Tyrosine kinase inhibitors for the treatment of relapsing forms of multiple sclerosis (RMS)

Abstract

To provide a method for treating relapsing multiple sclerosis.SOLUTION: (R) - l - (l-acryloylpiperidin-3-yl) - 4-amino-3 - (4-phenoxyphenyl) - 1H - imidazo [4, 5-c] pyridin-2 (3H) - one to a subject in need thereof. Another aspect of the present disclosure is to provide methods of treating RMS comprising administering to a subject in need thereof BTK inhibitors, including (R) - l - (l-acryloylpiperidin-3-yl) - 4-amino-3 - (4-phenoxyphenyl) - imidazo [4, 5-c] pyridin-2 (LA) - one.SELECTED DRAWING: Figure 1

Description

[Technical Field]

[0001] This application claims priority to U.S. Provisional Application No. 62 / 963,238, filed January 20, 2020, U.S. Provisional Application No. 62 / 970,502, filed February 5, 2020, and U.S. Provisional Application No. 63 / 013,895, filed April 22, 2020, the contents of each of which are incorporated herein by reference for all purposes.

[0002] Introduction and Overview The present disclosure relates to the field of therapeutic tyrosine kinase inhibitors, particularly Bruton's tyrosine kinase ("BTK") inhibitors, for treating relapsing forms of multiple sclerosis (RMS). [Background technology]

[0003] Multiple sclerosis (MS) is a neurological disease that affects more than one million people worldwide. It is the most common cause of neurological disability in young and middle-aged adults and has significant physical, psychological, social, and economic impacts on patients and their families. MS is an immune-mediated process in which an abnormal response of the body's immune system is directed at the central nervous system (CNS). During the course of the disease, sclerosis, or lesions or scars, appear in the myelin sheath of nerve cells, interfering with the transmission of electrical signals. The sclerosis accumulates over time, resulting in the debilitating symptoms experienced by MS patients. MS patients generally experience one of four clinical courses of the disease: clinically isolated syndrome, relapsing-remitting, secondary-progressive, and primary-progressive, each of which can be mild, moderate, or severe. Approximately 85% of MS patients have relapsing-remitting disease and experience clearly defined relapses (also called exacerbations or exacerbations), which are episodes of acute worsening of neurological function, followed by periods of partial or complete recovery (remission) without disease progression. Within the scope of this disclosure, "relapsing multiple sclerosis," "relapsing MS," or "RMS" can include clinically isolated syndrome ("CIS"), relapsing-remitting multiple sclerosis ("RRMS"), and relapsing secondary-progressive multiple sclerosis ("R-SPMS"). See, e.g., "Relapsing Multiple Sclerosis," "Relapsing MS," "RRMS," and "R-SPMS."

[0004] Immunomodulatory drugs have become the mainstay of MS treatment. Recent results from clinical trials have demonstrated the efficacy of drugs targeting B lymphocytes, particularly B cell-depleting agents such as ocrelizumab (anti-CD20) (Non-Patent Document 2). Targeting B cells demonstrates therapeutic benefit by modulating T cell activity and represents a departure from the prevailing dogma based on animal models that places B cells at the center of current MS drug development (Non-Patent Document 3). The importance of immune cells present in the CNS is also well known and needs to be considered in the pathogenesis of MS (Non-Patent Document 4).

[0005] Despite these recent advances, there remains a significant unmet need for therapies targeting neuroinflammation in the CNS to halt long-term disability and neurodegeneration in patients with relapsing forms of multiple sclerosis (RMS) and progressive forms of the disease (primary progressive multiple sclerosis ("PPMS") and non-relapsing secondary progressive multiple sclerosis ("NR-SPMS")) (Non-Patent Document 5). Even the most current, highly effective disease-modifying therapies, acting primarily on peripheral adaptive immunity, moderately or temporarily halt neuroinflammatory and neurodegenerative processes and halt disease progression, as demonstrated by recent studies of progressive forms of MS (Non-Patent Document 6; Non-Patent Document 7).

[0006] Beyond existing strategies to modulate the cellular components of adaptive immunity, innate immunity mediated by myeloid lineages (bone marrow-derived monocytes / macrophages and CNS-resident microglial cells) may play a key role in the prevention of acute relapses in MS despite the persistence of approved disease-modifying therapies. There is growing evidence that innate immunity contributes to many of the neurodegenerative aspects of disease (Non-Patent Document 8; Non-Patent Document 9). Immunomodulation of innate immunity may suppress "smoldering neuroinflammation" and other manifestations of disease progression, conditions that cannot be addressed by currently approved therapies.

[0007] The Bruton's tyrosine kinase (BTK) pathway is important for signal transduction in myeloid cells, including B lymphocytes and CNS microglia. Each of these cell types has been implicated in the pathophysiology of multiple sclerosis (MS). Furthermore, because BTK signaling is essential for the maturation of B cells into antibody-secreting plasma cells, BTK inhibition can regulate both cellular and humoral immunity. Thus, inhibitors of BTK signaling represent a dual mechanism for targeting both aspects of the immune system. [Prior art documents] [Non-patent literature]

[0008] [Non-Patent Document 1] Lublin et al., Defining the clinical course of multiple sclerosis; 2013 revised edition, Neurology 2014; 83: 278-286 [Non-patent document 2] Hauser et al., N Engl J Med. 2017;376(3):221-34 [Non-patent document 3] Lehmann-Horn K et al., Int J Mol Sci. 2017;18(10):2048 [Non-patent document 4] Hemmer B et al., Nat Clin Pract Neurol. 2006;2(4):201-11 [Non-patent document 5] Stys PK et al., Nat Rev Neurosci. 2012;13(7):507-14 [Non-patent document 6] Montalban X et al., N Engl J Med. 2017;376(3):209-20 [Non-Patent Document 7] Kappos L et al. Lancet 2018;391~(10127):1263~73 [Non-patent document 8] Hemmer B et al., Lancet Neurol. 2015;14(4):406-19 [Non-Patent Document 9] Rahmanzadeh R et al., Rev Neurosci. 2018 June 8 Summary of the Invention [Means for solving the problem]

[0009] Therefore, compounds that inhibit BTK, which can inhibit antigen-induced B cell activation that contributes to neuroinflammation and regulate maladaptive microglial cells associated with neuroinflammation in the brain and spinal cord, may be useful for the treatment of RMS with superior benefits compared to currently available therapies.

[0010] Accordingly, the following embodiments are provided. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof. In some embodiments, a method of reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing forms of multiple sclerosis (RMS). ... Methods for reducing the number of new or enlarging T2 lesions are provided, comprising administering a BTK inhibitor to a subject with relapsing multiple sclerosis (RMS), the inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, methods for reducing the total number of gadolinium (Gd)-enhanced T1 hyperintense lesions are provided, comprising administering a BTK inhibitor to a subject with relapsing multiple sclerosis (RMS), the inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, provided is a method of reducing relapse rate in a subject with multiple sclerosis (MS), comprising administering to the subject a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

[0011] In another embodiment, the dose of the BTK inhibitor is about 5 mg to about 60 mg. In another embodiment, the dose is 5 mg. In another embodiment, the dose is 15 mg. In another embodiment, the dose is 30 mg. In another embodiment, the dose is 60 mg. In some embodiments, a method of treating relapsing multiple sclerosis (RMS) comprises administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein administration of the BTK inhibitor inhibits the formation of new active brain lesions as measured by MRI. In another embodiment, the BTK inhibitor compound is administered as monotherapy. In some embodiments, the RMS is selected from clinically isolated syndrome (CIS), relapsing-remitting multiple sclerosis (RRMS), and relapsing secondary-progressive multiple sclerosis (R-SPMS). In another embodiment, the subject is a human.

[0012] In some embodiments, the dosage is once a day. In some embodiments, the dosage is administered once a day with food. In some embodiments, a 15 mg dosage is administered once a day with food. In some embodiments, a 30 mg dosage is administered once a day with food. In some embodiments, a 60 mg dosage is administered once a day with food.

[0013] In some embodiments, administration of a BTK inhibitor reduces RGS1 expression in brain cells, which in some embodiments include microglia.

