethylammonium bromide), cetrimonium bromide, cetylpyridinium chloride, chlorhexidine, chlorobutanol, chlorocresol, cresol, ethylparaben, methylparaben, phenol, phenoxyethanol, phenylethyl alcohol, phenylmercuric acetate, phenylmercuric borate, phenylmercuric nitrate, propylparaben, sodium benzoate, sodium dehydroacetate, sodium propionate, sorbic acid, potassium sorbate, thimerosal, thymol, and combinations thereof.

[0188] In certain embodiments, the preservative is propylene glycol.

[0189] In certain embodiments, the preservative is present in an amount of at least about 10% by weight of the composition. In certain embodiments, the preservative is present in an amount of at least about 20% by weight of the composition. In certain embodiments, the preservative is present in an amount of at least about 25% by weight of the composition. In certain embodiments, the preservative is present in an amount of at least about 30% by weight of the composition.

[0190] In certain embodiments, the preservative is present in an amount of about 30% to about 40% of the composition.

[0191] In certain embodiments, the preservative is present in an amount of about 32% to about 37% of the composition. In certain embodiments, the preservative is present in an amount of about 33% to about 36% of the composition.

[0192] In certain embodiments, the preservative is present in an amount of about 33% of the composition. In certain embodiments, the preservative is present in an amount of about 34% of the composition. In certain embodiments, the preservative is present in an amount of about 35% of the composition.

[0193] antioxidants In certain embodiments, the compositions of the present invention comprise an antioxidant selected from the group consisting of aminocarboxylic acids, aminopolycarboxylic acids, ascorbic acid, ascorbyl palmitate, butylhydroxyanisole, butylhydroxytoluene, monothioglycerol, sodium ascorbate, sodium formaldehyde sulfoxylate, sodium metabisulfite, BHT, BHA, sodium bisulfite, vitamin E or a derivative thereof, propyl gallate, and combinations thereof.

[0194] In certain embodiments, the antioxidant is an aminopolycarboxylic acid selected from EDTA (ethylenediaminetetraacetic acid), DTPA (diethylenetriaminepentaacetic acid), EGTA (ethylene glycol-bis(β-aminoethyl ether)-N,N,N',N'-tetraacetic acid), NTA (nitrilotriacetic acid), BAPTA (1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid), NOTA (2,2',2''-(1,4,7-triazonane-1,4,7-triyl)triacetic acid), DOTA (tetracarboxylic acid), and EDDHA (ethylenediamine-N,N'-bis(2-hydroxyphenylacetic acid).

[0195] In certain embodiments, the antioxidant is EDTA.

[0196] In certain embodiments, the antioxidant is present in an amount of about 0.001% to about 1 wt.% of the composition. In certain embodiments, the antioxidant is present in an amount of about 0.005% to about 0.75 wt.% of the composition. In certain embodiments, the antioxidant is present in an amount of about 0.01% to about 0.5 wt.% of the composition. In certain embodiments, the antioxidant is present in an amount of about 0.05% to about 0.25 wt.% of the composition. In certain embodiments, the antioxidant is present in an amount of about 0.075% to about 0.2 wt.% of the composition. In certain embodiments, the antioxidant is present in an amount of about 0.1 wt.% of the composition.

[0197] In some embodiments, the pharmaceutical composition comprises about 5 mg / mL to about 50 mg / mL of maralixibat chloride; about 300 mg / mL to about 400 mg / mL of propylene glycol; about 1 mg / mL of disodium EDTA; a sweetener, a flavoring agent, or a combination thereof, and water.

[0198] In some embodiments, the pharmaceutical composition comprises about 5 mg / mL to about 50 mg / mL of maralixibat chloride; about 300 mg / mL to about 400 mg / mL of propylene glycol; about 1 mg / mL of disodium EDTA; about 10 mg / mL of sucralose, about 5 mg / mL of grape flavor, and water.

[0199] In some embodiments, the pharmaceutical composition comprises about 10 mg / mL maralixibat chloride; about 360 mg / mL propylene glycol; about 1 mg / mL disodium EDTA; about 10 mg / mL sucralose, about 5 mg / mL grape flavor, and water.

[0200] Pediatric Formulations and Compositions In certain embodiments, provided herein are pediatric formulations or compositions comprising a therapeutically effective amount of any compound described herein. In certain examples, the pharmaceutical composition comprises an ASBT inhibitor (e.g., maralixibat or maralixibat chloride).

[0201] In certain embodiments, dosage forms suitable for pediatric formulations or compositions include, by way of non-limiting example, aqueous or non-aqueous oral dispersions, liquids, gels, syrups, elixirs, slurries, suspensions, solutions, controlled-release formulations, fast-dissolving formulations, effervescent formulations, lyophilized formulations, chewable tablets, gummy candies, orally disintegrating tablets, powders for reconstitution as suspensions or solutions, sprinkle oral powders or granules, dragees, delayed-release formulations, extended-release formulations, pulsed-release formulations, multiparticulate formulations, and mixed immediate-release and controlled-release formulations. In some embodiments, provided herein are pharmaceutical compositions wherein the pediatric dosage form is selected from solutions, syrups, suspensions, elixirs, powders for reconstitution as suspensions or solutions, dispersible / effervescent tablets, chewable tablets, gummy candies, lollipops, freezer pops, lozenges, oral strips, orally disintegrating tablets, orally disintegrating strips, sachets, and sprinkle oral powders or granules.

[0202] In another aspect, provided herein is a pharmaceutical composition, wherein at least one excipient is a flavoring or sweetening agent.In some embodiments, provided herein is a coating.In some embodiments, provided herein is a taste-masking technology selected from the following: coating drug particles with a taste-neutral polymer by spray drying, wet granulation, fluidized bed, and microencapsulation; coating a mixture of molten wax and other pharmaceutical adjuvants with molten wax; entrapment of drug particles by complexation, aggregation, or solidification of aqueous polymer dispersion; adsorption of drug particles to resin and inorganic support; and solid dispersion in which drug and one or more neutral-tasting compounds are melted and cooled or co-precipitated by solvent evaporation.In some embodiments, provided herein is a delayed-release or sustained-release formulation, comprising drug particles or granules in a rate-controlling polymer or matrix.

[0203] Suitable sweeteners include sucrose, glucose, fructose, or high-intensity sweeteners, i.e., agents with a sweetening power greater than that of sucrose (e.g., at least 10 times sweeter than sucrose). Suitable high-intensity sweeteners include aspartame, saccharin, sodium or potassium or calcium saccharin, acesulfame potassium, sucralose, alitame, xylitol, cyclamate, neomate, neohesperidin dihydrochalcone or mixtures thereof, thaumatin, palatinit, stevioside, rebaudioside, and Magnasweet®. The total concentration of sweetener, based on the reconstituted liquid composition, can range from substantially zero to about 300 mg / ml.

[0204] To enhance the palatability of the liquid composition when reconstituted with an aqueous medium, one or more taste-masking agents may be added to the composition to mask the taste of the ASBT inhibitor. The taste-masking agent may be a sweetener, a flavoring agent, or a combination thereof. The taste-masking agent typically accounts for up to about 0.1% or 5% by weight of the total pharmaceutical composition. In a preferred embodiment of the present invention, the composition includes both a sweetener and a flavoring agent.

[0205] Flavoring agents herein are substances capable of enhancing the taste or aroma of a composition. Suitable natural or synthetic flavoring agents can be selected from standard reference books, such as Fenaroli's Handbook of Flavor Ingredients, 3rd edition (1995).Non-limiting examples of flavoring and / or sweetening agents useful in the formulations described herein include, for example, acacia syrup, acesulfame K, alitame, anise, apple, aspartame, banana, bavarois cream, berry, blackcurrant, butterscotch, calcium citrate, camphor, caramel, cherry, cherry cream, chocolate, cinnamon, bubble gum, citrus, citrus punch, citrus cream, cotton candy, cocoa, cola, cool cherry, cool citrus Ingredients: cyclamate, cylamate, dextrose, eucalyptus, eugenol, fructose, fruit punch, ginger, glycyrrhiza (licorice) syrup, grapes, grapefruit, honey, isomalt, lemon, lime, lemon cream, monoammonium glycyrrhizinate (MagnaSweet®), maltol, mannitol, maple, marshmallow, menthol, mint cream, mixed base Lee, Neohesperidin DC, Neotame, Orange, Pear, Peach, Peppermint, Peppermint Cream, Prosweet® Powder, Raspberry, Root Beer, Rum, Saccharin, Safrole, Sorbitol, Spearmint, Spearmint Cream, Strawberry, Strawberry Cream, Stevia, Sucralose, Sucrose, Sodium Saccharin, Saccharin, Aspartame, Acesulfame Potassium, Mannitol, Tarin, Ciritol, Sucralose, Sorbitol Flavorings include tall, Swiss cream, tagatose, tangerine, thaumatin, tutti-frutti, vanilla, walnut, watermelon, wild cherry, wintergreen, xylitol, or any combination of these flavoring ingredients, such as anise-menthol, cherry-anise, cinnamon-orange, cherry-cinnamon, chocolate-mint, honey-lemon, lemon-lime, lemon-mint, menthol-eucalyptus, orange-cream, vanilla-mint, and mixtures thereof. Flavorings may be used alone or in combinations of two or more. In some embodiments, the aqueous liquid dispersion contains a sweetener or flavoring agent at a concentration ranging from about 0.001% to about 5.0% by volume of the aqueous dispersion.In one embodiment, the aqueous liquid dispersion comprises a sweetener or flavoring agent at a concentration ranging from about 0.001% to about 1.0% by volume of the aqueous dispersion. In another embodiment, the aqueous liquid dispersion comprises a sweetener or flavoring agent at a concentration ranging from about 0.005% to about 0.5% by volume of the aqueous dispersion. In yet another embodiment, the aqueous liquid dispersion comprises a sweetener or flavoring agent at a concentration ranging from about 0.01% to about 1.0% by volume of the aqueous dispersion. In yet another embodiment, the aqueous liquid dispersion comprises a sweetener or flavoring agent at a concentration ranging from about 0.01% to about 0.5% by volume of the aqueous dispersion.

[0206] In certain embodiments, the pediatric pharmaceutical compositions described herein contain one or more compounds described herein as active ingredients in the form of a free acid or free base, or in the form of a pharmaceutically acceptable salt. In some embodiments, the compounds described herein are utilized as N-oxides or in crystalline or amorphous form (i.e., polymorphs). In some situations, the compounds described herein exist as tautomers. All tautomers are included within the scope of the compounds presented herein. In certain embodiments, the compounds described herein exist in unsolvated or solvated forms, where solvated forms include any pharmaceutically acceptable solvent, such as water, ethanol, etc. Solvated forms of the compounds presented herein are also considered to be described herein.

[0207] "Carriers" for pediatric pharmaceutical compositions, in some embodiments, comprise pharmaceutically acceptable excipients and are selected based on compatibility with the compounds described herein, such as a compound of any of Formulas I-VI, and the release profile characteristics of the desired dosage form. Exemplary carrier materials include, for example, binders, suspending agents, disintegrants, fillers, surfactants, solubilizers, stabilizers, lubricants, wetting agents, diluents, and the like. See, e.g., Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pa. 1975; Liberman, H.A. and Lachman, L., Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, NY, 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999); all of which are incorporated by reference in their entirety for all purposes.

[0208] Furthermore, in certain embodiments, the pediatric pharmaceutical compositions described herein are formulated as dosage forms.Thus, in some embodiments, the dosage forms provided herein are suitable for administration to individuals and include the compounds described herein.In certain embodiments, suitable dosage forms include, but are not limited to, aqueous oral dispersions, liquids, gels, syrups, elixirs, slurries, suspensions, solid oral dosage forms, aerosols, sustained-release formulations, fast-dissolving formulations, effervescent formulations, lyophilized formulations, tablets, powders, pills, dragees, capsules, delayed-release formulations, sustained-release formulations, pulsed-release formulations, multiparticulate formulations, and mixed immediate-release and controlled-release formulations.

