PPAR-alpha / gamma agonists for use in the treatment of liver failure - Patent Application 20070122997

Abstract

The present invention relates to compounds for use in the treatment of liver failure.

Description

[Technical Field]

[0001] The present invention is in the medical field and relates to compounds for use in the treatment of liver failure. [Background technology]

[0002] Liver failure is the significant inability of the liver to perform its normal functions. As used herein, symptoms of liver failure include acute liver failure (ALF), decompensated cirrhosis, acute cirrhosis decompensation (AD), and acute onset chronic liver failure (ACLF).

[0003] acute liver failure (ALF) The term "ALF" refers to a disorder characterized by the acute loss of liver function in the absence of preexisting chronic liver disease. Acute liver failure is also known as fulminant hepatic failure or fulminant liver failure. ALF is a rare and severe consequence of rapid hepatocellular injury that can progress to a fatal outcome over days to weeks. Various injuries to hepatocytes result in a consistent pattern of rapid onset of elevated aminotransferases, impaired consciousness, and coagulopathy. The absence of preexisting liver disease distinguishes ALF from liver failure resulting from end-stage chronic liver disease (decompensated cirrhosis, acute decompensation, and acute exacerbation of chronic liver failure). In ALF, agents that cause hepatocellular injury trigger either direct toxic necrosis or the slower processes of apoptosis and immune damage. The time between the onset of symptoms and the development of hepatic encephalopathy distinguishes different forms of acute liver failure. There are two types of ALF: direct, very rapid injury (within hours), referred to as hyperacute liver failure, and slower, immune-based injury (over days to weeks), considered acute or subacute. As used herein, the term "hepatic encephalopathy," or HE, refers to the development of confusion, altered level of consciousness, and coma as a result of liver failure. In advanced stages, this is referred to as hepatic coma or coma hepaticum. The five most common causes of ALF in developed countries are paracetamol (acetaminophen) toxicity, ischemia, drug-induced liver injury, hepatitis B, and autoimmunity, accounting for nearly 80% of cases. In developing countries, hepatitis A, B, and E are the primary causes of ALF. The remaining causes of ALF, accounting for less than 15% of cases, include heatstroke, pregnancy-related injuries (e.g., acute fatty liver of pregnancy and HELLP [hemolysis, elevated liver enzymes, and low platelets] syndrome), nonhepatotrophic viral infections such as Budd-Chiari syndrome and herpes simplex, and diffusely infiltrating malignancies. The prognosis is poor without treatment, so timely recognition and management of patients with acute liver failure are important. Whenever possible, patients with acute liver failure should be managed in the intensive care unit of a liver transplant center.

[0004] Decompensated cirrhosis and acute decompensation (AD) As used herein, the term "cirrhosis" refers to a condition characterized by replacement of liver tissue with fibrosis and regenerative nodules, leading to loss of liver function until decompensation. Ascites (fluid retention in the abdominal cavity) is the most common complication associated with cirrhotic decompensation. This ascites is associated with reduced quality of life, increased risk of infection, and poor long-term outcomes. Other potentially life-threatening complications include hepatic encephalopathy and bleeding from esophageal varices. Cirrhotic decompensation has many possible clinical manifestations. These signs and symptoms can be either a direct result of hepatocellular failure or secondary to the resulting portal hypertension. The effects of portal hypertension include splenomegaly, esophagogastric varices, and portocollateral circulation due to the formation of venous collateral veins between the portal venous system and the periumbilical veins caused by portal hypertension.

[0005] Cirrhosis is divided into two clinical categories: compensated cirrhosis and decompensated cirrhosis.

[0006] As used herein, the term "compensated cirrhosis" means that the liver is severely damaged but still able to perform many important vital functions. Patients with compensated cirrhosis experience minimal or no symptoms and can live without serious clinical complications. Patients in the early stages of compensated cirrhosis are characterized by low levels of portal hypertension and the absence of esophageal varices. Patients in the advanced stages of compensated cirrhosis are characterized by higher levels of portal hypertension and the presence of esophageal varices but without ascites or bleeding.

[0007] As used herein, the term "decompensated cirrhosis" refers to a liver that is extensively damaged and unable to function properly. Patients with decompensated cirrhosis develop various symptoms, such as fatigue, loss of appetite, jaundice, weight loss, ascites and / or edema, hepatic encephalopathy, and / or bleeding. Patients with early-stage decompensated cirrhosis are characterized by the presence of ascites, with or without esophageal varices, which have never been present in the patient. Patients with advanced stages of decompensated cirrhosis are characterized by more severe ascites alone or in association with bleeding, bacterial infection, and / or hepatic encephalopathy. Complications associated with decompensated cirrhosis may develop, such as ascites, edema, bleeding disorders, decreased bone mass and density, hepatomegaly, menstrual irregularities in women and gynecomastia in men, impaired mental status, itching, renal insufficiency, and muscle fatigue.

[0008] The term "acute decompensation" refers to a sudden deterioration of liver function in patients with advanced chronic liver disease, compensated cirrhosis, or stable decompensated cirrhosis, requiring immediate hospitalization. At the time of hospitalization, patients with AD have multiple symptoms, including severe ascites, hepatic encephalopathy, variceal bleeding with or without sepsis, and / or impaired renal function and / or coagulation disorder and / or impaired cardiovascular function and / or impaired respiratory function. AD is a life-threatening condition with an overall mortality rate of 11% at 28 days.

[0009] Acute-on-chronic liver failure (ACLF) ACLF is the most serious liver condition observed in patients with known chronic liver disease who have acute decompensation of liver function.

[0010] ACLF is a sudden, life-threatening deterioration of the condition in patients with advanced cirrhosis or cirrhosis due to chronic liver disease. Three key features characterize this syndrome: ACLF generally occurs in the context of intense systemic inflammation, frequently occurs in close temporal relation to a precipitating event (e.g., infection or alcoholic hepatitis) that promotes the inflammatory response, and is associated with single or multiple organ failure affecting vital organs, namely the liver, kidneys, brain, coagulation and / or cardiovascular function, and / or minimal respiratory function. In sepsis, organ failure is confirmed using the modified Continuous Organ Failure Assessment score (DOFA score or EASL-CLIF Consortium Organ Failure Scoring System), which takes into account hepatic, renal, and cerebral function as well as coagulation, circulatory, and respiratory functions, thus allowing for the stratification of patients into subgroups with different mortality risks. Several classifications for grading ACLF have been proposed (APASL, EASL / CLIF, NASCELD). Using EASL / CLIF, patients were stratified into four prognostic stages (no acute exacerbation of chronic liver failure, and stages 1, 2, and 3 of acute exacerbation of chronic liver failure) according to the number of organ failures at diagnosis. Predisposition to ACLF correlates with the severity of underlying chronic liver disease (i.e., the development of fibrosis leading to cirrhosis). Regardless of the underlying chronic liver disease (cholestatic liver disease, metabolic liver disease, chronic viral hepatitis, nonalcoholic steatohepatitis (NASH), or alcoholic hepatitis), compensated cirrhosis and stable decompensated cirrhosis are the main conditions associated with the development of ACLF. In Western countries, alcoholic cirrhosis accounts for 50–70% of all underlying liver diseases associated with ACLF, whereas viral hepatitis-related cirrhosis accounts for approximately 10–30% of all cases.

[0011] The severity of the underlying disease can be assessed by the Model for End-Stage Liver Disease (MELD) score.

[0012] ACLF requires a precipitating event occurring in the setting of cirrhosis and / or chronic liver disease and rapidly progresses to multiple organ failure with high mortality. The precipitating event can be reactivation of hepatitis B or superimposed viral hepatitis, alcohol, drugs, ischemic, surgical, sepsis, or idiopathic. However, approximately 40% of patients with ACLF do not have a precipitating event.