[0014] In some embodiments, administration of a BTK inhibitor reduces the number of new gadolinium (Gd)-enhancing T1-hyperintense lesions as measured by MRI. In some embodiments, the number of new Gd-enhancing T1-hyperintense lesions is equal to or less than one. In some embodiments, the number of new Gd-enhancing T1-hyperintense lesions is zero. In some embodiments, no new Gd-enhancing T1-hyperintense lesions form after 12 weeks of BTK inhibitor treatment. In some embodiments, one or a few new Gd-enhancing T1-hyperintense lesions form after 12 weeks of BTK inhibitor treatment.

[0015] In some embodiments, a method is provided for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions to a subject with relapsing multiple sclerosis (RMS), comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

[0016] In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is administered to a subject with relapsing multiple sclerosis (RMS).

[0013] Methods for reducing the number of new or enlarging T2 lesions are provided, comprising administering

[0017] In some embodiments, a method is provided for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS).

[0018] In some embodiments, provided is a method of reducing relapse rate in a subject with multiple sclerosis (MS), comprising administering to the subject a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

[0019] In some embodiments, administration of a BTK inhibitor reduces the number of new or enlarging T2 lesions as measured by MRI. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than two. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than one. In some embodiments, the number of new or enlarging T2 lesions is zero. In some embodiments, after 12 weeks of BTK inhibitor treatment, equal to or less than two new or enlarging T2 lesions form. In some embodiments, after 12 weeks of BTK inhibitor treatment, equal to or less than one new or enlarging T2 lesion forms. In some embodiments, after 12 weeks of BTK inhibitor treatment, no new or enlarging T2 lesions form.

[0020] In some embodiments, administration of the BTK inhibitor reduces the total number of Gd-imaging T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

[0021] In some embodiments, the dose is 60 mg, and one or zero new Gd-enhancing T1 hyperintense lesions are formed after 12 weeks of BTK inhibitor treatment. In some embodiments, zero new Gd-enhancing T1 hyperintense lesions are formed after 12 weeks of BTK inhibitor treatment. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than two.

[0022] In some embodiments, administration of the BTK inhibitor reduces the total number of Gd-imaging T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

[0023] In one embodiment, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein 12 weeks after the BTK administration, no new Gd-imaging T1 hyperintensity lesions form.

[0024] In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of treating relapsing multiple sclerosis (RMS) in a subject in need thereof. In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of reducing the number of new or enlarging T2 lesions in a subject with relapsing multiple sclerosis (RMS). In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS). In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of reducing relapse rate in a subject with multiple sclerosis (MS). [Brief explanation of the drawings]

[0025] [Figure 1] FIG. 1 illustrates an exemplary overall design of the procedure. [Figure 2A] Figure 1 shows the primary endpoint outcome, number of new Gd-enhanced T1-hyperintense lesions after 12 weeks of BTK inhibitor treatment (Cohort 1: 12 weeks; Cohort 2: 16 weeks), or 4 weeks of placebo for patients in Cohort 2. Relative reductions (RRs) in lesions were adjusted for baseline Gd-enhanced T1-hyperintense lesion activity (present / absent) using a negative binomial model. CI: confidence interval. [Figure 2B] Figure 1 shows the estimated dose-response curve for new Gd-enhanced T1-hyperintense brain lesions (primary endpoint) after BTK inhibitor treatment based on multiple comparison procedures and modeling (MCP-Mod). The best-fit model was selected as the model with the smallest generalized AIC (Akaike Information Criterion). [Figure 3A] Figure 1 shows secondary endpoint results, number of new or enlarging T2 lesions after 12 weeks of BTK inhibitor treatment (Cohort 1: 12 weeks; Cohort 2: 16 weeks), or 4 weeks of placebo for patients in Cohort 2. Relative reductions (RRs) in lesions were adjusted for baseline Gd-enhanced T2-hyperintense lesion activity using a negative binomial model. CI: confidence interval. [Figure 3B] FIG. 1 shows an estimated dose-response curve for new or enlarging T2 lesion counts (secondary endpoint) after BTK inhibitor treatment based on MCP-Mod analysis. [Figure 4]Figure 1 shows the relative expression levels of differentially expressed genes (DEGs) in mouse microglia after IgG treatment, and after IgG and BTK inhibitor treatment compared to control. CTL = control; IgG = immunoglobulin; RGS1 = regulator of G-protein signaling 1. [Figure 5] Figure 5A shows RGS1 mRNA quantification after in vitro treatment of mouse microglia with IgG alone and IgG plus a BTK inhibitor, as well as after in vitro treatment of naive mouse microglia with a BTK inhibitor (Figure 5B). CTL = control; IgG = immunoglobulin; mRNA = messenger ribonucleic acid. [Figure 6] Figure 1 shows relative RGS1 mRNA expression in microglia after in vivo treatment of naive mice with various doses (0.6, 6, and 24 mg / kg) of BTK inhibitors. veh: vehicle (control). [Figure 7A] A UMAP (Uniform Manifold Approximation and Projection) plot based on a single-cell RNAseq dataset is shown, identifying various CNS cells, including microglia (open circles) (Figure 7A). [Figure 7B] FIG. 7B shows relative RGS1 levels in secondary progressive multiple sclerosis (SPMS) patients and controls. DETAILED DESCRIPTION OF THE INVENTION

[0026] Reference will now be made in detail to certain embodiments, examples of which are illustrated in the accompanying drawings. While the present disclosure provides exemplary embodiments, it will be understood that they are not intended to limit the invention to these embodiments. On the contrary, the present invention is intended to cover all alternatives, modifications, and equivalents which may be included within the scope of the present disclosure as defined by the appended claims.

[0027] The section headings used herein are for organizational purposes only and do not limit the scope of the desired subject matter. The present teachings are not intended to be limiting in any way. In the event that any document incorporated by reference conflicts with a term defined herein, the present specification controls. While the present teachings will be described in connection with various embodiments, it is not intended that the present teachings be limited to such embodiments. On the contrary, the present teachings encompass various alternatives, modifications, and equivalents, as will be appreciated by those skilled in the art.

[0028] I. Definition Unless otherwise stated, the following terms used in the specification and claims are defined for purposes of this disclosure and have the following meanings:

[0029] As used herein, "BTK inhibitor," "BTK inhibitor compound," and "compound" refer to a compound having the following structure: [ka] and / or pharmaceutically acceptable salts thereof, which have the following structure: [ka] It is also known as 4-amino-3-(4-phenoxyphenyl)-1-[(3R)-1-(prop-2-enoyl)piperidin-3-yl]-1,3-dihydro-2H-imidazo[4,5-c]pyridin-2-one, having the formula:

[0030] "Pharmaceutically acceptable carrier" or "pharmaceutically acceptable excipient" means a carrier or excipient that is generally safe, non-toxic, and not biologically or otherwise undesirable and is useful in preparing pharmaceutical compositions, and includes carriers or excipients that are acceptable for veterinary use as well as human pharmaceutical use. As used in the specification and claims, "pharmaceutically acceptable carrier / excipient" includes both one and more than one such excipient.

[0031] "Treating" or "treatment" of a disease includes: (1) preventing a disease, e.g., preventing the development of clinical symptoms of the disease in a mammal that may have been exposed to or be susceptible to the disease but has not yet experienced or exhibited symptoms of the disease; (2) inhibiting the disease, such as preventing or reducing the onset of the disease or its clinical symptoms; or (3) Relieving disease, such as causing regression of the disease or its clinical symptoms Includes:

[0032] "May" or "possibly" means that the subsequently described event or circumstance may occur, but need not occur, and that the description includes instances in which the event or circumstance occurs and instances in which it does not occur.

[0033] A "therapeutically effective amount" means the amount of a BTK inhibitor compound that, when administered to a mammal for treating a disease, is sufficient to effect such treatment for the disease. A "therapeutically effective amount" will vary depending on the compound, the disease and its severity, and the age, weight, etc., of the mammal being treated.

[0034] Before describing the present teachings in detail, it is to be understood that this disclosure is not limited to particular compositions or process steps, as such may vary.

[0035] It should be noted that, 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 "conjugate" includes a plurality of conjugates, reference to a "cell" includes a plurality of cells, etc.

[0036] Numerical ranges are inclusive of the numbers defining the range. Measurements and measurable values ​​are understood to be approximate, taking into account significant digits and errors associated with the measurements. Also, the use of "comprise," "comprises," "comprising," "contain," "contains," "containing," "include," "includes," and "including" is not intended to be limiting. It is to be understood that both the foregoing general and detailed descriptions are exemplary and explanatory only and are not restrictive of the teachings.