[0209] In certain aspects, pediatric compositions or formulations containing one or more compounds described herein are orally administered for local delivery of maralixibat, maralixibat chloride, or other compounds described herein to the colon and / or rectum. Unit dosage forms of such compositions include pills, tablets, or capsules formulated for enteral delivery to the colon. In certain embodiments, such pills, tablets, or capsules contain the compositions described herein encapsulated or embedded in microspheres. In some embodiments, the microspheres include, by way of non-limiting example, chitosan microcore HPMC capsules and cellulose acetate butyrate (CAB) microspheres. In certain embodiments, oral dosage forms are prepared using conventional methods known to those skilled in the art of pharmaceutical formulation. For example, in certain embodiments, tablets are manufactured using standard tablet processing procedures and equipment. An exemplary method for forming tablets is by direct compression of a powder, crystalline, or granular composition containing the active agent, alone or in combination with one or more carriers, additives, etc. In alternative embodiments, tablets are prepared using wet granulation or dry granulation methods. In some embodiments, tablets are molded rather than compressed, starting from a moist or otherwise tractable material.

[0210] In certain embodiments, tablets prepared for oral administration contain various excipients, including, by way of non-limiting example, binders, diluents, lubricants, disintegrants, fillers, stabilizers, surfactants, preservatives, colorants, flavoring agents, and the like. In some embodiments, binders are used to impart cohesion to the tablet and ensure that it remains intact after compression. Suitable binder materials include, by way of non-limiting example, starches (including cornstarch and pregelatinized starch), gelatin, sugars (including sucrose, glucose, dextrose, and lactose), polyethylene glycol, propylene glycol, waxes, and natural and synthetic gums, such as acacia, sodium alginate, polyvinylpyrrolidone, cellulosic polymers (including hydroxypropyl cellulose, hydroxypropylmethylcellulose, methylcellulose, ethylcellulose, hydroxyethylcellulose, and the like), Veegum, and combinations thereof. In certain embodiments, diluents are utilized to increase the bulk of the tablet to provide a practical tablet size. Suitable diluents include, but are not limited to, dicalcium phosphate, calcium sulfate, lactose, cellulose, kaolin, mannitol, sodium chloride, dry starch, powdered sugar, and combinations thereof. In certain embodiments, lubricants are used to facilitate tablet production; examples of suitable lubricants include, but are not limited to, vegetable oils such as peanut oil, cottonseed oil, sesame oil, olive oil, corn oil, and theobroma oil, glycerin, magnesium stearate, calcium stearate, stearic acid, and combinations thereof. In some embodiments, disintegrants are used to promote tablet disintegration, and examples include but are not limited to, starch, clay, cellulose, algin, gum, cross-linked polymers, and combinations thereof. Fillers include, but are not limited to, materials such as silicon dioxide, titanium dioxide, alumina, talc, kaolin, powdered cellulose, and microcrystalline cellulose, as well as soluble materials such as mannitol, urea, sucrose, lactose, dextrose, sodium chloride, and sorbitol.In certain embodiments, stabilizers are used to inhibit or retard drug decomposition reactions, including, by way of example, oxidation reactions. In certain embodiments, the surfactant is an anionic, cationic, amphoteric, or nonionic surfactant.

[0211] In some embodiments, maralixibat, maralixibat chloride, or other compounds described herein are administered orally with a carrier suitable for delivery to the distal gastrointestinal tract (e.g., the distal ileum, colon, and / or rectum).

[0212] In certain embodiments, pediatric compositions described herein comprise maralixibat, maralixibat chloride, or other compounds described herein in combination with a matrix (e.g., a matrix comprising hypermellose) that allows for controlled release of the active agent in the distal portion of the ileum and / or colon. In some embodiments, the composition comprises a polymer that is pH-sensitive (e.g., Cosmo Pharmaceuticals' MMX™ matrix), allowing for controlled release of the active agent in the distal portion of the ileum. Examples of such pH-sensitive polymers suitable for controlled release include, but are not limited to, polyacrylic acid polymers (e.g., anionic polymers of methacrylic acid and / or methacrylic acid esters, e.g., Carbopol® polymers) that contain acidic groups (e.g., —COOH, —SO3H) and swell at the basic pH of the intestine (e.g., a pH of about 7 to about 8). In some embodiments, compositions suitable for controlled release in the distal ileum comprise a particulate active agent (e.g., a micronized active agent). In some embodiments, a non-enzymatically degrading poly(dl-lactide-co-glycolide) (PLGA) core is suitable for delivery of enteroendocrine peptide secretagogues to the distal ileum. In some embodiments, dosage forms containing enteroendocrine peptide secretagogues are coated with enteric polymers (e.g., Eudragit® S-100, cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methylcellulose phthalate, anionic polymers of methacrylic acid, methacrylic acid esters, etc.) for site-specific delivery to the distal ileum and / or colon. In some embodiments, a bacteria-activating system is suitable for targeted delivery to the distal portion of the ileum. Examples of microflora-activating systems include dosage forms containing pectin, galactomannan, and / or Azo hydrogels and / or glycoside conjugates of active agents (e.g., conjugates of D-galactoside, β-D-xylopyranoside, etc.).Examples of gut microflora enzymes include bacterial glycosidases such as D-galactosidase, β-D-glucosidase, α-L-arabinofuranosidase, β-D-xylopyranosidase, and the like.

[0213] The pediatric pharmaceutical compositions described herein optionally comprise an additional therapeutic compound described herein and one or more pharmaceutically acceptable additives, such as a compatible carrier, binder, filler, suspending agent, flavoring agent, sweetener, disintegrant, dispersing agent, surfactant, lubricant, colorant, diluent, solubilizer, humectant, plasticizer, stabilizer, penetration enhancer, wetting agent, antifoaming agent, antioxidant, preservative, or one or more combinations thereof. In some embodiments, a film coating is provided around the formulation of the compound of Formula I using standard coating procedures, such as those described in Remington's Pharmaceutical Sciences, 20th Edition (2000). In one embodiment, the compound described herein is in the form of particles, and some or all of the particles of the compound are coated. In certain embodiments, some or all of the particles of the compound described herein are microencapsulated. In some embodiments, the particles of the compound described herein are not microencapsulated and are not coated.

[0214] In further embodiments, tablets or capsules containing ASBTI or other compounds described herein are film-coated for delivery to targeted sites in the gastrointestinal tract. Examples of enteric film coatings include, but are not limited to, hydroxypropylmethylcellulose, polyvinylpyrrolidone, hydroxypropylcellulose, polyethylene glycol 3350, 4500, 8000, methylcellulose, pseudoethylcellulose, amylopectin, and the like.

[0215] Solid dosage forms for pediatric administration Pediatric solid dosage forms of the present invention can be manufactured by standard manufacturing techniques. Non-limiting examples of oral solid dosage forms for pediatric administration are set forth below.

[0216] Foamable composition The foamable compositions of the present invention may be prepared according to techniques well known in the pharmaceutical arts.

[0217] Effervescent formulations include an effervescent pair of a base component and an acid component, which generate gas in the presence of water. In some embodiments, the base component can include, for example, an alkali metal or alkaline earth metal carbonate or bicarbonate. The acid component can include, for example, an aliphatic carboxylic acid, such as citric acid, or its salt. The base component and acid component can each independently comprise, for example, 25% to 55% (w / w) of the effervescent composition. The ratio of the acid component to the base component can be within the range of 1:2 to 2:1.

[0218] The effervescent composition of the present invention can be formulated with additional pharmaceutically acceptable carriers or excipients, if necessary. For example, one or more taste-masking agents can be used. Because pediatric patients often prefer colorful pharmaceutical combinations, dyes can also be used. The composition can be in the form of, for example, tablets, granules, or powder, or granules or powder in a sachet.

[0219] Chewable tablets The chewable tablets of the present invention can be prepared according to techniques well known in the art of pharmacy.

[0220] Chewable tablets are tablets that are intended to disintegrate in the mouth under the action of chewing or sucking, giving the active ingredient a greater opportunity to come into contact with bitter taste receptors on the tongue.

[0221] One way to overcome this problem is to adsorb the active ingredient onto a suitable substrate, an approach known in the art and described, for example, in U.S. Patent No. 4,647,459, which is incorporated herein by reference in its entirety for all purposes.

[0222] Another approach involves forming the active ingredient into an aggregate with a pre-swollen, substantially anhydrous hydrocolloid. The hydrocolloid absorbs saliva and acquires a slippery texture, thereby smoothing the aggregate particles and masking the taste of the active ingredient. This approach is known in the art and is described, for example, in European Patent Application No. 0190826, which is incorporated herein by reference in its entirety for all purposes.

[0223] Another approach involves the use of water-insoluble, hygroscopic excipients such as microcrystalline cellulose, which is known in the art and is described, for example, in U.S. Patent No. 5,275,823, which is incorporated herein by reference in its entirety for all purposes.

[0224] In addition to the above approaches, the chewable tablets of the present invention may contain other standard tableting excipients such as disintegrants and taste masking agents.

[0225] Orodispersible Tablet The orodispersible tablets of the present invention may be prepared according to techniques well known in the art of pharmacy.

[0226] In the orodispersible tablets of the present invention, the excipient mixture is such that it provides a disintegration rate so that its disintegration in the buccal cavity occurs in a very short time, particularly less than 60 seconds. In some embodiments, the excipient mixture is characterized in that the active substance is in the form of microcrystalline coated or uncoated microgranules. In some embodiments, the orodispersible tablets contain one or several disintegrants of the carboxymethylcellulose type or the insoluble reticulated PVP type, one or several swelling agents which may include carboxymethylcellulose, starch, modified starch, or microcrystalline cellulose, or optionally direct compression sugar.

[0227] reconstitution powder Powders for reconstituted pharmaceutical compositions of the present invention can be prepared according to techniques well known in the art of pharmacy.

[0228] In some embodiments, the powder for reconstitution of the present invention contains an effective amount of at least one internal dehydrating agent. The internal dehydrating agent can enhance the stability of the powder. In some embodiments, the internal dehydrating agent is magnesium citrate or disodium carbonate. In some embodiments, the powder composition contains a pharmaceutically acceptable diluent such as sucrose, dextrose, mannitol, xylitol, or lactose.

[0229] The powder compositions of the present invention may be packaged in sachets or bottles for co-dissolution or for short-term (eg, 7 days) storage in liquid form.

[0230] Gummy candy The gummy candies of the present invention can be prepared according to techniques well known in the pharmaceutical arts.

[0231] Traditional gummy candies are made from a gelatin base. Gelatin gives the candy its elasticity, desirable chewy consistency, and longer shelf life. In some embodiments, the gummy candy pharmaceutical composition of the present invention comprises a binder, a sweetener, and an active ingredient.

[0232] In some embodiments, the binder is pectin gel, gelatin, food starch, or any combination thereof.

[0233] In some embodiments, the gummy candy comprises a sweetener, a binder, natural and / or artificial flavors, and colors and preservatives. In some embodiments, the gummy candy comprises glucose syrup, natural sugar cane juice, gelatin, citric acid, lactic acid, natural colors, natural flavors, fractionated coconut oil, and carnauba wax.

[0234] ASBT inhibitors (e.g., maralixibat) can be used in the preparation of medicaments for the prophylactic and / or therapeutic treatment of cholestasis or cholestatic liver disease (e.g., PFIC). Methods for treating any of the diseases or conditions described herein in an individual in need of such treatment can include administering to the individual a therapeutically effective amount of a pharmaceutical composition comprising at least one ASBT inhibitor described herein, or a pharmaceutically acceptable salt, pharmaceutically acceptable N-oxide, pharmaceutically active metabolite, pharmaceutically acceptable prodrug, or pharmaceutically acceptable solvate thereof. [Example]

[0235] The following examples are provided to further illustrate some of the embodiments disclosed herein. The examples are intended to illustrate, but not limit, the disclosed embodiments.