[0013] During the development of liver failure, translocation of bacterial products, with or without the concomitant translocation of live bacteria from the intestinal lumen, plays a key role in the development of multiple organ dysfunction and failure due to an intense systemic inflammatory response syndrome.

[0014] The host response determines the severity of injury. Inflammation and neutrophil dysfunction are primarily important in the pathogenesis of ACLF, with a prominent proinflammatory cytokine profile driving the transition from stable decompensated cirrhosis to AD and ultimately ACLF. In these patients, the inflammatory response can lead to immune dysregulation that may predispose to infection, further exacerbating the proinflammatory response and creating a vicious cycle. Cytokines are believed to play an important role in ACLF. Elevated serum levels of several cytokines, including tumor necrosis factor (TNF)-α, sTNF-αR1, sTNF-αR2, interleukin (IL)-2, IL-2R, IL-4, IL-6, IL-8, IL-10, and interferon-α, have been described in patients with ACLF.

[0015] Hyperbilirubinemia is almost universally present, and jaundice is considered a fundamental diagnostic criterion for AD and ACLF. Various authors have used different cutoff levels for jaundice, ranging from 6 to 20 mg / dL of serum bilirubin. Besides jaundice, another prominent feature of liver dysfunction is coagulation disorder. Coagulation tests are usually abnormal in patients with cirrhosis due to impaired synthesis and increased consumption of clotting factors. Ongoing liver damage eventually leads to an inexorable downward spiral and death.

[0016] Besides the liver, the most common organ to fail is the kidney. Renal failure can be classified into four types: hepatorenal syndrome, parenchymal disease, hypovolemia-induced, and drug-induced renal failure. Bacterial infection (such as spontaneous bacterial peritonitis) is the most common cause of renal failure in cirrhosis, followed by hypovolemia (secondary to gastrointestinal bleeding and excessive diuretic therapy).

[0017] HE is one of the common symptoms of AD and ACLF. HE can be an exacerbating factor or a consequence of AD and ACLF. Ammonia is central to the pathogenesis of HE. In fact, numerous studies have highlighted that hyperammonemia plays an important role in the development of HE in patients with cirrhosis and other liver diseases. Due to liver failure, large amounts of serum ammonia escape liver metabolism, and such high ammonia concentrations can reach the brain, which is closely related to a high incidence of cerebral edema and herniation.

[0018] Furthermore, brain swelling is a key feature of AD and ACLF, resembling a condition in ALF.

[0019] One of the hallmarks of AD and ACLF is cardiovascular collapse, which resembles that in patients with ALF. This cardiovascular abnormality is associated with an increased risk of mortality, especially in patients with AD and ACLF who also present with renal dysfunction.

[0020] Respiratory complications in AD and ACLF can be classified as acute respiratory failure (e.g., pneumonia) and those that occur as a consequence of cirrhosis (e.g., portopulmonary hypertension and hepatopulmonary syndrome). Patients with cirrhosis are at increased risk of pneumonia.

[0021] Patients with AD and ACLF have a statistically higher mortality rate than patients without ACLF at the same MELD score. Regardless of the inciting event, the final common pathway leading to acute deterioration of liver function and multiple organ failure appears to be excessive activation of systemic inflammation, followed by a period of immune system paralysis. The initial cytokine storm causes severe alterations in the macrocirculation, microcirculation, and disruption of normal organ function, resulting in multiple organ failure.

[0022] Early intervention to mitigate or reverse the damage is crucial. For patients with more than three organ failures, current management of ACLF is primarily based on supportive care of organ failure in an intensive care setting. However, a significant proportion of patients with ACLF have previous episodes of acute decompensation (ascites, encephalopathy, gastrointestinal bleeding, or bacterial infection). Indeed, the onset of liver failure in patients with cirrhosis represents a critical point in medical management, as this condition is frequently associated with rapidly progressive multiple organ dysfunction. The lack of liver detoxification, metabolic and regulatory functions, and alterations in the immune response can lead to life-threatening complications, such as renal failure, increased susceptibility to infection, hepatic coma, and systemic hemodynamic dysfunction. Furthermore, only 20% of patients with advanced cirrhosis can be treated by liver transplantation.

[0023] There is a need for adequate treatment of liver failure, particularly AD, ACLF, ALF and decompensated cirrhosis. [Prior art documents] [Patent documents]

[0024] [Patent Document 1] International Publication No. 9962872 [Patent Document 2] International Publication No. 2001021602 [Patent Document 3] International Publication No. 2002092084 [Non-patent literature]

[0025] [Non-Patent Document 1] J. Pharm. Sci. 1977, Vol. 66, No. 2 [Non-patent document 2] Handbook of Pharmaceutical Salts: Properties, Selection, and Use, edited by P. Heinrich Stahl and Camille G. Wermuth, 2002 [Non-patent document 3] A. Benardeau et al., Bioorg. Med. Chem. Lett., 2009, 19, 2468-2473 [Non-patent document 4] Pourcet et al., Gastroenterology, 2018, Vol. 154 (No. 5), pp. 1449-1464 e20 Summary of the Invention [Means for solving the problem]

[0026] The present invention relates to a PPARα / γ agonist selected from aleglitazar, muraglitazar or tesaglitazar, a pharmaceutically acceptable salt thereof or a combination thereof, for use in a method for the treatment of liver failure in a subject in need thereof.

[0027] The present invention also provides the use of a PPARα / γ agonist selected from aleglitazar, muraglitazar or tesaglitazar, a pharmaceutically acceptable salt thereof or a combination thereof, for the manufacture of a medicament for use in a method for the treatment of liver failure.

[0028] The present invention further provides a method for the treatment of liver failure, comprising administering to a subject in need thereof a pharmaceutically effective amount of a PPARα / γ agonist selected from aleglitazar, muraglitazar, or tesaglitazar, a pharmaceutically acceptable salt thereof, or a combination thereof.

[0029] In one particular embodiment, the compound is aleglitazar or a pharmaceutically acceptable salt thereof.

[0030] In a further particular embodiment, the compound is muraglitazar or a pharmaceutically acceptable salt thereof.

[0031] In a further particular embodiment, the compound is tesaglitazar or a pharmaceutically acceptable salt thereof.

[0032] In certain embodiments, the PPARα / γ agonists of the present invention are for use in the treatment of liver failure selected from acute decompensation (AD), exacerbated chronic liver failure (ACLF), acute liver failure (ALF), and decompensated cirrhosis.

[0033] In certain embodiments, the PPARα / γ agonists of the present invention are for use in the treatment of AD.

[0034] In another particular embodiment, the PPARα / γ agonists of the invention are for use in the treatment of decompensated cirrhosis.

[0035] More particularly, the PPARα / γ agonists of the present invention are for use in the treatment of ACLF.

[0036] In another embodiment, a PPARα / γ agonist of the invention is administered to a subject with AD, decompensated cirrhosis with or without ACLF, or at risk for AD and ACLF.

[0037] In another embodiment, a PPARα / γ agonist of the invention is administered to a subject with decompensated cirrhosis or at risk of decompensated cirrhosis or acute decompensation.

[0038] In certain embodiments, the PPARα / γ agonists of the present invention are for use in the prevention of decompensated cirrhosis.

[0039] In yet another embodiment, the PPARα / γ agonists of the present invention are for use in a method for converting decompensated cirrhosis to compensated cirrhosis.

[0040] According to another embodiment, the PPARα / γ agonists of the present invention are for use in a method for the prevention of hepatic decompensation in a subject with ACLF.