[0037] Unless otherwise stated herein above, embodiments herein that are described as "comprising" various components are also contemplated as "consisting of" or "consisting essentially of" the recited components; embodiments herein that are described as "consisting of" various components are also contemplated as "comprising" or "consisting essentially of" the recited components; and embodiments herein that are described as "consisting essentially of" various components are also contemplated as "consisting of" or "comprising" the recited components (this interchangeability does not apply to the use of these terms in the claims).

[0038] The terms "or combinations thereof" and "or combinations thereof," as used herein, refer to any and all permutations and combinations of the terms listed before the term. For example, "A, B, C, or combinations thereof" is intended to include at least one of A, B, C, AB, AC, BC, or ABC, and, where order is important in the particular context, also includes BA, CA, CB, ACB, CBA, BCA, BAC, or CAB. Continuing with this example, expressly included are one or more of BB, AAA, AAB, BBC, AAABCCCC, CBBAAA, CABABB, etc. Combinations containing repeats of items or terms. Those skilled in the art will typically understand that there is no limit to the number of items or terms in any combination unless otherwise clear from the context.

[0039] "Or" is used in its inclusive sense, ie, equivalent to "and / or," unless the context requires otherwise.

[0040] II. Administered BTK Inhibitor Compounds In some embodiments, the BTK inhibitor compound (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is administered to treat relapsing forms of multiple sclerosis (RMS) in a subject in need thereof. In some embodiments, the BTK inhibitor compound is a pharmaceutically acceptable salt of (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, a therapeutically effective amount of the BTK inhibitor compound is administered. In some embodiments, a dose of 5 to 60 mg of the BTK inhibitor compound is administered.

[0041] BTK inhibitor compounds can be prepared, for example, according to the methods and schemes described in U.S. Pat. No. 9,688,676 B2, specifically column 62, line 8 to column 65, line 32, and column 67, lines 28 to 69, which are incorporated herein by reference.

[0042] The following preparation of the compound (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided to enable one of ordinary skill in the art to prepare the BTK inhibitor compound. The synthetic route should not be considered limiting the scope of the disclosure, but merely exemplary and representative thereof.

[0043] Exemplary Synthesis of (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one: [ka]

[0044] In a 100 mL round-bottom flask, (R)-4-amino-3-(4-phenoxyphenyl)-1-(piperidin-3-yl)-1H-imidazo[4,5-c]pyridin-2(3H)-one (150 mg, 0.37 mmol, 1.00 equiv.), DCM-CHOH (6 mL) TEA (113 mg, 1.12 mmol, 3.00 equiv.) was added. This was followed by the dropwise addition of prop-2-enoyl chloride (40.1 mg, 0.44 mmol, 1.20 equiv.) with stirring for 5 min at 0 °C. The resulting solution was stirred for 2 h at 0 °C. o C. The resulting mixture was concentrated under reduced pressure. The residue was applied to a silica gel column containing dichloromethane / methanol (30:1). The crude product (100 mg) was purified by Prep-HPLC under the following conditions (column, XBridge Prep C). 18 OBD column, 5 μm, 19 × 150 mm; mobile phase, water and ACN containing 0.05% TFA (25.0% ACN to 45.0% in 8 min). 54.5 mg of (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one was obtained as a white solid. LC-MS m / z: 465.2 (M+1).

[0045] III. Treatment method Provided herein are methods for treating relapsing multiple sclerosis (RMS), comprising: The method includes administering a therapeutically effective amount of a BTK inhibitor compound comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one and / or a pharmaceutically acceptable salt thereof to a subject in need thereof. In some embodiments, the therapeutically effective amount is about 5 to about 60 mg. In some embodiments, the subject is a mammal. In some embodiments, the mammal is a human. In some embodiments, the subject has one or more symptoms of RMS prior to treatment, and the treatment reduces or eliminates one or more symptoms. In some embodiments, the subject suffers from neuropathic pain, musculoskeletal pain, or spasticity caused by RMS.

[0046] In some embodiments, subjects with RMS have at least one documented relapse within the last year, and / or more than two documented relapses within the last two years, and / or more than one active Gd-enhancing brain lesion on an MRI scan within the last six months prior to screening.

[0047] In some embodiments, a dose of about 5-10 mg, 10-15 mg, 15-20 mg, 20-25 mg, 25-30 mg, 30-35 mg, 35-40 mg, 40-45 mg, 45-50 mg, 50-55 mg, or 55-60 mg is administered. In some embodiments, the dose is 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 45 mg, 50 mg, 55 mg, or 60 mg. In some embodiments, the dose is 5 mg. In some embodiments, the dose is 15 mg. In some embodiments, the dose is 30 mg. In some embodiments, the dose is 60 mg.

[0048] In some embodiments, the dose is administered daily. The daily dose can be delivered as a single dose or divided into multiple portions. For example, in some embodiments, the dose is administered once a day (e.g., about every 24 hours). In some embodiments, the dose is administered twice a day. In some embodiments, the dose is subdivided into two portions that are administered twice a day (e.g., about every 12 hours). In some embodiments, the dose is subdivided into three portions that are administered three times a day (e.g., about every 8 hours). In some embodiments, the dose is subdivided into four portions that are administered four times a day (e.g., about every 6 hours).

[0049] In some embodiments, the dose is administered orally. In some embodiments, the dose is administered in the form of a tablet. In some embodiments, the dose is administered in the form of a pill, capsule, semisolid, powder, sustained release formulation, solution, suspension, elixir, aerosol, or any other suitable composition.

[0050] In some embodiments, the subject is administered the BTK inhibitor compound for a period of about 4, 8, 12, 16, or 20 weeks. In some embodiments, the subject is administered the BTK inhibitor compound for a period of about 12 weeks. In some embodiments, the dose is once daily.

[0051] In some embodiments, the dose is administered with food. In some embodiments, the dose is administered once daily with food. In some embodiments, a 5 mg, 15 mg, 30 mg, or 60 mg dose is administered with food. In some embodiments, a 5 mg, 15 mg, 30 mg, or 60 mg dose is administered once daily with food. In some embodiments, a 60 mg dose is administered once daily with food. In some embodiments, the dose is administered in an oral solution or tablet. In some embodiments, the dose is administered in an oral solution or tablet with food. In some embodiments, the dose is administered once daily in an oral solution or tablet with food. In some embodiments, the dose is administered once daily in an oral solution or tablet with food. In some embodiments, a 60 mg dose is administered in an oral solution or tablet. In some embodiments, a 60 mg dose is administered in an oral solution or tablet with food. In some embodiments, a 60 mg dose is administered in an oral solution or tablet with food. In some embodiments, a 60 mg dose is administered once daily in an oral solution or tablet. In some embodiments, a 60 mg dose is administered once daily in an oral solution or tablet with food.

[0052] RGS1 (regulator of G protein signaling 1) functions as a negative regulator of G protein signaling pathways and is involved in various inflammatory diseases. RGS1 has been identified as a risk factor for MS and has also been found to be enriched in microglia (International Multiple Sclerosis Genetics Consortium, Science 365:6460 (2019)). As detailed in Example 3 below, RNA sequencing revealed a BTK-dependent transcriptional signature in mouse microglia, and RGS1 was identified as one of the upregulated genes in this BTK-dependent microglial signature. Furthermore, the in vitro and in vivo studies in Example 3 show that BTK inhibition normalizes the IgG-activated mouse microglial signature, including downregulation of RGS1. Thus, in some embodiments, administration of a BTK inhibitor reduces RGS1 expression in brain cells. Brain cells may include microglia. In some embodiments, the level of RGS1 expression is measured in brain cells in vitro or in vivo.

[0053] In some embodiments, administration of a BTK inhibitor reduces new active brain lesions. In some embodiments, administration of a BTK inhibitor reduces new active gadolinium (Gd)-enhanced T1 hyperintense lesions. In some embodiments, administration of a BTK inhibitor reduces new or enlarging T2 lesions.