[0236] Example 1. A Randomized, Double-Blind, Placebo-Controlled Phase 3 Clinical Trial to Evaluate the Efficacy and Safety of Maralixibat in the Treatment of Subjects with PFIC Test Overview The primary analysis was conducted in the intent-to-treat (ITT) population of subjects with documented biallelic mutations in ABCB11 (PFIC2) based on standard-of-care genotyping (primary cohort criteria). Subjects predicted to have complete lack of bile salt export pump (BSEP) function based on the type of ABCB11 mutation (PFIC2) determined by standard-of-care genotyping were excluded from the primary cohort and could only be enrolled in the supplemental cohort. Subjects with other PFIC subtypes (e.g., PFIC1 / 3 / 4 / 5 / 6, or novel PFIC variants) or post-surgical subjects (e.g., subjects with internal or external biliary diversion or reversal of biliary diversion surgery) were enrolled in separate supplemental cohorts and evaluated as part of secondary and exploratory analyses.

[0237] Subjects in the primary cohort were randomized 1:1 to receive maralixibat or placebo. Subjects in the supplemental cohort were randomized 1:1 to receive maralixibat or placebo within the following subcohorts: a) PFIC1; b) PFIC3; c) all other supplemental cohort subjects. All subjects received study treatment in addition to standard of care, including concomitant antipruritic treatment.

[0238] The primary cohort enrolled 31 subjects to achieve a minimum of 26 study completers. In the supplemental cohort, overall enrollment was 62 subjects.

[0239] The outline of the phase 3 clinical trial is summarized in Figure 2. The trial was divided into four parts: 1) a screening period (up to 6 weeks); 2) a dose escalation period (4-6 weeks); 3) a stable dosing period (20-22 weeks); and 4) a safety follow-up period (7 days).

[0240] Study population Key inclusion criteria for the Phase 3 clinical trial were: 1) subjects aged 1 to 18 years with a baseline body weight of 5.0 kg or greater; 2) cholestasis confirmed by a total sBA ≥ 3 × ULN; 3) a mean AM ItchRO(Obs) score ≥ 1.5 during 4 consecutive weeks of the screening period leading up to the baseline visit; 4) completion of at least 21 valid morning ItchRO(Obs) entries during 4 consecutive weeks of the screening period leading up to the baseline visit; 5) a diagnosis of PFIC based on chronic cholestasis confirmed by persistent (> 6 months) pruritus in addition to biochemical abnormalities and / or pathological evidence of progressive liver disease; and: a) Primary cohort: subjects with biallelic disease-causing mutations in ABCB11 (PFIC2) based on standard of care genotyping. b) Supplementary cohort: i) subjects with genetic test results consistent with biallelic disease-causing mutations in ATP8B1 (PFIC1), ABCB4 (PFIC3), or TJP2 (PFIC4) based on standard of care genotyping; ii) subjects with a PFIC phenotype who do not have a known mutation, or have another known mutation not listed above, or have intermittent cholestasis confirmed by fluctuations in sBA levels; iii) subjects with PFIC after internal or external fistula surgery, or subjects in whom internal or external fistula surgery has been reversed.

[0241] A valid entry is one that is completed and not answered "don't know"; the maximum number of invalid reports allowed is 7, with no more than 2 invalid reports during the last 7 days prior to randomization.

[0242] Key exclusion criteria for the phase 3 trial were: 1) predicted complete absence of bile salt export pump (BSEP) function based on the type of ABCB11 mutation (PFIC2) determined by standard-of-care genotyping (applicable to the primary cohort only); 2) recurrent intrahepatic cholestasis, as indicated by sBA levels <3 × ULN or a history of intermittent pruritus (applicable to the primary cohort only); 3) current or recent (<1 year) history of atopic dermatitis or other non-cholestatic disease associated with pruritus; 4) history of surgical disruption of the enterohepatic circulation (applicable to the primary cohort only); 5) chronic diarrhea requiring intravenous fluid or nutritional intervention for diarrhea and / or its sequelae at or within 6 months prior to screening; 6) previous liver transplantation or impending need for liver transplantation; 7) decompensated cirrhosis (international normalized ratio [INR] >1.5, and / or albumin <30 g / L, clinically significant ascites, and / or variceal bleeding, and / or history or presence of encephalopathy; 8) ALT or TSB >15 × ULN at screening; 9) presence of other liver disease; 10) presence of any other disease or condition known to interfere with drug absorption, distribution, metabolism, or excretion, including metabolism of bile salts in the intestine, at the investigator's discretion (e.g., inflammatory bowel disease); 11) possible malignant liver mass on imaging, including screening ultrasound; 12) known diagnosis of human immunodeficiency virus (HIV) infection; 13) any previous cancer diagnosis within 5 years prior to the screening visit (carcinoma in situ 14) Any known history of alcohol or drug abuse; 15) Administration of bile acid or lipid-binding resins or phenylbutyrate during the screening period; 16) Administration of any investigational drug, biologic, or medical device during the screening period; 17) Previous use of an ileal bile acid transporter inhibitor (IBATi); 18) Non-compliance with medical regimens, unreliability, medical conditions, mental instability, or cognitive impairment that, in the opinion of the investigator or sponsor's medical monitor, may undermine the legal validity of informed consent, compromise subject safety, or lead to non-compliance with the study protocol or inability to perform study procedures; 19) Known hypersensitivity to maralixibat or any of its excipients.

[0243] Study Medication The study drug administered was maralixibat chloride, provided as an oral solution form (e.g., 5, 10, 15, and 20 mg / mL) with either a 0.5-, 1.0-, or 3.0-mL-sized dosing dispenser. The reference / comparison product was placebo, provided as an oral solution with a dosing dispenser of the same size (either 0.5 mL, 1.0 mL, or 3.0 mL). Maralixibat and placebo (study drug) were provided in 30 mL volumes packaged in 30 mL-sized amber PET bottles and required refrigerated storage conditions (2°C to 8°C).

[0244] One of the excipients in the maralixibat oral solution is propylene glycol (PG); to limit a subject's exposure to PG, a specific concentration of oral solution was prescribed for a given subject based on body weight and target dose. The dosing regimen limited PG exposure to ≤26 mg / kg / day while providing a reasonable (neither too large nor too small) dose volume to ensure accurate dosing.

[0245] The placebo solution contained all components of the study drug except the active drug substance. All packaged study drug components, including the dosing dispenser, were identical to maintain blinding.

[0246] Administration of investigational drug Interactive Response Technology (IRT) was used for subject screening and enrollment, randomization, study drug supply distribution and management, inventory management and supply ordering, study drug expiration date tracking and management, and emergency unblinding. Individual subjects' treatments were automatically assigned by IRT. After confirming study eligibility, subjects were randomized 1:1 to receive maralixit or placebo according to a computer-generated randomization schedule, stratified by cohort.

[0247] Subjects received (or self-administered) various volumes of ready-to-use oral solution study medication at each dosing visit, beginning at the baseline visit (Visit 1). The dose volume was determined based on individual body weight, dose level (150, 300, 450, or 600 μg / kg) according to the dose escalation schedule, and the strength of the administered solution (5, 10, 15, or 20 mg / mL).

[0248] Study drug was administered on a BID regimen during the dose-escalation and stable-dose periods of the study. Morning doses were administered approximately 30 minutes before breakfast, and evening doses were administered approximately 30 minutes before the main dinner. Study drug was administered at approximately the same time each day throughout the study.

[0249] For subjects assigned to maralixibat, the dose escalation period consisted of the following weekly steps: dose level 1, 150 μg / kg maralixibat BID for 1 week; dose level 2, 300 μg / kg maralixibat BID for 1 week; dose level 3, 450 μg / kg maralixibat BID for 1 week; dose level 4, 600 μg / kg maralixibat BID for the remainder of the study.

[0250] Exam Schedule The test procedures and assessments performed throughout the study can be seen in the assessment schedule in Table 1.

[0251] Genetic testing results. Variations in ATP8B1 (PFIC1), ABCB11 (PFIC2), ABCB4 (PFIC3), TJP2 (PFIC4), NR1H4 (PFIC5), and MYO5B (PFIC6) are predictive of PFIC. Standard of care genotyping results were reviewed and documented by the sponsor or designee to confirm PFIC subtype and determine cohort assignment.

[0252] Efficacy. Pruritus severity was assessed using the Caregiver / Patient Itch Reported Outcome Scale (ItchRO™), administered as a twice-daily electronic diary. All subjects' caregivers completed the observer tool, ItchRO(Obs). The ItchRO(Obs), whenever possible, was completed by the same caregiver for consistency. Only subjects aged 9 years or older at screening completed the patient tool, ItchRO(Pt). If a subject turned 9 years old at any time after screening, they did not complete the ItchRO(Pt). Starting the day after the screening visit, and continuing daily throughout the study, pruritus was assessed and recorded via ItchRO twice daily. Pruritus severity was measured by completing the first question on the ItchRO(Obs) (How severe were your child's itch-related symptoms?) or the ItchRO(Pt) (How itchy did you experience itching?). Itching frequency was measured by completing the third question in ItchRO(Obs) (how long did your child scratch or rub their skin) or ItchRO(Pt) (how often did they scratch or rub their skin due to itching last night / today?). Caregivers and subjects rated the severity and frequency of itching using five options to describe itching symptoms. ItchRO(Pt) and ItchRO(Obs) were previously described in Kamath, et al., "Development of a Novel Tool to Assess the Impact of Itching in Pediatric Cholestasis," Patient, 11:69-82 (2018), which is incorporated herein by reference in its entirety for all purposes. [Table 1] TIFF2025535313000010.tif255162AFP = alpha-fetoprotein; C4 = 7a-hydroxy-4-cholesten-3-one; CBC = complete blood count; CIS = caregiver impression of severity; CIC = caregiver impression of change; ECG = electrocardiogram; EDQ = exploratory diary questionnaire; EOT = end of treatment; ET = early termination; FGF-19 = fibroblast growth factor-19; ItchRO = itch reported outcome; P = provided; PedsQL = pediatric quality of life scale; PIC = patient impression of change; PIS = patient impression of severity; PK = pharmacokinetics; R = returned; S = serum; U = urine; V = visit a Subjects who do not initially meet the eligibility criteria may be reassessed during the 6-week screening period before being recorded as a screening dropout, and subjects may be rescreened. b The investigational site should record the dates of upcoming scheduled procedures related to PFIC (e.g., PEBD, ileal exclusion, liver transplant, or entry onto a liver transplant waiting list) if known at the time of the visit. c Blood pressure, heart rate, temperature, respiratory rate, height and weight will be measured by trained staff using standardized methodologies (including a calibrated stadiometer or headboard and calibrated balance, respectively). d If an ultrasound or liver MRI within the last 6 months is available, a screening ultrasound is not necessary. e Women of childbearing potential only; results must be confirmed before offering study drug. fGenotyping results will be confirmed by the sponsor or designee. g Caregivers and age-appropriate subjects will be instructed to complete the eDiary twice daily (morning and evening). h Must be completed by caregiver for all subjects. i Only subjects aged 9 years or older at the time of screening need to complete this. j It must be completed by subjects and caregivers using age-appropriate PedsQL modules. k Subjects are required to fast as much as possible for six hours prior to sample collection. Fluid intake is permitted if needed, but is not recommended. l A blood sample should be taken before administration of the vitamin supplement. m PK samples will be drawn pre-dose and approximately 2.5 hours after the morning dose. n If necessary, investigational medication may be provided between study site visits by mail directly to the patient. o Subjects will self-administer (or be administered) their first dose of study medication in the clinic on Study Site Visit Day 1 / 0 after breakfast under the supervision of the investigator or trained site staff.

[0253] Serum bile acids and other cholestatic biomarkers. Blood samples were collected as described in Table 1 to measure levels of cholestatic biomarkers, including total sBA, sBA subspecies, C4, FGF-19, and autotaxin, as well as liver-related parameters. Subjects were encouraged to fast for at least 6 h prior to collection (water intake was permitted if necessary but not recommended). Total sBA and target bile acid subspecies were quantified using a liquid chromatography-mass spectrometry (LC-MS) method for exploratory evaluation. Furthermore, total sBA screening is assessed using an enzymatic assay for evaluation of inclusion criteria. C4, a key intermediate in the pathway of bile acid synthesis from cholesterol, is determined by a validated LC-MS / MS method.