[0041] In another embodiment, the PPARα / γ agonists of the present invention are for use in the treatment of ALF.

[0042] In another embodiment, the PPARα / γ agonists of the present invention are for use in the prevention of renal failure or the prevention of hepatic encephalopathy.

[0043] According to one particular embodiment, a PPARα / γ agonist of the present invention is administered to a subject with ACLF without renal failure or ACLF with non-renal organ failure accompanied by renal insufficiency.

[0044] According to another embodiment, the PPARα / γ agonists of the present invention are for use in the treatment of sepsis-associated ACLF.

[0045] In certain embodiments, the present invention further relates to a method for the treatment of liver failure selected from acute decompensation (AD), exacerbated chronic liver failure (ACLF), acute liver failure (ALF), and decompensated cirrhotic AD, comprising administering to a subject in need thereof a pharmaceutically effective amount of a PPAR α / γ agonist of the present invention.

[0046] In another specific embodiment, the present invention further relates to a method for the prevention of decompensated cirrhosis, comprising administering to a subject in need thereof a pharmaceutically effective amount of a PPARα / γ agonist of the present invention.

[0047] In another specific embodiment, the present invention further relates to a method for converting decompensated cirrhosis to compensated cirrhosis, comprising administering to a subject in need thereof a pharmaceutically effective amount of a PPARα / γ agonist of the present invention.

[0048] In another specific embodiment, the present invention further relates to a method for the prevention of hepatic decompensation in a subject with ACLF, comprising administering to said subject a pharmaceutically effective amount of a PPARα / γ agonist of the present invention.

[0049] In another specific embodiment, the present invention further relates to a method for the prevention of renal failure or in the prevention of hepatic encephalopathy, comprising administering to a subject in need thereof a pharmaceutically effective amount of a PPARα / γ agonist of the present invention.

[0050] In another specific embodiment, the present invention further relates to a method for the treatment of septic ACLF, comprising administering to a subject in need thereof a pharmaceutically effective amount of a PPARα / γ agonist of the present invention.

[0051] In certain embodiments, the present invention further relates to the use of a PPARα / γ agonist of the present invention for the manufacture of a medicament for use in a method for the treatment of liver failure selected from acute decompensation (AD), exacerbated chronic liver failure (ACLF), acute liver failure (ALF), and decompensated cirrhotic AD.

[0052] In another particular embodiment, the present invention further relates to the use of a PPARα / γ agonist of the present invention for the manufacture of a medicament for use in a method for the prevention of decompensated cirrhosis.

[0053] In another particular embodiment, the present invention further relates to the use of a PPARα / γ agonist of the present invention for the manufacture of a medicament for use in a method for the conversion of decompensated cirrhosis to compensated cirrhosis.

[0054] In another specific embodiment, the present invention further relates to the use of a PPARα / γ agonist of the present invention for the manufacture of a medicament for use in a method for the prevention of hepatic decompensation in a subject with ACLF.

[0055] In another particular embodiment, the present invention further relates to the use of a PPARα / γ agonist of the present invention for the manufacture of a medicament for use in a method for the prevention of renal failure or in the prevention of hepatic encephalopathy.

[0056] In another specific embodiment, the present invention further relates to the use of a PPARα / γ agonist of the present invention for the manufacture of a medicament for use in a method for the treatment of septic ACLF. [Brief explanation of the drawings]

[0057] [Figure 1A] Figure 1 shows the effect of Compound 1 (tesaglitazar) on liver injury and systemic inflammation in a model of acute liver failure. Mice were treated daily with 1 mg / kg Compound 1 or vehicle (Vehicle h.) for 3 days prior to LPS / GalN injection. Blood samples were collected 6 hours after LPS / GalN injection for measurement of serum liver marker and cytokine levels. Figure 1 shows the effect of Compound 1 on ASAT after GalN / LPS injection. Data are means. Statistical significance was assessed using #, ##, and ### for p<0.05, p<0.01, and p<0.001, respectively, for comparison with vehicle (Vehicle h) using a two-tailed Mann-Whitney test. [Figure 1B]Figure 1 shows the effect of Compound 1 (tesaglitazar) on liver injury and systemic inflammation in a model of acute liver failure. Mice were treated daily with 1 mg / kg Compound 1 or vehicle (Vehicle h.) for 3 days prior to LPS / GalN injection. Blood samples were collected 6 hours after LPS / GalN injection for measurement of serum liver marker and cytokine levels. Figure 1 shows the effect of Compound 1 on ALAT after GalN / LPS injection. Data are means. Statistical significance was assessed using #, ##, and ### for p<0.05, p<0.01, and p<0.001, respectively, for comparison with vehicle (Vehicle h) using a two-tailed Mann-Whitney test. [Figure 1C] Figure 1 shows the effect of Compound 1 (tesaglitazar) on liver injury and systemic inflammation in a model of acute liver failure. Mice were treated daily with 1 mg / kg Compound 1 or vehicle (Vehicle h) for 3 days prior to LPS / GalN injection. Blood samples were collected 6 hours after LPS / GalN injection for measurement of serum liver marker and cytokine levels. The effect of Compound 1 on total bilirubin after GalN / LPS injection is shown. Data are means. Statistical significance was assessed using #, ##, and ### for p<0.05, p<0.01, and p<0.001, respectively, for comparison with vehicle (Vehicle h) using a two-tailed Mann-Whitney test. [Figure 1D] Figure 1 shows the effect of Compound 1 (tesaglitazar) on liver injury and systemic inflammation in a model of acute liver failure. Mice were treated daily with 1 mg / kg Compound 1 or vehicle (Vehicle h) for 3 days prior to LPS / GalN injection. Blood samples were collected 6 hours after LPS / GalN injection for measurement of serum liver marker and cytokine levels. Figure 1 shows the effect of Compound 1 on total bile acids after GalN / LPS injection. Data are means. Statistical significance was assessed using #, ##, and ### for p<0.05, p<0.01, and p<0.001, respectively, for comparison with vehicle (Vehicle h) using a two-tailed Mann-Whitney test. [Figure 1E]Figure 1 shows the effect of Compound 1 (tesaglitazar) on liver injury and systemic inflammation in a model of acute liver failure. Mice were treated daily with 1 mg / kg Compound 1 or vehicle (Vehicle h.) for 3 days prior to LPS / GalN injection. Blood samples were collected 6 hours after LPS / GalN injection for measurement of serum liver markers and cytokine levels. Figure 1 shows the effect of Compound 1 on circulating IL6 after GalN / LPS injection. Data are means. Statistical significance was assessed using #, ##, and ### for p<0.05, p<0.01, and p<0.001, respectively, for comparisons with vehicle (Vehicle h) using a two-tailed Mann-Whitney test. [Figure 2A] Figure 1 shows the effects of Compound 1 (tesaglitazar), Compound 2 (muraglitazar), and Compound 3 (aleglitazar) on LPS activation of THP1 macrophages. After differentiation into macrophages, THP1 cells were treated with the indicated compounds for 24 hours before stimulation with LPS. Cell supernatants were collected 6 hours after LPS to measure MCP1 secretion. The % inhibition of MCP1 secretion was calculated relative to the mean LPS-vehicle condition (Vehicle). Figure 1 shows the effect of Compound 1 on MCP1 secretion by THP1-differentiated macrophages. Data are means. #, ##, ### indicate p<0.05, p<0.01, p<0.001 compared to the untreated condition using a two-tailed Mann-Whitney test. $, $$$ indicate p<0.05, p<0.001 using a nonparametric Kruskal-Wallis test to assess statistical significance of compound treatment versus LPS alone. [Figure 2B]Figure 1 shows the effects of Compound 1 (tesaglitazar), Compound 2 (muraglitazar), and Compound 3 (aleglitazar) on LPS activation of THP1 macrophages. After differentiation into macrophages, THP1 cells were treated with the indicated compounds for 24 hours before stimulation with LPS. Cell supernatants were collected 6 hours after LPS to measure MCP1 secretion. The % inhibition of MCP1 secretion was calculated relative to the mean LPS-vehicle condition (Vehicle). Figure 1 shows the effect of Compound 2 on MCP1 secretion by THP1-differentiated macrophages. Data are means. #, ##, ### indicate p<0.05, p<0.01, p<0.001 compared to the untreated condition using a two-tailed Mann-Whitney test. $, $$$ indicate p<0.05, p<0.001 using a nonparametric Kruskal-Wallis test to assess statistical significance of compound treatment versus LPS alone. [Figure 2C] Figure 1 shows the effects of Compound 1 (tesaglitazar), Compound 2 (muraglitazar), and Compound 3 (aleglitazar) on LPS activation of THP1 macrophages. After differentiation into macrophages, THP1 cells were treated with the indicated compounds for 24 hours before stimulation with LPS. Cell supernatants were collected 6 hours after LPS to measure MCP1 secretion. The % inhibition of MCP1 secretion was calculated relative to the mean LPS-vehicle condition (Vehicle). Figure 1 shows the effect of Compound 3 on MCP1 secretion by THP1-differentiated macrophages. Data are means. #, ##, ### indicate p<0.05, p<0.01, p<0.001 compared to the untreated condition using a two-tailed Mann-Whitney test. $, $$$ indicate p<0.05, p<0.001 using a nonparametric Kruskal-Wallis test to assess statistical significance of compound treatment versus LPS alone. DETAILED DESCRIPTION OF THE INVENTION