[0054] In some embodiments, administration of a BTK inhibitor reduces the number of new gadolinium (Gd)-enhancing T1-hyperintense lesions as measured by MRI. In some embodiments, the number of new Gd-enhancing T1-hyperintense lesions is less than 1. In some embodiments, the number of new Gd-enhancing T1-hyperintense lesions is less than or equal to 0.77, 0.7, 0.6, 0.5, 0.4, 0.3, 0.2, or 0.1. In some embodiments, no new Gd-enhancing T1-hyperintense lesions form after 12 weeks of BTK inhibitor treatment.

[0055] In some embodiments, administration of a BTK inhibitor reduces the number of new or enlarging T2 lesions as measured by MRI. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 2. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 1.9, 1.8, 1.7, 1.6, 1.5, 1.4, 1.3, 1.2, 1.1, 1.0, 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, 0.2, or 0.1. In some embodiments, the number of new or enlarging T2 lesions is less than 1.9, 1.8, 1.7, 1.6, 1.5, 1.4, 1.3, 1.2, 1.1, 1.0, 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, 0.2, or 0.1 after 12 weeks of BTK inhibitor treatment. After a period of time, no new or enlarging T2 lesions formed.

[0056] In some embodiments, administration of the BTK inhibitor reduces the total number of Gd-imaging T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

[0057] In some embodiments, the dose is 60 mg, and one or zero new Gd-enhancing T1 hyperintense lesions are formed after 12 weeks of BTK inhibitor treatment. In some embodiments, zero new Gd-enhancing T1 hyperintense lesions are formed after 12 weeks of BTK inhibitor treatment. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 2. In some embodiments, the number of new or enlarging T2 lesions is equal to or less than 2, 1.9, 1.8, 1.7, 1.6, 1.5, 1.4, 1.3, 1.2, 1.1, 1.0, 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, 0.2, or 0.1.

[0058] In some embodiments, administration of the BTK inhibitor reduces the total number of Gd-imaging T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

[0059] In one embodiment, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein 12 weeks after the BTK administration, no new Gd-imaging T1 hyperintensity lesions form.

[0060] In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering to a subject in need thereof a dose of about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering to a subject in need thereof about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering to a subject in need thereof about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method of treating relapsing multiple sclerosis (RMS) is provided, comprising administering to a subject in need thereof a dose of about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks.

[0061] In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks.In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks.

[0062] In some embodiments, a method for reducing the number of new gadolinium (Gd)-enhanced T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS). In some embodiments, a method of reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-enhanced T1 hyperintense lesions is provided, comprising administering to a subject with relapsing multiple sclerosis (RMS) a dose of about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering to a subject having relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered once daily.In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering to a subject having relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1-hyperintense lesions is provided, comprising administering to a subject with relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments of the methods provided above, the BTK inhibitor is administered to a subject with relapsing multiple sclerosis (RMS) in need of a reduction in the number of new gadolinium (Gd)-imaging T1-hyperintense lesions.

[0063] In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. ... In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 30 mg of a BTK inhibitor comprising 3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks.In some embodiments, a method for reducing the number of new gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks. In some embodiments of the methods provided above, the BTK inhibitor is administered to a subject with relapsing multiple sclerosis (RMS) in need of a reduction in the number of new gadolinium (Gd)-imaging T1 hyperintense lesions.

[0064] In some embodiments, a method of reducing the number of new or enlarging T2 lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS). In some embodiments, a method of reducing the number of new or enlarging T2 lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks ... Methods for reducing the number of enlarging T2 lesions are provided, comprising administering to a subject with relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg. In some embodiments, methods for reducing the number of new or enlarging T2 lesions are provided, comprising administering to a subject with relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering to a subject having relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering to a subject with relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks. In some embodiments of the methods provided above, the BTK inhibitor is administered to a subject with relapsing multiple sclerosis (RMS) in need of a reduction in the number of new or enlarging T2 lesions.

[0065] In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least 12 weeks. In some embodiments, a method of reducing the number of new or enlarging T2 lesions is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks.In some embodiments, a method of reducing the number of new or enlarging T2 lesions is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor is administered. In some embodiments, a method of reducing the number of new or enlarging T2 lesions is provided, comprising administering 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks. In some embodiments, a method for reducing the number of new or enlarging T2 lesions is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least 12 weeks. In some embodiments of the methods provided above, the BTK inhibitor is administered to a subject with relapsing multiple sclerosis (RMS) in need of a reduction in the number of new or enlarging T2 lesions.

[0066] In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS). In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject having relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-enhanced T1 hyperintense lesions is provided, comprising administering to a subject with relapsing multiple sclerosis (RMS) a dose of about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering to a subject having relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering to a subject with relapsing multiple sclerosis (RMS) a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one at a dose of about 5 to about 60 mg, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. ... The method includes administering about 5 to about 60 mg of a BTK inhibitor comprising a [4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments of the methods provided above, the BTK inhibitor is administered to a subject with relapsing multiple sclerosis (RMS) in need of a reduction in the total number of gadolinium (Gd)-enhanced T1 hyperintense lesions.

[0067] In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor is administered once daily for a period of at least about 12 weeks.In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor is administered once daily for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions is provided, comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS), wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments of the methods provided above, the BTK inhibitor is administered to a subject with relapsing multiple sclerosis (RMS) in need of a reduction in the total number of gadolinium (Gd)-imaging T1 hyperintense lesions.

[0068] In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one. In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method of reducing relapse rate in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks.In some embodiments, a method for reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily. In some embodiments, a method for reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments of the methods provided above, a BTK inhibitor is administered to a subject with multiple sclerosis in need of reducing the relapse rate.

[0069] In some embodiments, a method for reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method for reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks. In some embodiments of the methods provided above, the BTK inhibitor is administered to a subject having multiple sclerosis in need of reducing relapse rates, comprising administering 60 mg of a BTK inhibitor comprising H-imidazo[4,5-c]pyridin-2(3H)-one to the subject, wherein the BTK inhibitor compound is administered for a period of at least about 12 weeks.

[0070] In some embodiments, a method for reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 5 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method for reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 15 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 30 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments, a method of reducing relapse rates in a subject with multiple sclerosis (MS) is provided, comprising administering to the subject 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, wherein the BTK inhibitor compound is administered once daily for a period of at least about 12 weeks. In some embodiments of the methods provided above, a BTK inhibitor is administered to a subject with multiple sclerosis in need of reducing the relapse rate.

[0071] In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of treating relapsing forms of multiple sclerosis (RMS) in a subject in need thereof. In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of reducing the number of new or enlarging T2 lesions in a subject with relapsing forms of multiple sclerosis (RMS). In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS). In some embodiments, a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one is provided for use in a method of reducing the relapse rate in a subject with multiple sclerosis (MS).

[0072] In some embodiments, the BTK inhibitor compound is administered as monotherapy. In some embodiments, the method comprises administering a BTK inhibitor compound and at least one additional therapeutic agent. The additional therapeutic agent can be administered simultaneously or sequentially with the BTK inhibitor compound.

[0073] The frequency of administration will depend on the condition being treated, the age of the subject being treated, and the severity of the condition being treated. The amount of RMS to be treated can be determined by a skilled artisan, such as an attending physician, based on considerations such as the patient's overall condition and the general state of health of the subject being treated. In some embodiments, the BTK inhibitor compound is administered in a therapeutically effective amount for the treatment of RMS. The therapeutically effective amount typically depends on the weight of the subject being treated, their physical or health condition, the extent of the condition being treated, or the age of the subject being treated, the pharmaceutical formulation method, and / or the method of administration (e.g., the time and route of administration).

[0074] In some embodiments, a method of treating relapsing forms of multiple sclerosis (RMS) is provided, comprising administering to a subject in need thereof about 5 to about 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, and / or a pharmaceutically acceptable salt thereof. In some embodiments, administration of the inhibitor reduces the number of new active brain lesions. In some embodiments, the lesions are Gd-enhanced T1 hyperintense lesions. In some embodiments, the number of lesions is detected by magnetic resonance imaging (MRI).