[0254] Clinical laboratory evaluations were performed as shown in Table 2. Serum bile acid results, except for results at screening, were blinded to the site and study team until after database lock for Study MRX-502. Anion and osmolal gaps were calculated, as well as corrected sodium, α-tocopherol / total lipid ratio, retinol / RBP molar ratio, FIB-4, and APRI.

[0255] Health-Related Quality of Life and Pruritus Assessment. Patients underwent health-related quality of life (HRQoL) assessments throughout the study. The PedsQL™ is a questionnaire administered to subjects and caregivers using age-appropriate PedsQL modules. Subjects aged 8-12 years and 13-18 years self-completed the PedsQL Child Report and PedsQL Teenager Report, respectively. Subjects' caregivers completed the age-appropriate Parent PedsQL Report (i.e., Report for Infants, Toddlers, Young Children, Children, and Teenagers).

[0256] Caregiver Impression of Severity of Pruritus (CIS). The CIS is a questionnaire administered to caregivers as outlined in Table 2. The CIS is designed to assess caregivers' perception of the severity of their child's pruritus. The questionnaire was administered with a 1-week recall period.

[0257] Patient Impression of Severity of Pruritus (PIS). The PIS is a questionnaire administered to caregivers as outlined in Table 2. Subjects aged 9 years and older self-completed the questionnaire. The PIS is designed to assess the subject's perception of the severity of pruritus. The questionnaire was administered with a 1-week recall period.

[0258] Clinician Scratch Scale (CSS). The CSS provides an assessment of itch severity. Clinician assessment of a subject's itch focused on scratching observed by the physician and visible damage to the skin as a result of scratching. The CSS uses a 5-point scale, with 0 indicating no evidence of scratching and 4 indicating cutaneous mutilation with bleeding, hemorrhage, and scarring. Clinician assessment of itch, performed by the principal investigator or co-investigator using the CSS, was recorded at screening, baseline, and additional study visits, as outlined in Table 2. [Table 2]

[0259] Patient Impression of Change (PIC). The PIC is designed to assess the subject's perception of itch at Week 26 (EOT) compared with the subject's perception of itch before the start of treatment with the study drug. The PIC was completed by subjects aged 9 years or older at the Week 26 (EOT) visit.

[0260] Caregiver Impression of Change (CIC). The CIC is designed to assess caregiver perceptions of the subject's itch-related symptoms and xanthomas severity at Week 26 (EOT) compared with the subject's itch-related symptoms and xanthomas severity before the start of treatment with the study drug. The CIC was completed by all caregivers at the Week 26 (EOT) visit.

[0261] Exploratory Diary Questionnaire. Pruritus was assessed using the EDQ caregiver / patient-reported outcome administered as a twice-daily electronic diary. Caregivers of all subjects under 9 years of age completed the observer tool: EDQ (Obs). Subjects 9 years of age and older completed the patient tool: EDQ (Pt). Subjects and caregivers were trained in the use of the electronic diary during the screening visit (Visit 0). Pruritus was assessed and recorded by subjects or caregivers twice daily via the EDQ, beginning the day after the screening visit and continuing daily throughout the study, as described in Table 2.

[0262] Clinical Pharmacology Evaluation. To assess plasma levels of maralixibat, blood samples (anticoagulant K3 EDTA) were collected pre-dose and 2.5 hours after the morning dose (within a 30-minute window) at Week 10 (Visit 5) and Week 26 (Visit 9; EOT / ET). Actual PK blood sample collection times were recorded relative to the time of dosing.

[0263] Healthcare utilization. Number of hospitalizations, length of stay, and emergency department visits (in days) related to the underlying condition, as well as any surgeries and procedures specific to the subject's PFIC status, were collected during post-baseline visits, as outlined in Table 2. Date of visit / admission, date of discharge, relationship / issue, and discharge status were collected.

[0264] As summarized in Figure 5, the following definitions will be used for the PFIC population in the analysis of various endpoints in this study. Primary and secondary endpoints: 1) PFIC2, participants in PFIC2 who meet the criteria for the primary cohort; 2) participants in PFIC, PFIC1, PFIC2 (who meet the criteria for the primary cohort), PFIC3, PFIC4, PFIC5, and PFIC6. Exploratory endpoints: PFIC2 and PFIC1, PFIC2, PFIC4, PFIC5, PFIC6, abbreviated PFIC2.

[0265] The PFIC cohort (PFIC1, PFIC2, PFIC3, PFIC4, PFIC5, and PFIC6) included participants with biallelic disease-causing mutations in ATP8B1 (PFIC1), ABCB11 (PFIC2, truncating and non-truncating variants), ABCB4 (PFIC3), TJP2 (PFIC4), and MYO5B (PFIC6), as well as PFIC patients with a history of bile diversion or Kasai surgery, heterozygous PFIC1 and PFIC2 patients, and participants with unknown variants. The number of participants with each mutation depended on the number of genotyped patients in the enrolled study cohort (see Figure 5 and Tables 3 and 4).

[0266] Unless otherwise noted, percentages are 100 x n / N. All subjects with PFIC1-PFIC6 have biallelic disease. [1] nt-PFIC2 = non-truncated PFIC2 (primary cohort); nt-PFIC2-IsBA = non-truncated PFIC2 with low or variable serum bile acids; nt-PFIC2-surg = non-truncated PFIC2 with history of surgery; t-PFIC2 = truncated PFIC2; PFIC1-surg = PFIC1 with history of surgery; PFIC4-surg = PFIC4 with history of surgery; nt-PFIC2-het = non-truncated PFIC2 heterozygous; PFIC1-het = PFIC1 heterozygous; No variant detected = no established variant associated with PFIC disease. [2] nt-PFIC2 = partial loss of BSEP function; t-PFIC2 = complete loss of BSEP function. Applicable only to PFIC2 subjects, with the exception of one nt-PFIC2 subject (015002) with a heterozygous ABCB11 mutation; N / A for all other subjects.[3] One subject (015002) had a heterozygous ABCB11 mutation, and the other subject (021006) had a heterozygous ATP8B1 mutation.

[0267] Table 3 provides an overview of the disposition and demographics of participants in the MARCH clinical trial. Table 4 provides an overview of baseline health-related parameters of participants in the MARCH clinical trial. The results in Tables 3 and 4 include subject disposition, demographic and baseline characteristics, PFIC history, past medications, and treatment exposure and compliance. Table 3 shows that baseline and demographic characteristics were balanced between cohorts. [Table 3] [Table 4] [Table 5]

[0268] Example 2. Primary efficacy endpoint For this study, the primary endpoint was improvement in pruritus, measured as the change from baseline in the mean morning ItchRO(Obs) severity score, in the maralixibat-treated group compared with the placebo group. Primary analyses for the primary efficacy endpoint were conducted in 1) PFIC2 participants who met the primary cohort criteria in the intention-to-treat population (non-abbreviated primary "BSEP cohort" or "primary cohort" (N=31)), 2) all PFIC participants (excluding participants with a history of previous surgery, heterozygous participants, and unknown subtypes; "all PFIC cohort" or "PFIC cohort" (N=64)), and 3) the total study participant cohort, including participants with a history of previous surgery, heterozygous participants, and unknown subtypes. A mixed-effects model for repeated measures (MMRM) based on restricted maximum likelihood (REML) was used as the primary analysis method. Repeated measures included post-baseline visits during the dose-escalation phase (i.e., Week 6) and the fixed-dose phase (i.e., Weeks 10, 14, 18, 22, and 26), with the change from baseline in 6-week or morning 4-week average ItchRO(Obs) severity score as the dependent variable. The MMRM model included fixed, categorical effects of treatment group, visit, and the interaction between treatment group and visit, as well as continuous, fixed covariates for baseline morning 4-week average ItchRO(Obs) severity score and the interaction between baseline score and visit.

[0269] The primary efficacy analysis compared maralixibat with placebo using between-treatment contrasts (least squares [LS] mean differences) over the final 12 weeks of the study (i.e., weeks 15 to 18, 19 to 22, and 23 to 26 combined). The analytical solution for the overall treatment effect obtained from the MMRM was the equally weighted average of the three individual period-specific estimates for the period of interest (i.e., the final 12 weeks of the study). Significance tests were based on LS means, using a two-sided significance level (two-sided 95% confidence interval [CI]). The null hypothesis for the primary efficacy endpoint of equivalence of maralixibat with placebo was as follows: H 01 : The mean change in mean morning ItchRO(Obs) severity score between baseline and weeks 15 through 26 in the two treatment groups was equal.

[0270] The mean change from baseline in the primary efficacy endpoint (itch severity score (ItchRO[Obs])) in the BSEP deficiency cohort and the entire PFIC cohort is summarized in Figures 6–8. The BSEP deficiency cohort showed a 1.7-point decrease from baseline in the morning ItchRO[Obs] score, a difference of 1.089 points compared to the placebo group (Figure 6A). The BSEP deficiency cohort showed a 1.7-point decrease from baseline in the evening ItchRO[Obs] score, a difference of 1.111 points compared to the placebo group (Figure 7A). The BSEP deficiency cohort showed a 1.8-point decrease from baseline in the maximum daily ItchRO[Obs] score, a difference of 1.130 points compared to the placebo group (Figure 7B).

[0271] The entire PFIC cohort demonstrated a 1.8-point reduction from baseline in morning ItchRO[Obs] scores, a difference of 1.20 points compared to the placebo group (Figure 6B). The entire PFIC cohort demonstrated a 1.8-point reduction from baseline in evening ItchRO[Obs] scores, a difference of 1.157 points compared to the placebo group (Figure 8A). The entire PFIC cohort demonstrated a 1.9-point reduction from baseline in maximum daily ItchRO[Obs] scores, a difference of 1.198 points compared to the placebo group (Figure 8B).

[0272] The primary efficacy endpoint (mean change from baseline in itch severity score (ItchRO[Obs])) in the FIC1 (PFIC1) and MDR3 (PFIC3) cohorts is summarized in Figure 9. The FIC1 cohort demonstrated a 1.4-point reduction from baseline in morning itch ItchRO[Obs] score, a difference of 1.136 points compared to the placebo group (Figure 9A). The MDR3 cohort demonstrated a 1.8-point reduction from baseline in morning itch ItchRO[Obs] score, a difference of 0.594 points compared to the placebo group (Figure 9B).

[0273] The change from baseline in the average weekly morning ItchRO[Obs] score over time for the BSEP deficiency (also known as Primary) group is shown in Figure 10A. The change from baseline in the average weekly morning ItchRO[Obs] score over time for the PFIC group is shown in Figure 10B. The change from baseline in the average weekly morning ItchRO[Obs] score over time for all study participants is shown in Figure 10C. From these figures, it is clear that the ItchRO[Obs] scores for maralixibat-treated participants were significantly lower at each time point from 2 weeks to 26 weeks, suggesting a very strong response to maralixibat treatment across all PFIC types.

[0274] These results demonstrate that maralixibat is highly effective compared to placebo in significantly reducing pruritus in all PFIC patients, including PFIC1 participants, PFIC2 participants, PFIC3 participants, and all PFIC groups combined.

[0275] Example 3. Secondary efficacy endpoints Secondary efficacy endpoints were defined as: 1) the mean change in total serum bile acid (sBA) levels between baseline and the mean of weeks 18, 22, and 26 (Figures 11-12); 2) the percentage of ItchRO(Obs) responders from weeks 15 to 26 (Figures 13A and 14A); and 3) the percentage of sBA responders from weeks 18 to 26 (Figures 13B and 14B). Pruritus responders were defined as subjects with a change from baseline in morning 4-week mean ItchRO(Obs) severity ≥ 1.0 or a mean severity score ≤ 1.0. For the purposes of determining response, mean severity scores from three 4-week periods (weeks 15 to 18, 19 to 22, and 23 to 26) were used. Subjects were defined as ItchRO non-responders if the 4-week mean baseline score was missing or if all three 4-week mean (post-baseline) scores were missing. sBA responders are defined as subjects with a mean sBA level of <102 μmol / L (applicable only if baseline sBA is ≥102 μmol / L) or a mean percent change from baseline of ≤-75%. For purposes of determining response, the mean sBA values ​​from weeks 18, 22, and 26 are used. Subjects are defined as sBA non-responders if baseline sBA values ​​are missing or if sBA values ​​are missing at all three time points (i.e., weeks 18, 22, and 26). p values ​​for comparisons of maralixibat and placebo are calculated using Barnard's exact test.