[0058] The present invention relates to a PPARα / γ agonist selected from aleglitazar, muraglitazar or tesaglitazar, a pharmaceutically acceptable salt thereof or a combination thereof, for use in a method for the treatment of liver failure.

[0059] definition In the context of the present invention, the terms below have the following meanings:

[0060] Tesaglitazar (compound 1), also known as AZ 242, is (S)-2-ethoxy-3-(4-(4-((methylsulfonyl)oxy)phenethoxy)phenyl)propionic acid and has the formula I

[0061] [ka]

[0062] This corresponds to the compound (CAS number 251565-85-2).

[0063] Muraglitazar (compound 2) (formerly called BMS 298585) is N-[(4-methoxyphenoxy)carbonyl]-N-[[4-[2-(5-methyl-2-phenyl-4-oxazolyl)ethoxy]phenyl]methyl]glycine, also named 2-[(4-methoxyphenoxy)carbonyl-[[4-[2-(5-methyl-2-phenyl-1,3-oxazol-4-yl)ethoxy]phenyl]methyl]amino]acetic acid, and has formula II

[0064] [ka]

[0065] This corresponds to the compound (CAS number 331741-94-7).

[0066] Aleglitazar (compound 3) (formerly called Ro-0728804, R-1439) is (2S)-2-methoxy-3-{4-[2-(5-methyl-2-phenyl-1,3-oxazol-4-yl)ethoxy]-1-benzothiophen-7-yl}propionic acid and has formula III

[0067] [ka]

[0068] This corresponds to the compound (CAS number 475479-34-6).

[0069] The term "pharmaceutically acceptable" includes inorganic acid salts as well as organic acid salts. Representative examples of suitable inorganic acids include hydrochloric acid, hydrobromic acid, hydroiodic acid, phosphoric acid, etc. Representative examples of suitable organic acids include formic acid, acetic acid, trichloroacetic acid, trifluoroacetic acid, propionic acid, benzoic acid, cinnamic acid, citric acid, fumaric acid, maleic acid, methanesulfonic acid, etc. Further examples of pharmaceutically acceptable inorganic or organic acid addition salts include the pharmaceutically acceptable salts listed in J. Pharm. Sci. 1977, Vol. 66, No. 2 and Handbook of Pharmaceutical Salts: Properties, Selection, and Use, edited by P. Heinrich Stahl and Camille G. Wermuth, 2002. "Pharmaceutically acceptable salts" also include inorganic base salts as well as organic base salts. Representative examples of suitable inorganic bases include sodium or potassium salts, alkaline earth metal salts, such as calcium or magnesium salts, or ammonium salts. Representative examples of suitable salts with organic bases include, for example, salts with methylamine, dimethylamine, trimethylamine, piperidine, morpholine or tris-(2-hydroxyethyl)amine.

[0070] As used herein, the terms "treatment," "treat," or "treating" refer to any action intended to improve the health status of a patient, such as therapy, prevention, prophylactic administration, and delay of disease. In certain embodiments, such terms refer to the amelioration or eradication of a disease or its associated symptoms. In other embodiments, the terms refer to minimizing the spread or worsening of a disease resulting from the administration of one or more therapeutic agents to a subject with such a disease.

[0071] As used herein, the terms "subject," "individual," or "patient" are used interchangeably and refer to animals, preferably mammals, and even more preferably humans, including adults, children, newborns, and prenatal humans. However, the term "subject" can also refer to non-human animals, particularly mammals, such as dogs, cats, horses, cows, pigs, sheep, and non-human primates.

[0072] The phrase "substituted by at least" means that a group is substituted with one or more groups from the list.

[0073] In the context of the present invention, the term "about" applied to a numerical value means the value + / - 10%. For ease of explanation, this means that "about 100" refers to a value included within the range of 90 to 110. Furthermore, in the context of the present invention, the term "about X", where X is a numerical value, specifically discloses the X value, but also discloses lower and higher values, more specifically X values, of the range so defined.

[0074] Compounds for use in the present invention The present invention provides a PPARα / γ agonist selected from aleglitazar, muraglitazar or tesaglitazar, a pharmaceutically acceptable salt thereof or a combination thereof, for use in a method for the treatment of liver failure.

[0075] In certain embodiments, the PPAR α / γ agonist is selected from aleglitazar, muraglitazar, tesaglitazar, or a combination thereof. In certain embodiments, the PPAR α / γ agonist is selected from aleglitazar, muraglitazar, or tesaglitazar. In further particular embodiments, the PPAR α / γ agonist is tesaglitazar.

[0076] In a particular embodiment, the compound according to the invention for use is Compound 1: Tesaglitazar Compound 2: muraglitazar, and Compound 3: selected from aleglitazar.

[0077] In a more particular embodiment, the compound according to the invention for use is compound 3, tesaglitazar, or a pharmaceutically acceptable salt thereof.

[0078] The compounds for use according to the invention may be in the form of a pharmaceutically acceptable salt, in particular an acid or base salt, that is compatible with pharmaceutical use. Salts of the compounds for use according to the invention include pharmaceutically acceptable acid addition salts, pharmaceutically acceptable base addition salts, pharmaceutically acceptable metal salts, ammonium and alkylated ammonium salts. These salts can be obtained during the final purification steps of the compounds or by incorporating the salt into a previously purified agonist.

[0079] Liver failure In certain embodiments, the subject is a patient with liver failure selected from the group consisting of AD, ACLF, ALF, and cirrhosis, such as compensated or decompensated cirrhosis.

[0080] In certain embodiments, the subject is a patient with liver failure selected from the group consisting of ACLF, ALF, and decompensated cirrhosis.

[0081] Alternatively, the subject in need of treatment is at risk of liver failure selected from AD, ACLF, ALF and cirrhosis.In certain embodiments, the subject is at risk of liver failure selected from the group consisting of AD, ACLF, ALF and decompensated cirrhosis.In particular, the subject can be at risk of AD, ACLF or at risk of decompensated cirrhosis caused by chronic liver disease.