[0075] In some embodiments, a method of treating RMS is provided, comprising administering to a subject in need thereof about 5-10 mg, 10-15 mg, 15-20 mg, 20-25 mg, 25-30 mg, 30-35 mg, 35-40 mg, 40-45 mg, 45-50 mg, 50-55 mg, or 55-60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method for treating RMS is provided, comprising administering to a subject in need thereof about a 5 mg dose of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method for treating RMS is provided, comprising administering to a subject in need thereof about a 15 mg dose of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method for treating RMS is provided, comprising administering to a subject in need thereof an about 30 mg dose of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, and / or a pharmaceutically acceptable salt thereof. In some embodiments, a method for treating RMS is provided, comprising administering to a subject in need thereof an about 60 mg dose of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one, and / or a pharmaceutically acceptable salt thereof.

[0076] The choice of formulation depends on various factors, such as the mode of drug administration (e.g., for oral administration, formulations in the form of tablets, pills, or capsules are preferred) and the bioavailability of the drug substance. Recently, pharmaceutical formulations have been developed, particularly for drugs that exhibit low bioavailability, based on the principle that bioavailability can be increased by increasing the surface area, i.e., by reducing particle size. For example, U.S. Patent No. 4,107,288 describes a pharmaceutical formulation having particles in the size range of 10 to 1,000 nm, in which the active substance is supported on a crosslinked matrix of polymers. U.S. Patent No. 5,145,684 describes the preparation of a pharmaceutical formulation in which a drug substance is milled into nanoparticles (average particle size 400 nm) in the presence of a surface modifier, which are then dispersed in a liquid medium to yield a pharmaceutical formulation exhibiting significantly higher bioavailability. The bioavailability of drugs that decompose at gastric pH is increased by the release of the drug into the duodenum. This can be increased by administering such drugs in a drug-releasing formulation.

[0077] The compositions generally consist of a BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof in combination with a pharmaceutically acceptable excipient, such as a binder, surfactant, diluent, buffer, anti-adherent, glidant, hydrophilic or hydrophobic polymer, retardant, stabilizer or stabilizer, disintegrant or super-disintegrant, antioxidant, antifoaming agent, filler, flavor, colorant, lubricant, adsorbent, preservative, plasticizer, or sweetener, or mixtures thereof, that facilitates processing of the BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof into a preparation that can be used pharmaceutically. Any of the well-known techniques and excipients may be used as suitable and as understood in the art, see, e.g., Remington: The Science and Practice of Pharmacy, 21st Edition, (Pharmaceutical Press, 2005); Liberman, HA, Lachman, L., and Schwartz, JB (eds.), Pharmaceutical Dosage Forms, Vol. 1-2 Taylor & Francis 1990; RI Mahato, Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, 2nd Edition (Taylor & Francis, 2012).

[0078] In certain embodiments, the formulation may contain one or more pH adjusters or buffers. Acids such as acetic acid, boric acid, citric acid, fumaric acid, maleic acid, tartaric acid, malic acid, lactic acid, phosphoric acid, and hydrochloric acid; bases such as sodium hydroxide, sodium phosphate, sodium borate, sodium citrate, sodium acetate, sodium lactate, and tris-hydroxymethylaminomethane; and buffers such as citrate / dextrose, sodium bicarbonate, and ammonium chloride may be included. Such buffers used as bases may have counterions other than sodium, such as potassium, magnesium, calcium, ammonium, or other counterions. Such acids, bases, and buffers are included in the amounts necessary to maintain the pH of the composition within an acceptable range.

[0079] In certain embodiments, the formulation may also contain one or more salts in an amount necessary to bring the osmolality of the composition into an acceptable range. Such salts include salts with sodium, potassium, or ammonium cations and salts with chloride, citrate, ascorbate, borate, phosphate, bicarbonate, sulfate, thiosulfate, or bisulfite anions. Suitable salts include sodium chloride, potassium chloride, sodium thiosulfate, sodium bisulfite, and ammonium sulfate.

[0080] In certain embodiments, the formulation may also include one or more antifoaming agents to reduce foaming during processing, which may result in coagulation of the aqueous dispersion, air bubbles in the finished film, or generally impair processing. Exemplary antifoaming agents include silicone emulsion or sorbitan sesquioleate.

[0081] In certain embodiments, the formulation may also contain one or more antioxidants, such as non-thiol antioxidants, such as butylated hydroxytoluene (BHT), sodium ascorbate, ascorbic acid or its derivatives, and tocopherol or its derivatives. In certain embodiments, the antioxidant enhances chemical stability as needed. Other agents, such as citric acid or citrate salts or EDTA, may also be added to delay oxidation.

[0082] In certain embodiments, the formulation may also include one or more preservatives to inhibit microbial activity. Suitable preservatives include mercury-containing preservatives such as mercury-containing preservatives, ... mercury-containing preservatives, and mercury-containing preservatives such as mercury-containing preservatives. stabilized chlorine dioxide; and quaternary ammonium compounds such as benzalkonium chloride, cetyltrimethylammonium bromide, and cetylpyridinium chloride.

[0083] In certain embodiments, the formulation may also include one or more binders. Binders impart cohesiveness and include, for example, alginic acid and its salts; cellulose derivatives such as carboxymethylcellulose, methylcellulose (e.g., Methocel®), hydroxypropylmethylcellulose, hydroxyethylcellulose, hydroxypropylcellulose (e.g., Klucel®), ethylcellulose (e.g., Ethocel®), and microcrystalline cellulose (e.g., Avicel®); microcrystalline dextrose; amylose; magnesium aluminum silicate; polysaccharide acids; bentonite; gelatin; polyvinylpyrrolidone / vinyl acetate copolymer; crospovidone; povidone; starch; alpha hydroxylated starches; tragacanth, dextrins, sugars such as sucrose (e.g., Dipac®), glucose, dextrose, molasses, mannitol, sorbitol, xylitol (e.g., Xylitab®), and lactose; natural or synthetic gums such as acacia, tragacanth, gum ghatti mucilage from isapol bark, polyvinylpyrrolidone (e.g., Polyvidone® CL, Kollidon® CL, Polyplasdone® XL-10), larch arabogalactan, Veegum®, polyethylene glycol, polyethylene oxide, waxes, sodium alginate, and the like.

[0084] In certain embodiments, the formulation may also include a dispersing agent and / or viscosity modulating agent. Dispersing agents and / or viscosity modulating agents include substances that control the dispersion and homogeneity of the drug through a liquid medium or a granulation or blending method. In some embodiments, these agents also promote the effectiveness of a coating or erosion matrix. Exemplary diffusion enhancers / dispersing agents include, for example, hydrophilic polymers, electrolytes, Tween® 60 or 80, PEG, polyvinylpyrrolidone (PVP; commercially known as Plasdone®), and carbohydrate-based dispersing agents, such as hydroxypropylcellulose (e.g., HPC, H-PC-SL, and HPC-L), hydroxypropylmethylcellulose (e.g., HPMC K100, RPMC K4M, HPMC K15M, and HPMC K100M), sodium carboxymethylcellulose, methylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose phthalate, hydroxypropyl-methylcellulose acetate stearate (HPMCAS), amorphous cellulose, polyethylene oxide, magnesium aluminum silicate, triethanolamine, polyvinyl alcohol (PVA), vinylpyrrolidone / vinyl acetate copolymer (S630), 4-(1,1,3,3-tetramethylbutyl)-phenol polymer with ethylene oxide and formaldehyde (also known as tyloxapol), poloxamers (e.g., Pluronics F68®, F88®, and F108®, which are block copolymers of ethylene oxide and propylene oxide), and poloxamines (e.g., Tetronic 908®, also known as Poloxamine 908®, which is a tetrafunctional block copolymer derived from the sequential addition of propylene oxide and ethylene oxide to ethylenediamine (BASF Chemical Industry Co., Ltd. Corporation, Parsippany, NJ)), polyvinylpyrrolidone K12, polyvinylpyrrolidone K17, polyvinylpyrrolidone K25, or polyvinylpyrrolidone K30, polyvinylpyrrolidone / vinyl acetate copolymer (S-630), polyethylene glycol (e.g., the polyethylene glycol can have a molecular weight of about 300 to about 6000, or about 3350 to about 4000, or about 7000 to 5400), sodium carboxymethylcellulose, methylcellulose, polysorbate-80, sodium alginate, gums such as tragacanth gum and acacia gum, guar gum, xanthan (including xanthan gum), sugars, cellulosics such as sodium carboxymethylcellulose, methylcellulose, and calcines. Examples of suitable dispersing agents include sodium carboxymethylcellulose, polysorbate-80, sodium alginate, polyethoxylated sorbitan monolaurate, povidone, carbomer, polyvinyl alcohol (PVA), alginates, chitosan, and combinations thereof. Plasticizers such as cellulose or triethylcellulose can also be used as dispersing agents. Dispersing agents particularly useful for liposomal and self-emulsifying dispersions are dimyristoyl phosphatidylcholine, natural egg-derived phosphatidylcholine, natural egg-derived phosphatidylglycerol, cholesterol, and isopropyl myristate. Generally, binder levels of about 10 to about 70% are used in powder-filled gelatin capsule formulations. Binder levels in tablet formulations vary depending on whether the formulation is direct compression, wet granulation, roller compaction, or the use of other excipients, such as fillers, which may themselves act as moderate binders. Those skilled in the art will be able to determine binder levels for their formulations, but binder usage levels of up to 90% and more commonly up to 70% in tablet formulations are common.