[0276] Key secondary efficacy endpoints (as mean change from baseline in sBA levels) are shown in Figures 11-12. The BSEP deficiency cohort achieved a reduction in sBA levels of nearly 200 μmol / L, a difference of 186.723 μmol / L from placebo (Figure 11A). The full PFIC cohort achieved a reduction in sBA levels of more than 150 μmol / L, a difference of 160.43 μmol / L from placebo (Figure 11B). The FIC1 cohort achieved a reduction in sBA levels of nearly 100 μmol / L, a difference of 126.382 μmol / L from placebo (Figure 12A). The MDR3 cohort achieved a reduction in sBA levels of 150 μmol / L, a difference of 135.089 μmol / L from placebo (Figure 12B).

[0277] The percentages of pruritic and sBA responses for the BSEP deficiency cohort are shown in Figure 13. The percentage of pruritic responses in the BSEP deficiency cohort taking maralixibat was 57.1% compared to 23.5% in the placebo group, representing a p-value of 0.0736 (Figure 13A). The percentage of sBA responses in the BSEP deficiency cohort taking maralixibat was 35.7% compared to 5.9% in the placebo group, representing a p-value of 0.0410 (Figure 13B).

[0278] The percentages of pruritic and sBA responses for the entire PFIC cohort are shown in Figure 14. The percentage of pruritic responses in the entire PFIC cohort receiving maralixibat was 63.6% compared to 25.8% in the placebo group, representing a p-value of 0.0023 (Figure 14A). The percentage of sBA responses in the BSEP deficiency cohort receiving maralixibat was 45.5% compared to 6.5% in the placebo group, representing a p-value of 0.0004 (Figure 14B).

[0279] The change from baseline in sBA levels (μmol / L) over time for the BSEP deficiency (also known as major) group is shown in Figure 15A. The change from baseline in sBA levels (μmol / L) over time for the PFIC group is shown in Figure 15B. The change from baseline in sBA levels (μmol / L) over time for all study participants is shown in Figure 15C. From these figures, it is clear that maralixibat-treated participants had sBA levels >100 μmol / L lower at each time point from 2 weeks to 26 weeks, suggesting a very strong response to maralixibat treatment across all PFIC types.

[0280] These results demonstrate that maralixibat is highly effective in significantly lowering serum bile acids in all PFIC patients, including PFIC1, PFIC2, PFIC3, and all PFIC groups combined. The results further demonstrate that maralixibat is effective in reducing both pruritus and sBA in the majority of participants, with a very high degree of confidence, and in a significantly higher proportion of participants than placebo.

[0281] Example 4. Additional Efficacy Evaluation Additional efficacy endpoints will be defined as follows: 1) pruritic response: percentage of ratings ≤ 1; 2) pruritic response: percentage of ratings ≤ 1 or reduction of ≥ 1; 3) mean change from baseline in Clinician Scratch Scale (CSS) score; 4) mean change from baseline in total bilirubin; and 5) mean change from baseline in direct bilirubin.

[0282] Figure 16 shows pruritus responses by percentage of ratings ≦1 for the BSEP deficiency and PFIC cohorts. Responders were defined as a scratch score ≦1 on the ItchRO(Obs) severity score. Morning and evening values ​​were used to calculate percentages. [1] The model included treatment group, baseline morning pruritus score, and baseline evening pruritus score. [2] The model included treatment group, baseline morning pruritus score, baseline evening pruritus score, and PFIC type. The percentage of pruritus responders in the BSEP deficiency cohort who took maralixibat was >0.6 compared with 0.3 in the placebo group, representing a difference of 0.344 in the percentage of pruritus responders taking maralixibat (Figure 16A). The proportion of pruritus responders among PFIC cohort participants taking maralixibat was over 0.6 compared to 0.3 in the placebo group, representing a difference of 0.345 in the proportion of pruritus responders taking maralixibat (Figure 16B).

[0283] Figure 17 shows pruritus responses by percentage of scores ≤1 or reductions ≥1 for the BSEP deficiency and PFIC cohorts. Responders were defined as a scratch score ≤1 or a reduction of at least 1 point from baseline on the ItchRO(Obs) severity score. At each assessment, morning severity scores were compared to the baseline mean morning severity score, and evening severity scores were compared to the baseline mean evening severity score. Morning and evening severity scores were used to calculate percentages. [1] The model included treatment group, baseline morning pruritus score, and baseline evening pruritus score. [2] The model included treatment group, baseline morning pruritus score, baseline evening pruritus score, and PFIC type. The percentage of pruritus responders in the BSEP deficiency cohort who received maralixibat was >0.7 compared with 0.3 in the placebo group, representing a difference of 0.398 in the percentage of pruritus responders who received maralixibat (Figure 17A). The proportion of pruritus responders among PFIC cohort participants taking maralixibat was over 0.7 compared to 0.3 in the placebo group, representing a difference of 0.380 in the proportion of pruritus responders taking maralixibat (Figure 17B).

[0284] CSS scores over time for the BSEP deficiency (aka major) group are shown in Figure 18A. CSS scores over time for the PFIC group are shown in Figure 18B. These figures demonstrate that maralixibat-treated participants had significantly lower CSS scores at each time point from week 2 to week 26.

[0285] The mean change from baseline in Clinician Scratch Scale (CSS) scores is shown in Figure 19. Estimates are from a repeated measures mixed-effects model (MMRM) with change from baseline as the dependent variable, fixed categorical effects for treatment group, analysis visit, and the interaction between treatment and visit, and continuous fixed covariates for baseline score and the interaction between baseline score and visit. For the PFIC cohort, PFIC type was included in the model as an additional covariate. The improvement in CSS scores for the BSEP deficiency cohort relative to baseline was approximately 1.7 points compared to approximately 0.4 points for the placebo group, representing a difference in improvement of 1.328 points for the maralixibat-treated group (Figure 19A). The improvement in CSS scores for the PFIC cohort relative to baseline was approximately 1.8 points compared to approximately 0.5 points for the placebo group, representing a difference in improvement of 1.247 points for the maralixibat-treated group (Figure 19B).

[0286] These additional efficacy outcome results further highlight the surprising and unexpected efficacy of maralixibat in reducing pruritus in all PFIC patients. Furthermore, in a previous study of odevixibat in PFIC, efficacy measures for pruritus and serum bile acids did not increase efficacy in any of the outcome measures. Higher dose groups had lower efficacy parameters. Therefore, this was hypothesized to be the maximum expected effect size in PFIC for an IBAT inhibitor. The magnitude of reductions in pruritus and sBA observed in the MARCH study was greater than previous data for odevixibat.

[0287] The mean change from baseline in total bilirubin is shown in Figures 20-21. Estimates are from a repeated measures mixed-effects model (MMRM) with change from baseline as the dependent variable and fixed categorical effects for treatment group, period, and the interaction between treatment and period, as well as continuous fixed covariates for mean baseline score and the interaction between baseline score and period. [2] Mean values ​​from the MMRM for weeks 15 to 18, 19 to 22, and 23 to 26 are obtained as equal-weighted averages of the three individual visit-specific estimates. The improvement (reduction) in total bilirubin for the BSEP deficiency cohort was a 1.2 mg / dL decrease compared to baseline, compared with an increase of approximately 0.4 mg / dL in the placebo group, representing a difference in improvement of 1.585 mg / dL for the maralixibat-treated group (Figure 20A). The improvement (reduction) in total bilirubin for the PFIC cohort was a decrease of approximately 1.2 mg / dL versus an increase of approximately 0.8 mg / dL for the placebo group, representing a difference of 2,000 mg / dL in total bilirubin improvement for the maralixibat-treated group (Figure 20B). The change from baseline in total bilirubin over time for the BSEP deficiency (aka major) group is shown in Figure 21A. The change from baseline in total bilirubin over time for the PFIC group is shown in Figure 21B. These figures demonstrate that the total bilirubin of maralixibat-treated participants was significantly lower than baseline (at each time point from week 2 through week 26) and at least 1.0 mg / dL lower than baseline at week 18 and beyond.

[0288] The mean change from baseline in direct bilirubin is shown in Figures 22-23. Estimates are from a repeated measures mixed-effects model (MMRM) with change from baseline as the dependent variable and fixed categorical effects for treatment group, period, and the interaction between treatment and period, as well as continuous fixed covariates for mean baseline score and the interaction between baseline score and period. [2] Mean values ​​for the periods 15 to 18, 19 to 22, and 23 to 26 obtained from the MMRM were obtained as equal-weighted averages of the three individual visit-specific estimates. The improvement (reduction) in direct bilirubin for the BSEP deficiency cohort was a decrease of more than 0.8 mg / dL relative to baseline, compared with an increase of approximately 0.3 mg / dL for the placebo group, representing a difference in improvement of 1.196 mg / dL for the maralixibat-treated group (Figure 22A). The improvement (decrease) in direct bilirubin for the PFIC cohort was a decrease of approximately 0.9 mg / dL compared to an increase of approximately 0.7 mg / dL for the placebo group, representing a difference of 1.608 mg / dL in direct bilirubin improvement for the maralixibat-treated group (Figure 22B). The change from baseline in direct bilirubin over time for the BSEP deficiency (aka major) group is shown in Figure 23A. The change from baseline in direct bilirubin over time for the PFIC group is shown in Figure 23B. These figures demonstrate that the direct bilirubin of maralixibat-treated participants was significantly lower than baseline at each time point from week 2 through week 26, and at least 1.0 mg / dL lower than baseline at week 18 and beyond.

[0289] The change in height Z-score over time for participants in the BSEP deficiency (aka major) group is shown in Figure 24A. The change in height Z-score over time for participants in the PFIC group is shown in Figures 24B and 24C. These figures show an overall positive trend in the increase in height Z-score for participants in the maralixibat treatment group compared to the placebo group.

[0290] The change in weight Z-score over time for participants in the BSEP deficiency (aka major) group is shown in Figure 25A. The change in weight Z-score over time for participants in the PFIC group is shown in Figures 25B and 25C. It is very clear from the figures that while children in both the maralixibat-treated and placebo groups gained weight, participants in the maralixibat-treated group gained significantly more weight over time than placebo participants.

[0291] No significant changes in serum ALT were observed following MRX treatment in the entire PFIC cohort (Figures 26A and 26B).

[0292] In the Indigo phase 2 trial of maralixibat, only participants with PFIC2 responded; no patients with PFIC1 responded. Therefore, other (non-PFIC2) subtypes were not expected to respond, and therefore the MARCH trial was designed with separate cohorts.

[0293] Surprisingly, however, significant improvements in sBA, pruritus, total bilirubin, and direct bilirubin were all observed in this study across all PFIC types.

[0294] Furthermore, in non-PFIC2 patients, the magnitude of the effect on reducing sBA and alleviating pruritus was similar to or stronger than that in PFIC2 patients, which is unexpectedly contrary to previous study results.

[0295] Another surprising finding was that the group in the overall population included not only other PFIC subtypes but also post-surgical PFIC patients. Given that surgery has the same mechanism of interrupting the enterohepatic circulation, no one would have expected these patients to respond. However, these patients unexpectedly showed a significant response to maralixibat treatment.

[0296] Pharmacokinetic analysis Systemic concentrations of maralixibat in plasma were determined predose and approximately 2.5 hours after the morning dose at weeks 10 and 26 (EOT / ET). Summary statistics (number of observations, mean, standard deviation, coefficient of variation, median, minimum, maximum, and geometric mean) were determined for maralixibat concentrations at each nominal time point and sampling time.

[0297] Example 5. Assessment of adverse events and serious adverse events An adverse event (AE) or treatment-emergent adverse event (TEAE) is any untoward medical occurrence in a clinical study subject receiving a medicinal product that does not necessarily have a causal relationship to this treatment. Thus, a TEAE can be any untoward and unintended sign (including abnormal laboratory findings), symptom, or disease that is temporally associated with the use of a medicinal product (investigational drug), whether or not related to the medicinal product (investigational drug) (ICH Guidance E2A 1995). All TEAEs are collected from the time informed consent is signed until the defined follow-up period. This includes events occurring during the screening phase of the clinical trial, regardless of whether the investigational drug is administered.