[0082] In certain embodiments, the subject has ALF. In other embodiments, the subject has ALF caused by drug-induced liver injury, paracetamol toxicity, ischemia, hepatitis A, B, or E, autoimmunity, heatstroke, pregnancy-related injuries (e.g., acute fatty liver of pregnancy and HELLP [hemolysis, elevated liver enzymes, low platelets] syndrome), Budd-Chiari syndrome, non-hepatotropic viral infections such as herpes simplex, or diffusely infiltrating malignancies. In yet other embodiments, the subject has ALF caused by drug-induced liver injury, paracetamol toxicity, ischemia, hepatitis A, B, or E, or autoimmunity. In yet other embodiments, the subject has ALF caused by paracetamol toxicity.

[0083] In another specific embodiment, the subject is at risk for ALF. In another embodiment, the subject is at risk for ALF caused by drug-induced liver injury, paracetamol toxicity, ischemia, hepatitis A, B, or E, autoimmunity, heatstroke, pregnancy-related injuries (e.g., acute fatty liver of pregnancy and HELLP [hemolysis, elevated liver enzymes, low platelets] syndrome), Budd-Chiari syndrome, non-hepatotropic viral infections such as herpes simplex, or diffusely infiltrating malignancies. In yet another embodiment, the subject is at risk for ALF caused by drug-induced liver injury, paracetamol toxicity, ischemia, hepatitis A, B, or E, or autoimmunity. In yet another embodiment, the subject is at risk for ALF caused by paracetamol toxicity.

[0084] In certain embodiments, the subject has compensated or decompensated cirrhosis, particularly decompensated cirrhosis. In certain embodiments, the subject has alcoholic cirrhosis, for example, alcoholic compensated cirrhosis or alcoholic decompensated cirrhosis, more particularly alcoholic decompensated cirrhosis. In another specific embodiment, the subject has compensated or decompensated cirrhosis following non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject has decompensated cirrhosis following non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject has compensated or decompensated cirrhosis following non-alcoholic steatohepatitis (NASH). In another specific embodiment, the subject has decompensated cirrhosis following non-alcoholic steatohepatitis (NASH).

[0085] In certain embodiments, the subject is at risk of compensated or decompensated cirrhosis, particularly decompensated cirrhosis. In certain embodiments, the subject is at risk of alcoholic cirrhosis, such as alcoholic compensated cirrhosis or alcoholic decompensated cirrhosis, more particularly alcoholic decompensated cirrhosis. In another specific embodiment, the subject is at risk of compensated or decompensated cirrhosis following non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject is at risk of decompensated cirrhosis following non-alcoholic fatty liver disease (NAFLD). In another specific embodiment, the subject is at risk of compensated or decompensated cirrhosis following non-alcoholic steatohepatitis (NASH). In another specific embodiment, the subject is at risk of decompensated cirrhosis following non-alcoholic steatohepatitis (NASH).

[0086] In another specific embodiment, the subject has compensated or decompensated cirrhosis and is at risk for AD and ACLF. In another embodiment, the subject has decompensated cirrhosis and is at risk for AD and ACLF.

[0087] In another specific embodiment, the subject has or is at risk for ACLF.

[0088] As mentioned above, ACLF is a multi-organ syndrome that generally occurs in subjects with cirrhosis, especially in subjects with decompensated cirrhosis, and is accompanied by at least one organ failure and high short-term mortality.ACLF can occur in patients with chronic liver disease in response to excessive triggering factors.

[0089] In certain embodiments, the subject has chronic liver disease with cirrhosis and is at risk of developing ACLF.

[0090] As used herein, the term "chronic liver disease" refers to liver disease associated with chronic liver damage, regardless of underlying disease.Chronic liver disease can be caused by, for example, alcohol abuse (alcoholic hepatitis), viral infection (e.g., hepatitis A, B, C, E), autoimmune process (autoimmune hepatitis), nonalcoholic steatohepatitis (NASH), cancer, or chronic exposure to mechanical or chemical injury to the liver.Chemical injury to the liver can be caused by various substances, such as toxins, alcohol, carbon tetrachloride, trichloroethylene, iron, or drugs.

[0091] In certain embodiments, the subject has chronic liver disease with cirrhosis. - Alcohol abuse, - viral hepatitis (such as viral hepatitis caused by infection with hepatitis A, B, C, D, E, or G viruses), - use of medications, - metabolic diseases, - biliary tract diseases, - primary biliary cholangitis, - Primary sclerosing cholangitis, or - NASH He has cirrhosis secondary to

[0092] The present invention is particularly suitable for preventing or managing recurrence of AD and ACLF.

[0093] In certain embodiments, subjects with decompensated cirrhosis, AD, or ACLF exhibit a high MELD score. As used herein, the term "MELD score" or "model for end-stage liver disease" refers to a scoring system for assessing the severity of liver dysfunction. MELD uses a patient's serum bilirubin, serum creatinine, and international prothrombin time ratio (INR) to predict survival. MELD is calculated by the following formula: MELD = 3.78 [Ln plasma bilirubin (mg / dL)] + 11.2 [Ln INR] + 9.57 [Ln plasma creatinine (mg / dL)] + 6.43 [where LN means Napier's logarithm].

[0094] Bilirubin is a yellow breakdown product of normal heme catabolism. It is excreted in bile and urine. The majority of bilirubin (70-90%) comes from hemoglobin breakdown and, to a lesser extent, from other blood proteins. In serum, bilirubin is typically measured as both direct and total bilirubin. Direct bilirubin correlates with conjugated bilirubin and includes both conjugated bilirubin and bilirubin covalently bound to albumin. Indirect bilirubin correlates with unconjugated bilirubin. Serum bilirubin levels can be measured by any suitable method known in the art. Illustrative, non-limiting examples of methods for measuring serum bilirubin include methods using diazo reagents, DPD, bilirubin oxidase, or direct spectrophotometric determination of bilirubin. Briefly, the method for measuring bilirubin levels in serum using diazo reagents is based on the generation of azobilirubin, which acts as an indicator, by adding a mixture of sulfanilic acid and sodium nitrite. The method for measuring serum bilirubin using DPD is based on the reaction of bilirubin with 2,5-dichlorobenzenediazonium salt (DPD) in 0.1 mol / HCl to generate azobilirubin, which has a maximum absorbance at 540–560 nm. The staining intensity is proportional to the bilirubin concentration. Unconjugated bilirubin, which reacts in the presence of a detergent (e.g., Triton TX-100), is measured as total bilirubin, whereas only conjugated bilirubin reacts in the absence of detergent. The method for measuring serum bilirubin levels using bilirubin oxidase is based on the catalytic reaction of bilirubin to biliverdin, which has a maximum absorbance at 405–460 nm. The bilirubin concentration is proportional to the measured absorbance. The concentration of total bilirubin is measured by adding sodium dodecyl sulfate (SDS) or sodium cholate, which induces the separation and precipitation of unconjugated bilirubin from albumin. Serum bilirubin levels can also be measured by direct spectrophotometry at 454 nm and 540 nm.This dual wavelength measurement is used to reduce hemoglobin interference.

[0095] As used herein, the term "international prothrombin time ratio" or "INR" refers to a parameter used to measure the tendency of blood to clot. The INR is the ratio of a patient's prothrombin time to a normal (control) sample, raised to the power of the ISI value for the analytical system used. The prothrombin time (PT) measures factors I (fibrinogen), II (prothrombin), V, VII, and X, and is used in conjunction with activated partial thromboplastin time. The prothrombin time is the time it takes for plasma to clot after the addition of tissue factor. It measures the extrinsic pathway of coagulation. The INR normalizes the prothrombin time result and is calculated by the following formula: INR = (PTtest / PTnormal). <isi>is.