[0085] In certain embodiments, the formulation may also include one or more diluents, which refer to compounds used to dilute the compound of interest before delivery. Diluents can also be used to stabilize the compound by providing a more stable environment. Salts dissolved in buffered solutions (which can also provide pH control or maintenance) are utilized as diluents in the art, such as, but not limited to, phosphate buffered saline. In certain embodiments, diluents increase the bulk of the composition to facilitate compression or to create sufficient bulk for homogeneous mixing for capsule filling. Such compounds include, for example, lactose, starch, mannitol, sorbitol, dextrose, microcrystalline cellulose, e.g., Avicel®; dibasic calcium phosphate, dicalcium phosphate dihydrate; tricalcium phosphate, calcium phosphate; anhydrous lactose, spray-dried lactose; pregelatinized starch, compressible sugars, e.g., Di-Pac® (Amstar); hydroxypropyl methylcellulose, hydroxypropyl methylcellulose acetate stearate, sucrose-based diluents, powdered sugar; monobasic calcium sulfate monohydrate, calcium sulfate dihydrate; calcium lactate trihydrate, dextrates; hydrolyzed grain solids, amylose; powdered cellulose, calcium carbonate; glycine, kaolin; mannitol, sodium chloride; inositol, bentonite, and the like.

[0086] In certain embodiments, the formulation may also include one or more disintegrants that both dissolve and disperse the dosage form when contacted with gastrointestinal fluids. Disintegrants or disintegrants facilitate the breaking up or disintegration of materials. Examples of disintegrants include starches, such as natural starches, e.g., corn starch or potato starch, pregelatinized starches, e.g., National 1551 or sodium starch glycolate, e.g., Promogel® or Explotab®, celluloses, e.g., wood products, methylcrystalline celluloses, e.g., Avicel®, Avicel® PH101, Avicel® PH102, Avicel® PH105, Elceme® P100, Emcocel®, Vivacel®, and Solka-Floc®, methylcellulose, croscarmellose, or cross-linked celluloses, e.g., cross-linked sodium carboxymethylcellulose (Ac-D). i-Sol®), cross-linked carboxymethylcellulose, or cross-linked croscarmellose, cross-linked starch, e.g., cross-linked sodium starch glycolate, cross-linked polymers, e.g., crospovidone, cross-linked polyvinylpyrrolidone, alginates such as alginic acid, or salts of alginic acid, such as sodium alginate, clays, e.g., Veegum® HV (magnesium aluminum silicate), gums, e.g., agar, guar, locust bean, karaya, pectin, or tragacanth, sodium starch glycolate, bentonite, natural sponge, surfactants, resins, e.g., cation exchange resins, citrus fruit powder, These include starch, sodium lauryl sulfate, sodium lauryl sulfate-compounded starch, etc.

[0087] In certain embodiments, the formulation may also contain an erosion promoter. Erosion promoters include substances that control the erosion of specific substances in gastrointestinal fluids. Erosion promoters are generally known to those skilled in the art. Exemplary erosion promoters include, for example, hydrophilic polymers, electrolytes, proteins, peptides, and amino acids.

[0088] In certain embodiments, the formulation may also include one or more fillers, including compounds such as lactose, calcium carbonate, calcium phosphate, dibasic calcium phosphate, calcium sulfate, microcrystalline cellulose, cellulose powder, dextrose, dextrates, dextran, starch, pregelatinized starch, sucrose, xylitol, lactitol, mannitol, sorbitol, sodium chloride, polyethylene glycol, and the like.

[0089] In certain embodiments, the formulation may also contain one or more flavoring agents and / or sweeteners, such as acacia syrup, acesulfame K, alitum, anise, apple, aspartame, banana, bavarois 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, cyclamate, cyclamate, dextrose, eucalyptus, eugenol, fructose, fruit punch, ginger, glycyrrhizinate, glycyrrhiza (licorice) syrup, grape, grapefruit, honey, isomalt, lemon, lime, lemon cream, monoammonium glycyrrhiza, maltol, mannitol, maple, marshmallow, menthol, mint cream, mixed berry, neohesperidin DC, neo Flavoring ingredients may include tame, orange, pear, peach, peppermint, peppermint cream, powder, raspberry, root beer, rum, saccharin, safrole, sorbitol, spearmint, spearmint cream, strawberry, strawberry cream, stevia, sucralose, sucrose, sodium saccharin, saccharin, aspartame, acesulfame potassium, mannitol, talc, xylitol, sucralose, sorbitol, 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.

[0090] In certain embodiments, the formulation may also comprise one or more lubricants and glidants, which are compounds that prevent, reduce or inhibit adhesion or friction of materials.Exemplary lubricants include, for example, stearic acid, calcium hydroxide, talc, sodium stearyl malonate, hydrocarbons such as mineral oil or hydrogenated vegetable oil, for example, hydrogenated soybean oil, higher fatty acids and their alkali metal and alkaline earth metal salts, for example, aluminum, calcium, magnesium, zinc, stearic acid, sodium stearate, glycerol, talc, wax, boric acid, sodium benzoate, sodium acetate, sodium chloride, leucine, polyethylene glycol (for example, PEG4000) or methoxypolyethylene glycol, for example, Carbowax®, sodium oleate, sodium benzoate, glyceryl behenate, polyethylene glycol, magnesium or sodium lauryl sulfate, colloidal silica, for example, Syloid®, Cab-O-Sil®, starch, for example, corn starch, silicone oil, surfactant.

[0091] In certain embodiments, the formulation comprises an enteric or delayed release coating that softens and becomes friable. The composition may also contain one or more plasticizers, which are compounds used to bind the composition. Suitable plasticizers include, for example, polyethylene glycols, such as PEG300, PEG400, PEG600, PEG1450, PEG3350, and PEG800, stearic acid, propylene glycol, oleic acid, triethyl citrate, dibutyl sebacate, triethylcellulose, and triacetin. In some embodiments, the plasticizer may also function as a dispersing agent or wetting agent.

[0092] In certain embodiments, the formulation may also include one or more solubilizing agents, including compounds such as triacetin, triethyl citrate, ethyl oleate, ethyl caprylate, sodium lauryl sulfate, docusate sodium, vitamin E TPGS, dimethylacetamide, N-methylpyrrolidone, N-hydroxyethylpyrrolidone, polyvinylpyrrolidone, hydroxypropyl methylcellulose, hydroxypropyl cyclodextrin, e.g., Captisol®, ethanol, n-butanol, isopropyl alcohol, cholesterol, bile salts, polyethylene glycol 200-600, glycofurol, transcutol, propylene glycol, and dimethyl isosorbide. In one embodiment, the solubilizing agent is vitamin E TPGS and / or Captisol® or β-hydroxypropyl cyclodextrin.

[0093] In certain embodiments, the formulation also contains polyvinylpyrrolidone, e.g., polyvinylpyrrolidone K112, polyvinylpyrrolidone K17, polyvinylpyrrolidone K25, or polyvinylpyrrolidone K30, vinylpyrrolidone / vinyl acetate copolymer (S630), polyethylene glycol, e.g., polyethylene glycol may have a molecular weight of about 300 to about 6000, or about 3350 to about 4000, or about 7000 to about 5400, sodium carboxymethylcellulose, methylcellulose, hydroxypropylmethylcellulose, hydroxymethylcellulose acetate stearate, Polysol The emulsion may contain one or more suspending agents including compounds such as polysorbate-80, hydroxyethylcellulose, sodium alginate, gums such as gum tragacanth and gum arabic, guar gum, xanthans including xanthan gum, sugars, cellulose derivatives such as sodium carboxymethylcellulose, methylcellulose, sodium carboxymethylcellulose, hydroxypropylmethylcellulose, hydroxyethylcellulose, polysorbate-80, sodium alginate, polyethoxylated sorbitan monolaurate, polyethoxylated sorbitan monooleate, povidone, and the like.