[0298] Table 6 below summarizes TEAEs across all PFIC cohorts in the MARCH Phase 3 study. The most common TEAE was GI disorders [n(%)], 35 (74.5%) for maralixibat and 17 (37.0%) for placebo. A total of 90 patients experienced one or more TEAEs, of which 84 (93.3%) were mild or moderate in severity and transient in nature. The maximum grade in 84 of the 90 participants who experienced an AE was mild or moderate. [Table 6]

[0299] Serious adverse event (SAE) is any untoward medical occurrence (whether or not considered related to the investigational drug) that occurs at any dose: 1) results in death; 2) is life-threatening; 3) requires inpatient hospitalization or prolongation of existing hospitalization; 4) results in permanent or significant disability / incapacity; or 5) is a major medical event.

[0300] All SAEs (regardless of study-relatedness) will be collected from the time the subject signs the informed consent until a defined follow-up period and must be reported within 24 hours of first knowledge of the event.

[0301] Of 47 maralixibat-treated participants, 5 (10.6%) experienced an SAE. Of 46 placebo participants, 3 (6.5%) experienced an SAE.

[0302] TEAEs included diarrhea (57.4% vs. 19.6%) and abdominal pain (25.5% vs. 13%) for MRX vs. PBO, respectively (Table 7). Diarrhea was mostly grade 1 and transient, with a median duration of 5.5 days; there were no severe or critical events. One patient with mild diarrhea discontinued treatment (Table 6 and Figure 28). Abdominal pain was also mostly mild and transient, occurring concomitantly with diarrhea in almost all cases. No clinically meaningful changes from baseline in transaminase levels were observed in either group. [Table 7]

[0303] Transaminase adverse events (AEs) were observed in 17% and 6.5% of MRX and PBO patients, respectively (Table 7). Of the eight participants receiving MRX who had transaminase elevations, six had resolution without dose interruption; two patients continued to have stable elevations even after dose interruption (n=1) or dose reduction (n=1), and both eventually resumed their previous maximum dose. No patients discontinued MRX due to transaminase elevations.

[0304] There was no evidence to suggest that MRX treatment contributed to fat-soluble vitamin (FSV) deficiency. FSV deficiency, reported as an AE, was also less frequent with MRX than with PBO (27.7% vs. 34.8%). In the study population receiving regular FSV supplementation due to chronic cholestasis, no clinically meaningful changes from baseline in serum levels of vitamins A, D, and E were observed. Elevated bilirubin was less frequent with MRX than with PBO (14.9% vs. 19.6%). The international normalized ratio (INR) decreased (improved) at all assessed time points, with a mean change from baseline at 26 weeks of -0.3 for MRX and -0.03 for placebo.

[0305] Fractures occurred in 6.4% of MRX and 0% of PBO patients; none were considered treatment-related because all had clear alternative causes for the fracture, including pre-existing vitamin D deficiency, which was stable or improved during MRX treatment. Serious AEs were reported in 10.6% of MRX patients and 6.5% of PBO patients; none were considered related (except for one event of mild bilirubin elevation in MRX); all resolved without dose adjustment.

[0306] MRX was well tolerated, and GI reactions were the most frequent, but were usually mild and self-limiting. FSV deficiency and elevated bilirubin levels were more frequent in the PBO group. Overall, no changes in liver enzymes were observed during the study period, and individual elevations were mild and transient; no treatment discontinuations occurred.

[0307] Example 6. Safety monitoring of selected parameters Liver parameters Table 8 provides criteria for close monitoring of liver parameters.

[0308] For subjects with confirmed elevated ALT or TSB levels and who met the criteria for close monitoring, the following investigations were considered as clinically indicated: 1) close and frequent monitoring of liver enzymes and serum bilirubin tests, as clinically indicated; 2) symptoms and past, current, and intercurrent illnesses / diseases; 3) use or recent changes in concomitant medications (including non-prescription drugs, herbal and dietary supplement preparations), alcohol intake, recreational drug use, and special diet use; 4) history of exposure to environmental chemicals and travel history; 5) viral hepatitis serology (HAV IgM, HBsAg, HCV antibody, HCV RNA, CMV IgM, and EBV antibody panel); 6) autoimmune hepatitis serology (e.g., antinuclear antibody [ANA]); 7) AST, creatine phosphokinase (CPK), and lactate dehydrogenase (LDH); 8) CBC with differential (eosinophils); 9) reticulocyte count, PT / INR. [Table 8]

[0309] Example 7. Further results for FIC1, MDR3, TJP2, and MYO5B cohorts Treatment with MRX resulted in statistically significant and clinically meaningful improvements in pruritus in the familial intrahepatic cholestasis-associated protein 1 (FIC1), multidrug resistance 3 protein (MDR3), tight junction protein 2 (TJP2), and myosin VB (MYO5B) cohorts (Figures 33A and 33B). Significant improvements in serum bile acid levels were observed in the FIC1, MDR3, TJP2, and MYO5B cohorts (Figures 34A and 34B).

[0310] Treatment with MRX resulted in statistically significant and clinically meaningful improvements in pruritus severity and serum bile acid levels across the entire study population (Figures 35A and 35B). In patients without detected variants, MRX demonstrated improvements in pruritus and serum bile acid levels (Figures 35C and 35D). Weekly changes in ItchRO(Obs) scores and serum bile acid (sBA) were also observed in the FIC1 (Figures 35E and 35F) and MDR3 (Figures 35G and 35H) cohorts.

[0311] Example 8. Maralixibat provides significant relief of pruritus and improved sleep in children with progressive familial intrahepatic cholestasis Methods: Participants were randomized to receive MRX 570 μg / kg BID or placebo (PBO) (Figure 27A). The primary analysis assessed pruritus, assessed by caregivers using the ItchRO (Obs) 0-4 scale; and by clinicians using the Clinician Scratch Scale (CSS). Sleep was assessed using the Exploratory Diary Questionnaire (Observer) (EDQ [Obs]). Responses to pruritus and sleep were determined as mean weekly scores using a repeated-measures mixed-effects model for change from baseline to week 26 (CFB).

[0312] The observer-reported itch outcome (ItchRO(Obs)) is a 0-4 scale, with 0 = no itch, 1 = mild, 2 = moderate, 3 = severe, and 4 = very severe. A reduction of ≥ 1 point in ItchRO(Obs) is considered clinically meaningful.

[0313] The Clinician Scratch Scale (CSS) was scored on a scale of 0 to 4 (0 = no symptoms, and 4 = skin damage, bleeding, and scarring (worst scratching)).

[0314] The Exploratory Diary Questionnaire (Observer) (EDQ[Obs]) included questions about sleep disturbances related to pruritus on a 1–5 scale (1 = never / no itch to 5 = always / very severe).

[0315] Results: Sixty-four patients (nt-BSEP [n = 31], FIC1 [n = 13], MDR3 [n = 9], TJP2 [n = 7], and MYO5B [n = 4]) were randomized to MRX (n = 33) or PBO (n = 31). Baseline characteristics were well balanced between treatment groups (Table 9). Baseline pruritus scores (ItchRO[Obs]) were 2.7 and 2.9 for MRX and PBO, respectively. From baseline to week 26, the proportion (SE) of pruritus ratings ≤ 1 was higher in the MRX (0.62 [0.06]) group than in the PBO (0.27 [0.06]) group; the difference was significant (Δ [95% CI]: 0.35 [0.19, 0.50]) (Figure 27B). From weeks 15 to 26, the median proportion of reported days with an ItchRO(Obs) score of 0 to 1 was 95% for MRX and 9% for PBO (p = 0.0005). Itch responses from weeks 15 to 26 using ItchRO(Obs) were greater in the MRX group when measured in the morning (Δ[95% CI]: -1.20 [-1.73, -0.67]), evening (Δ: -1.16 [-1.69, -0.63]), or daily maximum (Δ: -1.20 [-1.74, -0.66]) (Figure 27C). The pruritus response measured by CSS was significantly greater in the MRX group (Δ: −1.8 [−2.2, −1.53]) than in the PBO group (Δ: −0.7 [−1.1, −0.3]), with a significant difference (Δ: −1.1 [−1.7, −0.6]; p < 0.0002). The CFB during sleep was significantly greater in the MRX group (Δ: −1.74 [−2.15, −1.33]) than in the PBO group (Δ: −0.55 [−0.99, −0.11]), with a significant difference (Δ: −1.19 [−1.78, −0.60]; p = 0.0002) (Figure 27D). Across the study, there was a strong correlation between the absolute itch scores and sleep scores (Spearman's r = 0.93; p < 0.0001), as well as a strong correlation between the change from baseline in itch and sleep (Spearman's r = 0.93; p < 0.0001) (Figure 27E). [Table 9] Unless otherwise stated, all data are mean values. Percentages are 100 x n / N. UDCA is ursodeoxycholic acid.

[0316] Conclusions: MRX was associated with complete or near-complete resolution of pruritus in the majority of patients with PFIC, and the effect was independent of how it was measured or who performed the assessment. Changes in pruritus were strongly correlated with changes in sleep, suggesting that MRX use can result in meaningful improvements in this domain of quality of life.

[0317] Example 9. Response and Long-Term Maintenance of Improved Liver Health with Maralixibat in Patients with Progressive Familial Intrahepatic Cholestasis (PFIC) Eighty-five patients from the MARCH trial were enrolled in MARCH-ON (Table 10, Figure 29A). During the MARCH trial, 47 patients received maralixibat (MRX-MRX) and 38 received placebo (PBO-MRX). [Table 10] Unless otherwise indicated, all data are mean values. Percentages are 100 x n / N. UDCA is ursodeoxycholic acid.

[0318] Patients included in the study had the following PFIC subtypes: nontruncated bile salt export pump (nt-BSEP, n = 27), familial intrahepatic cholestasis-associated protein type 1 (F1C1, n = 13), multidrug resistance 3 protein (MDR3, n = 9), tight junction protein 2 (TJP2, n = 6), myosin VB (MYO5B, n = 2), heterozygosity (n = 2), truncated BSEP (t-BSEP, n = 9), no variant detected (n = 8), fluctuating sBA (n = 2), and surgery (n = 7). Efficacy analyses included n = 33 patients in the MRX-MRX group and n = 24 patients in the PRO-MRX group. Subtypes nt-BSEP, F1C1, MDR3, TJP2, and MYO5B were included in the efficacy analysis. Baseline was defined as the initiation of maralixibat (MRX) treatment for each group.

[0319] Methods: Long-term maintenance of response was assessed for patients originally randomized to receive MRX in MARCH and continued treatment in MARCH-ON (MRX-MRX group; n=33). MRX response was assessed for patients who received PBO in the MARCH trial and switched to open-label MRX in MARCH-ON (PBO-MRX group; n=24). Assessments included: pruritus measured by the ItchRO[Obs] 0-4 scale, sBA, bilirubin, and growth z-score, and incidence of treatment-emergent adverse events (TEAEs). Baseline (BL) was defined as the initiation of MRX for each group.

[0320] Results: For the MRX-MRX group, the median (min, max) duration of MRX administration was 394 days (108,836). Of the 33 patients, 20 reached 52 weeks at the time of analysis. The significant improvements observed in the first 26 weeks of the MARCH study persisted from baseline (BL) to week 52 of MARCH-ON for pruritus severity (-2.17, p<0.0001), sBA (200 μmol / L, p=0.0004), bilirubin (-2.64 mg / dL, p=0.0084), height Z score (+0.54, p<0.0001), and weight Z score (+0.44, p=0.0010) (Figure 29B-C, Table 11). For the PBO-MRX group, the median duration of MRX administration was 256 days (29,569). Fifteen of the 24 total patients reached 26 weeks at the time of analysis. Newly acquired statistically significant reductions in pruritus and sBA levels were observed in the primary efficacy endpoints from BL to 26 weeks for pruritus (-1.05, p=0.0017) and sBA (-141 μmol / L, p=0.0003) (Figure 29D-E, Table 11), consistent with observations from the earlier MARCH MRX group. Overall, no new safety signals were identified (Table 12). The most frequent TEAEs were gastrointestinal (GI)-related, including early-onset diarrhea (51%) consistent with the mechanism of IBAT inhibition, and were mostly mild and transient. In the MRX-MRX subgroup, fewer patients experienced diarrhea in MARCH-ON, supporting the early and transient nature of these effects. [Table 11] [Table 12] Percentages are 100 x n / N. TEAEs are treatment-emergent adverse events.