[0096] The ISI value in the formula is the International Sensitivity Index for any given tissue factor, and indicates how a particular batch of tissue factor compares to the international reference tissue factor. The ISI is typically between 1.0 and 2.0.

[0097] The MELD score is strongly correlated with short-term mortality, with lower MELD scores associated with lower mortality and higher MELD scores associated with higher mortality. Thus, patients with low MELD scores, e.g., MELD scores below 9, have a 3-month mortality rate of approximately 1.9%, whereas patients with high MELD scores, e.g., MELD scores above 40, have a 3-month mortality rate of approximately 71.3%.

[0098] As used herein, the term "high MELD score" refers to a patient having a MELD score higher than 9, e.g., at least 10, at least 15, at least 19, at least 20, at least 25, at least 29, at least 30, at least 35, at least 39, at least 40, at least 45, or more. In certain embodiments, the present invention applies to subjects with a MELD score higher than 20.

[0099] In another specific embodiment, the patient to be treated exhibits impaired renal function. In the present invention, the term "impairment of kidney function," also known as "impairment of renal function," "renal impairment (disorder)," "renal insufficiency," "renal impairment," and "renal failure," refers to a medical condition in which the kidneys are unable to adequately filter waste products from the blood. Renal failure is primarily determined by a decrease in the glomerular filtration rate, which is the rate at which blood is filtered through the glomeruli of the kidney. Renal failure can cause problems such as an increase in fluid in the body (leading to swelling), increased acidity, increased potassium, decreased calcium, increased phosphate, and, in later stages, anemia.

[0100] The PPARα / γ agonists selected above for use according to the present invention can be used at any stage of ACLF. In certain embodiments, the subject has ACLF grade 2 or 3.

[0101] In another embodiment, the subject has ACLF without renal failure. In a particular embodiment, the subject has ACLF with renal failure. In another particular embodiment, the subject has AD or ACLF with non-renal organ failure and renal insufficiency.

[0102] In another embodiment, the subject is at risk of ACLF. In yet another embodiment, the subject has at least one ACLF-inducing event. In another embodiment, the inducing event is selected from alcoholic hepatitis, bacterial infection, fungal infection, or viral infection, sepsis, intoxication, visceral bleeding, and drug-induced liver injury. In another embodiment, the inducing event is a bacterial infection. In yet another specific embodiment, the PPAR α / γ agonist of the present invention is for use in a method for treating septic AD or ACLF.

[0103] In a further embodiment, the PPAR alpha / gamma agonist of the present invention is used in the method for treating or preventing hepatic encephalopathy.In a particular embodiment, the PPAR alpha / gamma agonist of the present invention is used in the method for treating or preventing hepatic encephalopathy in subjects with compensated or decompensated cirrhosis, particularly decompensated cirrhosis.In another embodiment, the PPAR alpha / gamma agonist of the present invention is used in the method for treating hepatic encephalopathy in subjects with AD or ACLF.

[0104] In the context of the present invention, the PPARα / γ agonist of the present invention is administered to a subject in a therapeutically effective amount. A "therapeutically effective amount" refers to an amount of drug effective to achieve a desired therapeutic result. The therapeutically effective amount of a drug may vary depending on factors such as the disease state, age, sex, and weight of the individual, as well as the ability of the drug to elicit a desired response in an individual. A therapeutically effective amount is also an amount in which the therapeutically beneficial effects outweigh any toxic or adverse effects of the active substance. The effective dosage and administration regimen of a drug depend on the disease or condition to be treated and may be determined by one skilled in the art. A skilled physician can easily determine and prescribe the effective amount of the pharmaceutical composition required. For example, to achieve the desired therapeutic effect, a physician can start the dosage of the drug used in the pharmaceutical composition at a level lower than the required dose and gradually increase the dosage until the desired effect is achieved. Generally, the appropriate dosage of the composition of the present invention will be the lowest dose of the compound effective to achieve the therapeutic effect with a particular administration regimen. Such an effective dose will generally be determined by the factors described above.

[0105] The PPARα / γ agonists of the present invention can be formulated into pharmaceutical compositions further comprising one or more pharmaceutically acceptable additives or excipients (e.g., physiological saline, physiological solution, isotonic solution, etc.) compatible with pharmaceutical use and well known to those skilled in the art. These compositions can also further comprise one or more agents or excipients selected from dispersants, solubilizers, stabilizers, preservatives, etc. Agents or excipients useful for these formulations (liquid and / or injectable and / or solid) are, inter alia, methylcellulose, hydroxymethylcellulose, carboxymethylcellulose, polysorbate 80, mannitol, gelatin, lactose, vegetable oils, acacia gum, liposomes, etc. These compositions can be formulated into the form of injectable suspensions, syrups, gels, oils, ointments, pills, tablets, suppositories, powders, gel caps, capsules, aerosols, etc., ultimately in galenic forms or devices ensuring long-term and / or sustained release. For this type of formulation, agents such as cellulose, carbonates or starch may be advantageously used.

[0106] The PPARα / γ agonist of the present invention can be administered by different routes and in different forms. For example, it can be administered via systemic means, orally, parenterally, by inhalation, by nasal spray, by nasal drop injection, or by injection, such as intravenously, intramuscularly, subcutaneously, transdermally, topically, or intraarterially. Of course, the administration route will be adapted to the drug form according to procedures well known to those skilled in the art.

[0107] In certain embodiments, the compound is formulated as a tablet. In another particular embodiment, the compound is administered orally.

[0108] The frequency and / or dosage associated with administration may be adapted by those skilled in the art depending on the patient's function, pathology, administration form, etc. Typically, the PPARα / γ agonist of the present invention may be administered at a dose comprised between 0.01 mg / day and 4000 mg / day, such as 50 mg / day to 2000 mg / day, such as 100 mg / day to 2000 mg / day, and particularly 100 mg / day to 1000 mg / day. Administration can be performed daily or even several times per day as needed. In one embodiment, the compound is administered at least once a day, such as once a day, twice a day, or three times a day. In certain embodiments, the PPARα / γ agonist is administered once or twice a day. In particular, oral administration can be performed once a day by taking a tablet containing the PPARα / γ agonist during a meal, such as breakfast, lunch, or dinner.

[0109] Preferably, the course of treatment with a PPARα / γ agonist of the present invention is for at least one week, particularly at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, or 24 weeks or more. In certain embodiments, the course of treatment is for at least one month, at least two months, or at least three months. In certain embodiments, the course of treatment is for at least one year, or longer depending on the condition of the subject being treated.

[0110] In certain embodiments, the PPARα / γ agonists ("drugs") of the present invention are for use as the sole active ingredient for the treatment or prevention disclosed in the present invention.

[0111] In yet another embodiment, the drug is for use in combination therapy.

[0112] In certain embodiments, the drug is for use in combination with therapy for a precipitating event.

[0113] In certain embodiments, the inciting event is a bacterial infection, a fungal infection, or a viral infection. Therefore, the drug can be combined with an antibacterial or antiviral agent. The most suitable agent will be selected depending on the organism or virus causing the infection, as is well known in the art. In certain embodiments, the inciting event is reactivation of hepatitis B virus. In that case, the drug can be combined with a nucleoside or nucleoside analog. Exemplary antiviral agents include, but are not limited to, tenofovir, tenofovir alafenamide, and entecavir. In another specific embodiment, the inciting event is a bacterial infection, and the drug can be combined with an antibiotic. Antibiotics useful for treating bacterial infections are well known in the art. Exemplary antibiotic families include, but are not limited to, beta-lactam antibiotics (e.g., penicillin), tetracyclines, cephalosporins, quinolones, lincomycin, macrolides, sulfonamides, glycopeptides, aminoglycosides, and carbapenems. In certain embodiments, the drug can be combined with an antibiotic from the carbapenem family, such as ertapenem.