[0094] In certain embodiments, the formulation may also contain one or more surfactants, including compounds such as sodium lauryl sulfate, docusate sodium, Tween 20, 60, or 80, triacetin, vitamin E TPGS, sorbitan monooleate, polyoxyethylene sorbitan monooleate, polyoxyethylene sorbitan monolaurate, polysorbate, polaxomer, bile salts, glyceryl monostearate, copolymers of ethylene oxide and propylene oxide, e.g., Pluronic® (BASF). Some other surfactants include polyoxyethylene fatty acid glycerides and vegetable oils, e.g., polyoxyethylene (60) hydrogenated castor oil; and polyoxyethylene alkyl ethers and alkylphenyl ethers, e.g., Octoxynol 10, Octoxynol 40. In some embodiments, surfactants may be included to promote physical stability or for other purposes.

[0095] In certain embodiments, the formulation also contains one or more viscosity enhancing agents, including, for example, methylcellulose, xanthan gum, carboxymethylcellulose, hydroxypropyl cellulose, hydroxypropyl methylcellulose, hydroxypropyl methylcellulose acetate stearate, hydroxypropyl methylcellulose phthalate, carbomer, polyvinyl alcohol alginate, acacia, chitosan, and combinations thereof. It may also include.

[0096] In certain embodiments, the formulation may also include one or more wetting agents, including compounds such as oleic acid, glyceryl monostearate, sorbitan monooleate, sorbitan monolaurate, triethanolamine oleate, polyoxyethylene sorbitan monooleate, polyoxyethylene sorbitan monolaurate, docusate sodium, sodium oleate, sodium lauryl sulfate, docusate sodium, triacetin, Tween 80, vitamin E TPGS, ammonium salts, and the like.

[0097] The preparations disclosed herein can be obtained by mixing one or more solid excipients such as carriers, binders, fillers, suspending agents, flavoring agents, sweeteners, disintegrants, dispersants, surfactants, lubricants, coloring agents, diluents, solubilizers, wetting agents, plasticizers, stabilizers, penetration enhancers, humectants, antifoaming agents, antioxidants, preservatives, or one or more combinations thereof with one or more of the compounds described herein, optionally milling the resulting mixture, and processing the granular mixture after addition of suitable excipients as needed to obtain tablets.

[0098] The preparations disclosed herein also include gelatin capsules and soft, sealed gelatin capsules, containing plasticizers such as glycerol or sorbitol.Capsules can also be made from polymers such as hypromellose.Capsules can contain active ingredients mixed with fillers such as lactose, binders such as starch, and / or lubricants such as talc or magnesium stearate, and optionally stabilizers.In soft capsules, the active compound can be dissolved or suspended in suitable liquids such as fatty oils, liquid paraffin, lipids, solubilizers, or liquid polyethylene glycol.In addition, stabilizers can be added.All preparations for oral administration should be in dosages suitable for such administration.

[0099] These formulations can be manufactured by conventional pharmaceutical techniques, including, for example, one or a combination of the following methods: (1) dry blending, (2) direct compression, (3) milling, (4) dry or non-aqueous granulation, (5) wet granulation, (6) fusion, or (7) extrusion. See, for example, Lachman et al., *The Theory and Practice of Industrial Pharmacy*, 3rd ed. (1986). Other methods include, for example, spray drying, pan coating, melt granulation, granulation, fluidized bed spray drying or coating (e.g., Wurster coating), tangential coating, top spray, tableting, extrusion, extrusion / spheronization, and the like.

[0100] It should be understood that there is considerable overlap between the excipients used in the solid dosage forms described herein.Therefore, the additives listed above should be considered as merely representative of the types of excipients that can be included in the solid dosage forms described herein, and are not intended to be limiting.The type and amount of such excipients can be easily determined by those skilled in the art according to specific desired properties.

[0101] In some embodiments, the solid dosage forms described herein are enterically coated oral dosage forms, i.e., oral dosage forms of the pharmaceutical compositions described herein that utilize an enteric coating to effect release of the compound in the intestine of the gastrointestinal tract. An "enterically coated" drug and / or tablet refers to a drug and / or tablet that remains intact in the stomach but dissolves and releases the drug upon reaching the intestine (in one embodiment, the small intestine). As used herein, an "enteric coating" is a material, such as a polymeric material, or a substance that encases the therapeutically active agent core, either in the dosage form or as particles. Typically, the therapeutically active agent is released from the dosage form by the enteric coating before being released. The enteric coating is preferably a coating that dissolves a substantial amount or all of the encapsulating material, thereby achieving delayed dissolution of the therapeutically active agent core or particle in the small and / or large intestine. Enteric coatings are discussed, for example, in Loyd, V. Allen, Remington: The Science and Practice of Pharmacy, 21st Edition (Pharmaceutical Press, 2005); P.J. Tarcha, Polymers for Controlled Drug Delivery, Chapter 3, CRC Press, 1991. Methods for applying enteric coatings to pharmaceutical compositions are well known in the art, including, for example, U.S. Patent Application Publication No. 2006 / 0045822.

[0102] Enteric-coated dosage forms can be compressed, molded, or push-type tablets (coated or uncoated) containing granules, powders, pellets, beads, or particles of the BTK inhibitor compound and / or its pharmaceutically acceptable salt and / or other excipients, with at least the tablet or BTK inhibitor compound coated. Enteric-coated oral dosage forms can be capsules (coated or uncoated) containing pellets, beads, or granules of the BTK inhibitor compound and / or its pharmaceutically acceptable salt and / or other excipients, with at least one of the capsules coated, with at least one of the capsules coated. Some examples of coatings originally used as enteric coatings are beeswax and glyceryl monostearate; beeswax, shellac, and cellulose; and cetyl alcohol, mastic, and shellac, and shellac and stearic acid (U.S. Pat. No. 2,809,918); polyvinyl acetate and ethyl cellulose (U.S. Pat. No. 3,835,221). More recently, coatings used are neutral copolymers of polymethacrylates (Eudragit L30D) (FW Goodhart et al., Pharm. Tech., pp. 64-71, April 1984); copolymers of methacrylic acid and methacrylic acid methyl ester (Eudragit S) or neutral copolymers of polymethacrylates containing metal stearates (Mehta et al., U.S. Pat. Nos. 4,728,512 and 4,794,001), cellulose acetate succinate, and hypromellose phthalate.

[0103] Any anionic polymer that exhibits a pH-dependent solubility profile can be used as an enteric coating in the methods and compositions described herein to achieve intestinal delivery.In one embodiment, it can be delivered to the small intestine.In another embodiment, it can be delivered to the duodenum.In some embodiments, the polymer described herein is an anionic carboxyl polymer.In other embodiments, polymers and their compatible mixtures and some of their properties include, but are not limited to:

[0104] Shellac: Also known as purified lac, this coating is a refined product obtained from the resinous secretions of insects. This coating dissolves in media with a pH greater than 7.

[0105] Acrylic polymers: The performance of acrylic polymers (primarily their solubility in body fluids) can vary based on the degree and type of substitution. Examples of suitable acrylic polymers include methacrylic acid copolymers and ammonium methacrylate copolymers. The Eudragit series L, S, and RS (manufactured by Rohm Pharma and also known as Evonik®) are available as aqueous dispersions or dry powders dissolved in organic solvents. The Eudragit series RL, NE, and RS are insoluble in the gastrointestinal tract but permeable and are primarily used to target the colon. The Eudragit series L, L-30D, and S are insoluble in the stomach and dissolve in the intestine, and can be selected and formulated to dissolve at pH values ​​above 5.5, or as low as 5 or as high as 7.