[0321] Conclusions: Significant and sustained responses in pruritus, sBA, bilirubin, and growth are observed with 52 weeks of MRX treatment across the broadest range of genetic PFIC types tested to date. The PBO-MRX group showed significant improvements in pruritus severity and sBA levels similar to those observed in the original MARCH maralixibat group. These data suggest an overall improvement in liver health with MRX treatment that can be maintained over time.

[0322] Example 10. Effect of maralixibat (MRX) on cholestatic pruritus in adults aged 16 years and older with Alagille syndrome (ALGS) The efficacy and safety of MRX were studied in participants with ALGS aged 16 years or older who transitioned to adult care and in participants who initiated MRX treatment after age 16 (Figure 30). The median treatment duration (min, max) for participants who initiated MRX before age 16 was 4.1 years (1.5, 5.9), with the oldest patient taking MRX at age 21 (Table 13). Three participants initiated MRX at age 16 or older and were followed for a median of 3.8 years. [Table 13]

[0323] ALT is alanine aminotransferase. Adverse events (AEs) decreased with increasing patient age (Table 14). [Table 14]

[0324] Patients receiving MRX had significant improvements in pruritus and sBA during childhood that were maintained into early adulthood (Figures 31A-B and 32A-B). Participants receiving MRX in early adulthood showed significant improvements in pruritus and sBA upon treatment that were sustained throughout treatment. MRX was generally well tolerated and demonstrated a safety and tolerability profile consistent with previously reported data.

[0325] These results provide important data for patients transitioning into adulthood while on MRX therapy, demonstrating the potential for MRX to have a positive impact on the management of adults with ALGS who survive to adulthood on their own livers.

[0326] Example 11. Maralixibat produces a significant reduction in bilirubin in patients with progressive familial intrahepatic cholestasis (PFIC) Methods: MARCH enrolled patients with a genetic diagnosis of PFIC, pruritus, and elevated sBA. Patients were randomized to MRX 570 μg / kg BID or placebo (PBO) for 26 weeks. Changes were determined using a repeated-measures mixed-effects model as the difference between the MRX and PBO groups in the mean change from baseline (CFB) for the last three measurements (Weeks 18, 22, and 26). Total bilirubin / direct bilirubin (TB / DB) categories were defined as normal (≤1.2 / 0.3 mg / dL) or abnormal (>1.2 / 0.3 mg / dL).

[0327] Results: The analysis included 64 patients from the entire PFIC cohort (FIC1, n=13; nt-BSEP, n=31; MDR3, n=9; TJP2, n=7; and MYO5B, n=4); patients were randomized to MRX (n=33) or PBO (n=31). Baseline median TB (Q1, Q3) in the MRX and PBO groups was 2.8 (1.4, 5.5) and 2.6 (0.8, 5.5) mg / dL, respectively, and DB was 2.1 (0.9, 4.0) mg / dL and 1.9 (0.5, 4.3) mg / dL. This study achieved significant CFB between MRX and PBO for TB (-1.1 vs. +0.9 mg / dL; group difference: 2.0; p=0.047) (Figure 36A) and DB (-0.8 vs. +0.8 mg / dL; group difference: 1.5; p=0.048) (Figure 36B). Among individuals with abnormal baseline bilirubin levels (TB: n=46; DB: n=56), there was significant CFB between the MRX and PBO groups for DB (-0.8 vs. +1.0 mg / dL; group difference: -1.8; p=0.042) (Figures 37A and 37B). Pre- and post-bilirubin values ​​were available for 60 individuals (32 MRX; 28 PBO) for post-hoc analysis evaluating bilirubin normalization. For the MRX group, TB normalized in 40% (10 / 25) of patients with abnormal baseline values, and no patients (0 / 7) progressed from normal to abnormal TB (Figures 38A and 38B). For the PBO group, TB normalized in none of the patients with abnormal baseline values ​​(0 / 18); instead, TB became abnormal in 30% (3 / 10) of patients (Figures 38A and 38B). For DB, the MRX group showed a higher frequency of normalization compared with PBO (38% vs. 8%) (Figure 39). In all individuals whose TB normalized, sBA decreased by 94.9% (95% CI: 68.5%, 98.9%), whereas in individuals whose TB did not normalize, sBA decreased by only 13.3% (95% CI: 1.4, 34.0); p<0.0001 (Figure 40). Regarding reported treatment-emergent adverse events, increased bilirubin was observed less frequently in the MRX group compared with the PBO group (14.9% vs. 19.6%).

[0328] Conclusions: MRX is the only IBAT inhibitor that demonstrated a significant reduction in TB / DB compared with PBO in children with PFIC, regardless of PFIC type. Forty percent of MRX patients with abnormal baseline bilirubin levels achieved normalization, whereas no normalization was observed in the PBO group, suggesting that MRX may provide clinically meaningful improvements in liver health in patients with PFIC. The reduction in bilirubin corresponded to a reduction in sBA.

[0329] Example 12. Maralixibat produces surprising and unexpected improvements in patients with truncated BSEP (t-BSEP) An unexpected finding was observed in patients with truncated BSEP (t-BSEP) deficiency (also known as truncated PFIC2 or t-PFIC2), where individual patients showed improvement, with reductions in sBA from baseline to week 26 and limited improvement in pruritus (Figures 41D and 42D). Some t-BSEP patients experienced reductions in pruritus, as shown in Figure 41D, and t-BSEP patients reported a reduction in morning pruritus severity over time, as measured by the itch-reported outcome.

[0330] Table 15 below shows data for individual t-BSEP patients. All patients who received maralixibat (MRX-MRX) or a switch from placebo to maralixibat (PBO-MRX) demonstrate a meaningful reduction in sBA. [Table 15]

[0331] This finding is highly surprising and unexpected given the predicted loss of function associated with this genotype.

[0332] All references cited anywhere within this specification are incorporated herein by reference in their entirety for all purposes.

[0333] While preferred embodiments of the present invention have been shown and described herein, it will be obvious to those skilled in the art that such embodiments are provided by way of example only.

[0334] The recitation of ranges of values ​​herein, unless otherwise stated herein, is merely intended to serve as a shorthand method of referring individually to each separate value and each endpoint falling within the range, and each separate value and endpoint is incorporated herein as if it were individually recited herein.

[0335] Numerous variations, changes, and substitutions will occur to those skilled in the art without departing from the invention. It should be understood that various alternatives to the embodiments of the invention described herein may be employed in practicing the invention. It is intended that the following claims define the scope of the invention, and that methods and structures within the scope of these claims and their equivalents be covered thereby. References

[0336] Al Mehaidib A, Al Shahrani A. 1381 Progressive familial intrahepatic cholestasis in Arabs. J Hepatol 2013;58:S555-6. Alissa FT, Jaffe R, Shneider BL. Update on progressive familial intrahepatic cholestasis. J Pediatr Gastroenterol Nutr 2008;46:241-52. Arnell H, Papadogiannakis N, Zemack H, et al. Follow-up in children with progressive familial intrahepatic cholestasis after partial external biliary diversion. J Pediatr Gastroenterol Nutr 2010;51:494-9. Cnaan A, Laird NM, Slasor P. Using the general linear mixed model to analyse unbalanced repeated measures and longitudinal data. Stat Med 1997;16, 2349-80. Davit-Spraul A, Gonzales E, Baussan C, et al. Progressive familial intrahepatic cholestasis. Orphanet J Rare Dis 2009;4:1. Emerick KM, Elias MS, Melin-Aldana H, et al. Bile composition in Alagille syndrome and PFIC patients having partial external biliary diversion. BMC Gastroenterol 2008;8:47. Ethical Considerations for Clinical Trials on Medicinal Products Conducted with Minors. 2017. Accessed at: https: / / ec.europa.eu / health / sites / health / files / files / eudralex / vol-10 / 2017_09_18_ethical_consid_ct_with_minors.pdf European Medicines Agency. 2010. Guideline on missing data in confirmatory clinical trials. Halaweish I, Chwals WJ. Long-term outcome after partial external biliary diversion for progressive familial intrahepatic cholestasis. J Pediatr Surg 2010;45:934-7. Hounnou G, Destrieux C, Desme J, et al. Anatomical study of the length of the human intestine. Surg Radiol Anat 2002;24:290-4. Jericho H. Bile acid pool dynamics in progressive familial intrahepatic cholestasis with partial external bile diversion. J Pediatr Gastroenterol Nutr 2015;60:368-74. Kenward MG, Roger JH. Small sample inference for fixed effects from restricted maximum likelihood. Biometrics 1997;53:983-97. Little R, Rubin D. Statistical analysis with missing data. New York: John Wiley: 1987. Little R, Yau L. Intent-to-treat analysis for longitudinal studies with drop-outs, Biometrics 1996;52:1324-33. Mallinckrodt CH, Clark WS, David SR. Accounting for dropout bias using mixed-effects models. J Biopharm Stat 2001;11:9-21. Mallinckrodt CH, Lane PW, Schnell D, et al. Recommendations for the primary analysis of continuous endpoints in longitudinal clinical trials. Drug Information Journal 2008;42:303-19. Mallinckrodt CH, Roger J, Chuang-Stein C, et al. Recent developments in the prevention and treatment of missing data. Drug Information Journal 2013;48:68-80. Molenberghs G, Kenward MG. Missing data in clinical studies. New York: Wiley:2007. Molenberghs G, Thijs H, Jansen I, et al. Analyzing incomplete longitudinal clinical trial data. Biostatistics 2004;5:445-64. Pawlikowska L, Strautnieks S, Jankowska I, et al. Differences in presentation and progression between severe FIC1 and BSEP deficiencies. J Hepatol 2010;53:170-8. Ratitch B, O’Kelly M. 2011. Implementation of pattern-mixture models using standard SAS / STAT procedures. Proceedings of PharmaSUG 2011 (Pharmaceutical Industry SAS Users Group), SP04, Nashville. Sambrotta M. Mutations in TJP2 cause progressive cholestatic liver disease. Nat Genet 2014;46:326-8. Schafer JL. Analysis of incomplete multivariate data. New Yori: Chapman & Hall:1997. Schukfeh N, Metzelder ML, Petersen C, et al. Normalization of serum bile acids after partial external biliary diversion indicates an excellent long-term outcome in children with progressive familial intrahepatic cholestasis. J Pediatr Surg 2012;47:501-5. Shneider BL, Magee JC, Bezerra JA, et al. Efficacy of fat-soluble vitamin supplementation in infants with biliary atresia. Pediatrics 2012;130:607-14. Siddiqui O, Hung HM, O’Neill R. MMRM vs. LOCF: a comprehensive comparison based on simulation study and 25 NDA datasets. J Biopharm Stat 2009;19:227-46. Stapelbroek JM, van Erpecum KJ, Klomp LWJ, et al. Liver disease associated with canalicular transport defects: current and future therapies. J Hepatol 2010;52:258-71. Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Medical Care 2001;39:800-12. Verbeke G, Molenberghs G. Linear mixed models for longitudinal data. New York: Springer: 2000. Weaver LT, Austin S, Cole TJ. Small intestinal length: a factor essential for gut adaptation. Gut 1991;32:1321-3. Whitington PF, Whitington GL. Partial external diversion of bile for the treatment of intractable pruritis associated with intrahepatic cholestasis. Gastroenterology 1988;95:130-6. Yang H, Porte RJ, Verkade HJ, et al. Partial external biliary diversion in children with progressive familial intrahepatic cholestasis and Alagille disease. J Pediatr Gastroenterol Nutr 2009;49:216-21.