[0114] In another specific embodiment, the triggering event is acute variceal bleeding. Therefore, the drug can be combined with a vasoconstrictor such as terlipressin, somatostatin, or an analogue such as octreotide or vapreotide, particularly octreotide. Such treatment can be accompanied by endoscopic treatment (preferably endoscopic esophageal variceal ligation performed at the time of endoscopic diagnosis within 12 hours after admission). Short-term antibiotic prophylaxis, such as with ceftriaxone, can also be administered.

[0115] In another specific embodiment, the inciting event is alcoholic hepatitis. Thus, the drug can be combined with prednisolone, which is indicated for patients with severe alcoholic hepatitis.

[0116] In another specific embodiment, the drug is for use in combination with supportive care. In certain embodiments, the supportive care is cardiovascular supportive care. For example, the drug can be combined with acute kidney injury therapy, such as diuretic withdrawal or volume expansion (with intravenous albumin). The drug may also be combined with a vasoconstrictor, such as terlipressin or norepinephrine, especially if there is no response to volume expansion. In certain embodiments, the supportive care is treatment of encephalopathy. For example, the drug can be combined with lactulose. Optionally, lactulose therapy can be further completed by administering an enema to empty the bowel. If a subject has severe hepatic encephalopathy that is not responsive to lactulose, albumin dialysis can be used. In yet another specific embodiment, the drug can be combined with rifaximin. In a further embodiment, the drug can be combined with lactitol. In certain embodiments, the supportive care is extracorporeal liver supportive care. For example, an extracorporeal liver assist device incorporating hepatocytes can be used. In another embodiment, plasma exchange can be performed in addition to administration of the drug as provided herein. In yet another embodiment, the extracorporeal liver support therapy is albumin exchange or endotoxin removal.

[0117] The following examples serve to illustrate the invention and should not be construed as limiting its scope. [Example]

[0118] chemistry Chemical names follow IUPAC nomenclature. Compound 1 (tesaglitazar), compound 2 (muraglitazar) and compound 3 (aleglitazar) are well known and may be synthesized by those skilled in the art according to known methods.

[0119] Tesaglitazar (compound 1) was synthesized according to the method described in WO 9962872 and purchased from TOCRIS (Ref 3965; Batch 1A / 263468).

[0120] Muraglitazar (compound 2) was synthesized according to the method described in WO2001021602.

[0121] Aleglitazar (compound 3) was synthesized according to the method described in WO 2002092084 or by A. Benardeau et al., Bioorg. Med. Chem. Lett., 2009, 19, 2468-2473.

[0122] Animal experiments Animal manipulation was carried out carefully to minimize stress. All experiments were performed in accordance with the French Ministry of Agriculture's guidelines for experiments with laboratory animals (Law 87-848). Studies were conducted in accordance with animal health regulations (Council Decree No. 2010 / 63 / UE of September 22, 2010 and French Decree No. 2013-118 on Animal Protection of February 1, 2013).

[0123] Example 1 Compound 1 ameliorates liver injury and function and reduces systemic inflammation in a model of acute liver failure Low doses of lipopolysaccharide (LPS) combined with the hepatotoxicant D-galactosamine (GalN) promote specific liver injury and induce proinflammatory cytokine production in mice, thereby recapitulating the clinical picture of acute liver injury in humans (Pourcet et al., Gastroenterology, 2018, Vol. 154(5), pp. 1449-1464 e20). Therefore, LPS / GalN-induced liver injury is a widely used mouse model for evaluating the effects of drugs on acute liver failure.

[0124] Preclinical Models of Acute Liver Failure To evaluate the efficacy of the compound on liver injury and function, as well as the inflammatory response that occurs during acute liver failure, male C57BL / 6J mice (8 weeks old, Janvier Labs) were given an intraperitoneal injection of 0.025 mg / kg LPS (Escherichia coli O111:B4, #L2630, Sigma-Aldrich) supplemented with 700 mg / kg D-galactosamine (GalN, G0500, Sigma-Aldrich). Compound 1 (1 mg / kg / day) or vehicle (1% carboxymethylcellulose, 0.1% Tween 80) was administered by oral gavage for 3 days prior to the LPS / GalN injection (n = 10–12 per group). Mice were sacrificed 6 hours after the LPS / GalN injection. Blood samples were obtained by retro-orbital sinus puncture from animals slightly sedated with isoflurane (Isoflurin 1000 mg / g, GTIN03760087152678, Axience) immediately before sacrifice. A group of mice (n=4) received an intraperitoneal injection and served as healthy controls.

[0125] Analysis in mouse serum Serum aspartate aminotransferase (ASAT) was measured using a Randox kit on a Daytona Plus automate (AS 8306) according to the manufacturer's recommendations. ASAT enzymatically converts alpha-oxoglutarate and L-aspartate to L-glutamate and oxaloacetate. In the presence of NADH, the generated oxaloacetate is converted by malate dehydrogenase to form L-malate and NAD+. The reaction kinetics was examined to calculate the concentration of ASAT.

[0126] Serum alanine aminotransferase (ALAT) was measured using a Randox kit on a Daytona Plus automate (AS 8304) according to the manufacturer's recommendations. ALAT enzymatically converts alpha-oxoglutarate and L-alanine to L-glutamate and pyruvate. In the presence of NADH, the generated pyruvate is converted by lactate dehydrogenase to form L-lactate and NAD+. The kinetics of the reaction was examined to calculate the concentration of ALAT.

[0127] Serum total bilirubin was measured using a Randox kit on a Daytona Plus automate (BR 8377) according to the manufacturer's recommendations. Bilirubin is oxidized with vanadate at approximately pH 2.9 to produce biliverdin. In the presence of detergent and vanadate, both conjugated and unconjugated bilirubin are oxidized. This oxidation reaction causes a decrease in the optical density of the yellow color specific to bilirubin. The decrease in optical density at 450 / 546 nm is proportional to the total bilirubin concentration in the sample.

[0128] Serum total bile acids were measured using a Randox kit on a Daytona Plus automate (BI 3863) according to the manufacturer's recommendations. In the presence of thio-NAD, bile acids are converted to 3-ketosteroids and thio-NADH by the enzyme 3-α-hydroxysteroid dehydrogenase (3-α-HSD). In the presence of excess NADH, enzyme cycling occurs efficiently, and the rate of thio-NADH formation is determined by measuring the specific change in absorbance at 405 nm. Serum interleukin-6 (IL6) concentrations were determined using a multiplex sandwich ELISA system (Mouse Magnetic Luminex #LSXAMSM-06, Biotech) according to the manufacturer's instructions. Briefly, serum samples were added to magnetic particles pre-coated with cytokine-specific antibodies. After washing, IL6 was detected by the addition of biotinylated antibodies. Finally, phycoerythrin-conjugated streptavidin was added, and analysis was performed using a Luminex 200 analyzer. The intensity of the phycoerythrin signal is proportional to the concentration of the specific cytokine.

[0129] result As expected in this model, mice injected with LPS / GalN had severe liver injury, as determined by extremely high levels of ASAT (>2000 U / L) and ALAT (>3000 U / L) (Figures 1A-1B). Compound 1 significantly alleviated liver injury by reducing ASAT and ALAT by 66% (p=0.01) and 57% (p=0.03), respectively (Figures 1A-1B). While compound 1 significantly improved these markers, liver function, including bilirubin and bile acid metabolism, was also significantly altered in this model, as demonstrated by a 73% reduction in total bilirubin (p=0.003) and a 79% reduction in total bile acids (p=0.004) (Figures 1C-1D). Interestingly, these hepatoprotective effects were associated with anti-inflammatory effects, as evidenced by a significant reduction in the pro-inflammatory cytokine IL6 (-78%, p=0.01) (Fig. 1E).