Claims

1. 1. A method for treating progressive familial intrahepatic cholestasis (PFIC) in a subject in need thereof, comprising administering to the subject maralixibat or a pharmaceutically acceptable salt thereof.

2. 2. The method of claim 1, wherein the pharmaceutically acceptable salt of maralixibat is maralixibat chloride, maralixibat bromide, maralixibat acetate, or maralixibat mesylate.

3. 2. The method of claim 1, wherein the pharmaceutically acceptable salt of maralixibat is maralixibat chloride.

4. 4. The method of any one of claims 1 to 3, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 10 μg / kg / day to about 1400 μg / kg / day.

5. 5. The method of any one of claims 1 to 4, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 300 μg / kg / day to about 1200 μg / kg / day.

6. 6. The method of any one of claims 1 to 5, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 600 μg / kg / day to about 1200 μg / kg / day.

7. 7. The method of any one of claims 1 to 6, wherein the maralixibat or a pharmaceutically acceptable salt thereof is maralixibat chloride, and the maralixibat chloride is administered in an amount of about 1200 μg / kg / day.

8. 8. The method of any one of claims 1 to 7, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered in an amount of about 0.5 mg / day to about 100 mg / day.

9. The method of any one of claims 1 to 8, wherein the PFIC is PFIC1, PFIC2, PFIC3, PFIC4, PFIC5, or PFIC6.

10. 10. The method of claim 9, wherein the PFIC is PFIC1.

11. 10. The method of claim 9, wherein the PFIC is PFIC2.

12. 12. The method of claim 11, wherein PFIC2 is non-truncated PFIC2.

13. 12. The method of claim 11, wherein PFIC2 is a truncated PFIC2.

14. 10. The method of claim 9, wherein the PFIC is PFIC3.

15. 10. The method of claim 9, wherein the PFIC is PFIC4.

16. 10. The method of claim 9, wherein the PFIC is PFIC5.

17. 10. The method of claim 9, wherein the PFIC is PFIC6.

18. The method of any one of claims 1 to 17, wherein the PFIC is heterozygous.

19. The method of any one of claims 1 to 18, wherein the subject has intermittent cholestasis.

20. 20. The method of any one of claims 1 to 19, wherein the subject is undergoing biliary diversion surgery.

21. The method of any one of claims 1 to 20, wherein the subject is a pediatric subject.

22. 22. The method of any one of claims 1 to 21, wherein the subject is over 1 year old and under 18 years old.

23. 23. The method of any one of claims 1 to 22, wherein the subject is under 12 months of age.

24. 24. The method of any one of claims 1 to 23, wherein the subject has a mutation in a gene selected from the group consisting of ATP8B1, ABCB11, ABCB4, TJP2, NR1H4, and MYO5B.

25. 24. The method of any one of claims 1 to 23, wherein the mutation is a non-truncating mutation.

26. The method of any one of claims 1 to 23, wherein the mutation is a truncation mutation.

27. The method of any one of claims 1 to 23, wherein the subject has a truncated BSEP protein.

28. 25. The method of any one of claims 1 to 24, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered once daily (QD).

29. 29. The method of any one of claims 1 to 28, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered twice daily (BID).

30. 30. The method of any one of claims 1 to 29, wherein the maralixibat or a pharmaceutically acceptable salt thereof is maralixibat chloride, and the maralixibat chloride is administered at 600 μg / kg / day BID, for a total daily dose of 1200 μg / kg / day.

31. 31. The method of any one of claims 1 to 30, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in symptoms of PFIC or a change in disease-related laboratory values ​​that is maintained for at least two months.

32. 32. The method of any one of claims 1 to 31, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in symptoms of PFIC or a change in disease-related laboratory values ​​that is maintained for at least 4 months.

33. 33. The method of any one of claims 1 to 32, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in symptoms of PFIC or a change in disease-related laboratory values ​​that is maintained for at least 6 months.

34. 34. The method of any one of claims 1 to 33, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a reduction in symptoms of PFIC or a change in disease-related laboratory values ​​that is maintained for at least one year.

35. 35. The method of any one of claims 31 to 34, wherein the alleviation of symptoms or change in disease-related laboratory values ​​is determined relative to baseline levels.

36. 36. The method of any one of claims 31 to 35, wherein the reduction in symptoms or change in disease-related laboratory values ​​comprises a decrease in sBA levels, a reduction in itching, a decrease in total bilirubin, a decrease in direct bilirubin, improved growth, or a combination thereof.

37. 37. The method of any one of claims 1 to 36, wherein administration of maralixibat reduces the intensity of pruritus.

38. 38. The method of claim 37, wherein the reduction in itch intensity is a decrease in the ItchRO(Obs) score, the CSS score, or a combination thereof.

39. 39. The method of any one of claims 1 to 38, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.0 point in the subject's ItchRO(Obs) score compared to baseline.

40. 40. The method of any one of claims 1 to 39, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.2 points in the subject's ItchRO(Obs) score compared to baseline.

41. 41. The method of any one of claims 1-40, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.4 points in the subject's ItchRO(Obs) score compared to baseline.

42. 42. The method of any one of claims 1-41, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.6 points in the subject's ItchRO(Obs) score compared to baseline.

43. 43. The method of any one of claims 1-42, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.0 point in the subject's CSS score compared to baseline.

44. 44. The method of any one of claims 1 to 43, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.2 points in the subject's CSS score compared to baseline.

45. 45. The method of any one of claims 1-44, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.4 points in the subject's CSS score compared to baseline.

46. 46. ​​The method of any one of claims 1-45, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease of at least 1.6 points in the subject's CSS score compared to baseline.

47. 47. The method of any one of claims 1 to 46, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in improvement in sleep as measured by a decrease of at least 1.0 point in the subject's EDQ(Obs) or EDQ(Pt) score compared to baseline.

48. 48. The method of any one of claims 1-47, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in improvement in sleep as measured by a decrease of at least 1.2 points in the subject's EDQ(Obs) or EDQ(Pt) score compared to baseline.

49. 49. The method of any one of claims 1-48, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in improvement in sleep as measured by a decrease of at least 1.4 points in the subject's EDQ(Obs) or EDQ(Pt) score compared to baseline.

50. 50. The method of any one of claims 1-49, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in improvement in sleep as measured by a decrease of at least 1.6 points in the subject's EDQ(Obs) or EDQ(Pt) score compared to baseline.

51. 51. The method of any one of claims 1-50, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's sBA concentration of at least 50 μmol / L compared to baseline.

52. 52. The method of any one of claims 1-51, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in the subject's sBA concentration of at least 100 μmol / L compared to baseline.

53. 53. The method of any one of claims 1 to 52, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin.

54. 54. The method of any one of claims 1-53, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin of at least 0.2 mg / dL compared to baseline.

55. 55. The method of any one of claims 1-54, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin of at least 0.5 mg / dL compared to baseline.

56. 56. The method of any one of claims 1-55, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in total bilirubin of at least 1.0 mg / dL compared to baseline.

57. 57. The method of any one of claims 1 to 56, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof directly results in a reduction of bilirubin.

58. 58. The method of any one of claims 1-57, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in direct bilirubin of at least 0.2 mg / dL compared to baseline.

59. 59. The method of any one of claims 1-58, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in direct bilirubin of at least 0.5 mg / dL compared to baseline.

60. 60. The method of any one of claims 1-59, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in a decrease in direct bilirubin of at least 1.0 mg / dL compared to baseline.

61. 61. The method of any one of claims 1-60, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in an improvement in the subject's height Z-score or weight Z-score, or both, compared to baseline.

62. 62. The method of claim 61, wherein administration of maralixibat or a pharmaceutically acceptable salt thereof results in an increase in body weight Z-score of at least 0.2 compared to baseline.

63. 63. The method of any one of claims 1-62, further comprising administering a fat-soluble vitamin (LSV) in a subject having an LSV deficiency.

64. 64. The method of claim 63, wherein the LSV is selected from the group consisting of vitamin A, vitamin D, and vitamin E.

65. 65. The method of any one of claims 1 to 64, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered before a meal.

66. 66. The method of claim 65, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered about 30 minutes before a meal.

67. 67. The method of claim 65 or claim 66, wherein maralixibat or a pharmaceutically acceptable salt thereof is administered BID about 30 minutes before a morning meal and about 30 minutes before an evening meal.

68. 68. The method of any one of claims 1 to 67, wherein maralixibat is administered in the form of a pharmaceutical composition comprising maralixibat or a pharmaceutically acceptable salt thereof, an antioxidant, and a preservative.

69. 69. The method of claim 68, wherein the pharmaceutical composition is a liquid composition for oral administration.

70. 70. The method of claim 69, wherein the liquid composition is an aqueous solution.

71. 71. The method of any one of claims 68-70, wherein maralixibat is present in an amount of about 2 mg / mL to about 100 mg / mL of the composition.

72. 72. The method of any one of claims 68-71, wherein maralixibat is present in an amount of about 5 mg / mL to about 50 mg / mL of the composition.

73. 73. The method of any one of claims 68-72, wherein maralixibat is present in an amount of about 8 mg / mL to about 20 mg / mL of the composition.

74. 74. The method of any one of claims 68-73, wherein maralixibat is present in an amount of about 9.5 mg / mL to about 10 mg / mL of the composition.

75. 75. The method of any one of claims 68 to 74, wherein the preservative is an antimicrobial preservative.

76. 76. The method of claim 75, wherein the antimicrobial preservative is selected from the group consisting of propylene glycol, ethyl alcohol, glycerin, benzalkonium chloride, benzethonium chloride, benzoic acid, benzyl alcohol, butylparaben, cetrimide (cetyltrimethylammonium bromide), cetrimonium bromide, cetylpyridinium chloride, chlorhexidine, chlorobutanol, chlorocresol, cresol, ethylparaben, methylparaben, phenol, phenoxyethanol, phenylethyl alcohol, phenylmercuric acetate, phenylmercuric borate, phenylmercuric nitrate, propylparaben, sodium benzoate, sodium dehydroacetate, sodium propionate, sorbic acid, potassium sorbate, thimerosal, thymol, and combinations thereof.

77. 77. The method of any one of claims 68 to 76, wherein the preservative is propylene glycol.

78. 78. The method of any one of claims 68 to 77, wherein the preservative is present in an amount of about 30% to about 40% w / w of the composition.

79. 79. The method of any one of claims 68-78, wherein the preservative is present in an amount of about 300 mg / mL to about 400 mg / mL of the composition.

80. 80. The method of any one of claims 68-79, wherein the antioxidant is selected from the group consisting of aminocarboxylic acids, aminopolycarboxylic acids, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, monothioglycerol, sodium ascorbate, sodium formaldehyde sulfoxylate, sodium metabisulfite, BHT, BHA, sodium bisulfite, vitamin E or a derivative thereof, propyl gallate, and combinations thereof.

81. 81. The method of any one of claims 68 to 80, wherein the antioxidant is an aminopolycarboxylic acid selected from EDTA (ethylenediaminetetraacetic acid), DTPA (diethylenetriaminepentaacetic acid), EGTA (ethylene glycol-bis(β-aminoethyl ether)-N,N,N',N'-tetraacetic acid), NTA (nitrilotriacetic acid), BAPTA (1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid), NOTA (2,2',2''-(1,4,7-triazonane-1,4,7-triyl)triacetic acid), DOTA (tetracarboxylic acid), and EDDHA (ethylenediamine-N,N'-bis(2-hydroxyphenylacetic acid).

82. 82. The method of any one of claims 68 to 81, wherein the antioxidant is EDTA.

83. 83. The method of any one of claims 68 to 82, wherein the antioxidant is present in an amount of about 0.01% to about 0.5% w / w of the composition.

84. 84. The method of any one of claims 68-83, wherein the pharmaceutical composition further comprises a sweetening agent, a taste-masking component, or a combination thereof.

85. The pharmaceutical composition comprises: a. about 8 mg / mL to about 20 mg / mL of maralixibat; b. about 330 mg / mL to about 380 mg / mL propylene glycol; c. Disodium EDTA at about 1 mg / mL; d. a sweetener, a taste-masking ingredient, or a combination thereof; and e water 85. The method of any one of claims 68 to 84, comprising:

Images