[0130] These results demonstrate that Compound 1 exerts hepatoprotective and anti-inflammatory effects, thereby alleviating liver injury and altered liver function in acute liver failure.

[0131] Example 2 Macrophage activation is inhibited by the compounds according to the present invention The human monocyte cell line THP-1 (Sigma) was used to test the efficacy of compounds for inhibiting immune system activation. THP1 monocytes were cultured in RPMI 1640 medium (#10-040-CV, Corning) with L-glutamine supplemented with 10% fetal bovine serum (FBS, #10270, Gibco), 1% penicillin / streptomycin (#15140, Gibco), and 25 mM Hepes (H0887, Sigma) at 37°C in a 5% CO incubator.

[0132] Compound 1 was purchased from TOCRIS (Ref 3965, Batch 1A / 263468).

[0133] To test the efficacy of compounds on macrophage activation, 2.5 x 10 4 THP-1 cells were cultured in 384-well plates and treated with 100ng / mL PMA (#P8139, Sigma) for 24 hours to induce differentiation into macrophages. The medium was then removed and FBS-free medium containing compounds was added for 24 hours. Finally, THP1 macrophages were stimulated with 100ng / mL LPS (Klebsiella pneumoniae, #L4268, Sigma-Aldrich) for 6 hours.

[0134] Monocyte chemoattractant protein 1 (MCP1) was measured in cell supernatants by homogeneous time-resolved fluorescence (HTRF) (62HMCP1PEG, Cisbio). Fluorescence was measured using an Infinite 500 (#30019337, Tecan) to determine MCP1 concentrations.

[0135] result Treatment of macrophages with LPS resulted in a two-fold increase in MCP1 levels (Figures 2A, 2B, and 2C). As shown in Figure 2A, compound 1 dose-dependently reduced LPS-induced MCP1 secretion, reaching 100% inhibition at 10 μM (p<0.001). Treatment of THP1 macrophages with compound 2 and compound 3 also demonstrated a dose-dependent reduction in MCP1 secretion, reaching 66% inhibition at 1 μM for compound 2 and 130% inhibition at 0.1 μM for compound 3 (Figures 2B-C).

[0136] These results demonstrate the efficacy of the compounds of the present invention to interfere with macrophage activation, thereby preventing tissue damage induced by overactivation of the immune system.

[0137] Example 3 Compounds of the present invention protect hepatocytes from apoptosis Hepatocyte death is a hallmark of liver failure in both healthy patients and those with fibrotic livers resulting from underlying chronic liver disease and can be induced by a variety of stressors (alcohol, drugs, cytokine storm, etc.).

[0138] To evaluate the efficacy of compounds in protecting hepatocytes from cell death, apoptosis was induced by staurosporine in the human hepatoblastoma-derived HepG2 cell line (ECACC, #85011430, Sigma-Aldrich). HepG2 cells were cultured in a 5% CO incubator at 37°C in high-glucose DMEM medium (#41965, Gibco, France) supplemented with 10% fetal bovine serum (FBS, #10270, Gibco), 1% penicillin / streptomycin (#15140, Gibco), 1% sodium pyruvate (#11360, Gibco), and 1% MEM non-essential amino acids (#11140, Gibco).

[0139] To assess caspase 3 / 7 activity, a surrogate marker of apoptosis, 1.5 × 10 4 Cells were plated in 384-well plates (#781080, Greiner, France). After cell attachment (8 h), cells were serum-starved for 16 h in the presence of compound (doses ranging from 0.3 to 10 μM) or vehicle. Cells were then treated with 10 μM staurosporine (#569397, Sigma-Aldrich, Germany) supplemented with compound for an additional 4 h before cell lysis and caspase activity measurement.

[0140] Caspase 3 / 7 activity was measured using the Caspase Glow™ 3 / 7 assay (#G8093, Promega, USA). Luminescence was measured using a Spark® microplate reader (#30086376, Tecan, USA). Light units (RLU) directly correlate with caspase 3 / 7 activity.

[0141] result Incubation of HepG2 cells with staurosporine induced apoptosis, as indicated by a dramatic five-fold increase in caspase 3 / 7 activity. Interestingly, the three compounds according to the present invention significantly inhibited caspase 3 / 7 activity in a dose-dependent manner. Compound 1 achieved 12% inhibition (p<0.001) at a dose of 10 μM, compound 2 achieved 24% inhibition (p<0.001) at a dose of 3 μM, and compound 3 achieved 17% inhibition (p<0.001) at a dose of 1 μM.

[0142] These results demonstrate that the compounds according to the invention directly protect hepatocytes from cell death by inhibiting apoptosis.

[0143] Taken together, these results show that treatment with the compounds according to the present invention reduces the overactivation of the immune system by a direct anti-inflammatory effect on macrophages, and also directly reduces liver cell death. Thus, the compounds according to the present invention show beneficial effects for treating patients with acute liver failure or exacerbation of chronic liver failure.< / isi>

Claims

1. A PPARα / γ agonist selected from aleglitazar, muraglitazar, tesaglitazar, pharmaceutically acceptable salts thereof or combinations thereof for use in a method for the treatment of liver failure in a subject in need thereof.

2. 2. The PPARα / γ agonist for use according to claim 1, which is aleglitazar or a pharmaceutically acceptable salt thereof, preferably aleglitazar.

3. 2. The PPAR alpha / gamma agonist for use according to claim 1, which is muraglitazar or a pharmaceutically acceptable salt thereof, preferably muraglitazar.

4. 2. The PPAR alpha / gamma agonist for use according to claim 1, which is tesaglitazar or a pharmaceutically acceptable salt thereof, preferably tesaglitazar.

5. 5. The PPARα / γ agonist for use according to any one of claims 1 to 4, wherein the liver failure is selected from acute decompensation (AD), acute onset of chronic liver failure (ACLF), acute liver failure (ALF) and decompensated cirrhosis.

6. 5. The PPAR alpha / gamma agonist for use according to any one of claims 1 to 4, wherein the subject has AD, decompensated cirrhosis with or without ACLF, or is at risk of AD and ACLF.

7. 5. The PPARα / γ agonist for use according to any one of claims 1 to 4, wherein the subject has decompensated cirrhosis or is at risk of decompensated cirrhosis or acute decompensation.

8. A PPARα / γ agonist for use according to any one of claims 1 to 4 for the prevention of decompensated cirrhosis.

9. 5. A PPARα / γ agonist for use according to any one of claims 1 to 4 in a method for converting decompensated cirrhosis to compensated cirrhosis.

10. 5. A PPARα / γ agonist for use according to any one of claims 1 to 4 in a method for the prevention of hepatic decompensation in a subject with ACLF.

11. 5. The PPARα / γ agonist for use according to any one of claims 1 to 4, wherein the liver failure is ALF.

12. 5. A PPARα / γ agonist for use according to any one of claims 1 to 4 in the prevention of renal failure or in the prevention of hepatic encephalopathy.

13. 5. The PPAR alpha / gamma agonist for use according to any one of claims 1 to 4, wherein the subject has ACLF without renal failure or the subject has ACLF with non-renal organ failure accompanied by renal insufficiency.

14. 5. A PPARα / γ agonist for use according to any one of claims 1 to 4 in the treatment of septic ACLF.

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