[0106] Cellulose derivatives: Examples of suitable cellulose derivatives are ethyl cellulose; a reaction mixture of partial acetate esters of cellulose with phthalic anhydride. Performance can vary based on the degree and type of substitution. Cellulose acetate phthalate (CAP) dissolves at pH >6. Aquateric (FMC) is an aqueous-based system and a spray-dried CAP pseudolatex with particles <1 μm. Other components in Aquateric can include Pluronic, Tweens, and acetylated monoglycerides. Other suitable cellulose derivatives include cellulose acetate trimellitate (Eastman); methylcellulose (Pharmacoat, Methocel); hydroxypropyl methylcellulose phthalate (HPMCP); hydroxypropyl methylcellulose succinate (HPMCS); and hydroxypropyl methylcellulose acetate succinate (HPMCAS, e.g., AQOAT (Shin Etsu)). Performance can vary based on the degree and type of substitution. For example, HPMCP grades such as HP-50, HP-55, HP-55S, and HP-55F are suitable. Performance may vary based on the degree and type of substitution. For example, suitable grades of hydroxypropyl methylcellulose acetate succinate include, but are not limited to, AS-LG(LF), which dissolves at pH 5, AS-MG(MF), which dissolves at pH 5.5, and AS-HG(HF), which dissolves at higher pHs. These polymers are available as granules or fine powders for aqueous dispersion.

[0107] Polyvinyl acetate phthalate (PVAP): PVAP dissolves at pH >5 and has very low permeability to water vapor and gastric fluids. Details of the above polymers and their pH-dependent solubility can be found in the article entitled "Enteric coated hard gelatin capsules" by Professor Karl Thoma and Karoline Bechtold at http: / / pop.www.capsugel.com / media / library / enteric-coated-hard-gelatin-capsules.pdf. In some embodiments, the coating may, and usually does, contain plasticizers and possibly colorants, talc, and / or other coating excipients such as magnesium stearate, as are well known in the art. Suitable plasticizers include triethyl citrate (Citroflex 2), triacetin (glyceryl triacetate), acetyl triethyl citrate (Citroflec A2), Carbowax 400 (polyethylene glycol 400), diethyl phthalate, tributyl citrate, acetylated monoglycerides, glycerol, fatty acid esters, propylene glycol, and dibutyl phthalate. In particular, anionic carboxylic acrylic polymers typically contain 10-25% by weight of plasticizers, particularly dibutyl phthalate, polyethylene glycol, triethyl citrate, and triacetin. Conventional coating techniques, such as fluidized bed or Wurster coater coating, spray coating, or pan coating, are used to apply the coating. The coating thickness must be sufficient to ensure that the oral dosage form remains intact until the desired local delivery site in the intestinal tract is reached.

[0108] In addition to plasticizers, colorants, surfactants, anti-adherents, anti-foaming agents, lubricants (e.g., carnauba wax or PEG), and other additives may be added to the coating to dissolve or disperse the coating material and improve coating performance and the coated product.

[0109] To accelerate the dissolution of the enteric coat, an enteric polymer (e.g., Eudragit L30 A double coating of half the thickness of Eudragit L30 D-55 can be applied, with the inner enteric coating having a buffer of pH 6.0 or less in the presence of 10% citric acid, followed by a final layer of standard Eudragit L30 D-55. By applying two layers of enteric coating, each half the thickness of a typical enteric coating, Liu and Basit were able to accelerate enteric coating dissolution compared to applying a similar unbuffered coating system as a single layer (Liu, F. and Basit, A. Jour nal of Controlled Release. Vol. 147 (2010) pp. 242-245).

[0110] The integrity of the enteric coating can be measured, for example, by the degradation of the drug within the micropellets. Enteric-coated dosage forms or pellets can be tested first in gastric fluid and separately in intestinal fluid dissolution tests as described in the USP to determine their functionality.

[0111] The enteric-coated tablet and capsule formulations containing the disclosed compounds can be prepared by methods well known in the art.For example, the tablets containing the compounds disclosed herein can be enteric-coated with a coating solution containing Eudragit®, diethyl phthalate, isopropyl alcohol, talc and water using a side-vented coating pan (Freund Hi-Coater).

[0112] Alternatively, a combination dosage form comprising enteric coated pellets that can be incorporated into a tablet or capsule can be prepared as follows.

[0113] Core material: The core material for pellets with a separate enteric coat layer can be constructed according to various principles. Seeds layered with an active agent (i.e., a BTK inhibitor compound and / or a pharmaceutically acceptable salt thereof), optionally mixed with an alkaline substance or buffer, can be used as the core material for further processing. The seeds to be layered with the active agent can be water-insoluble seeds containing various oxides, cellulose, organic polymers, and other substances, alone or in mixtures, or water-soluble seeds containing various inorganic salts, sugars, nonpareils, and other substances, alone or in mixtures. Furthermore, the seeds can contain the active agent in the form of crystals, aggregates, compacts, etc. The size of the seeds is not critical to the present invention but can vary between approximately 0.1 and 2 mm. Seeds to be layered with the active agent can be prepared by either powder or solution / suspension layering, for example, using granulation or spray-coating layering equipment.

[0114] Before layering the seeds, the active agent may be mixed with additional components. Such components may be binders, surfactants, fillers, disintegrants, alkaline additives, etc., and / or pharmaceutically acceptable ingredients, either alone or in mixture. Binders are, for example, polymers such as hydroxypropylmethylcellulose (HPMC), hydroxypropyl-cellulose (HPC), sodium carboxymethylcellulose, polyvinylpyrrolidone (PVP), or sugars, starches, or other pharmaceutically acceptable substances with cohesive properties. Suitable surfactants are found in the group of pharmaceutically acceptable nonionic or ionic surfactants, such as sodium lauryl sulfate.

[0115] Alternatively, the active agent, optionally mixed with suitable constituents, can be formulated into a core material. The core material can be produced by extrusion / spheronization, balling, or compression using conventional processing equipment. The formulated core material has a size of approximately 0.1 to 4 mm, for example, 0.1 to 2 mm. The produced core material can be further layered with additional ingredients, including the active agent, and / or used for further processing.

[0116] The active agent is mixed with pharmaceutical constituents to achieve favorable handling and processing properties and an appropriate concentration of the active agent in the final preparation. Pharmaceutical constituents such as fillers, binders, lubricants, disintegrants, surfactants and other pharmaceutically acceptable additives may be used.

[0117] Alternatively, the core materials described above may be prepared by using spray drying or spray congealing techniques.

[0118] Enteric coating layer(s): Before the enteric coating layer is applied onto the core material in the form of individual pellets, the pellets may optionally be coated with one or more separate layer(s) containing pharmaceutical excipients, optionally including alkaline compounds such as pH buffering compounds. This / these separate layer(s) separate the core material from the outer layer, which is the enteric coating layer(s). This / these separate layer(s) protecting the active agent core material should be water-soluble or disintegrate rapidly in water.

[0119] The separate layer(s) can be applied to the core material by a coating or layering procedure in a suitable device, such as a coating pan, a coating granulator, or a fluidized bed device, optionally using water and / or organic solvents for the coating process. Alternatively, the separate layers can be applied to the core material by using powder coating technology. The materials for separating the layers are pharmaceutically acceptable compounds, such as sugars, polyethylene glycols, polyvinylpyrrolidone, polyvinyl alcohol, polyvinyl acetate, hydroxypropyl cellulose, methyl cellulose, ethyl cellulose, hydroxypropyl methyl cellulose, sodium carboxymethyl cellulose, and water-soluble salts of enteric coating polymers, used alone or in mixtures. Additives, such as plasticizers, colorants, pigments, fillers, anti-tacking and anti-static agents, such as magnesium stearate, titanium dioxide, talc, and other additives, can also be included in the separating layer(s).

[0120] When an optional separating layer is applied to the core material, its thickness can vary. The maximum thickness of the separating layer(s) is usually limited only by the processing conditions. The separating layer can act as a diffusion barrier and can act as a pH buffer zone. The optional separating layer(s) is not critical to the embodiment of the present invention. However, the separating layer(s) can improve the chemical stability of the active substance and / or the physical properties of the novel composite tableted dosage form.

[0121] Alternatively, the separating layer may be formed in situ by reaction between an enteric coating polymer layer applied over the core material and an alkaline-reactive compound in the core material. The separating layer thus formed comprises a water-soluble salt formed between the enteric coating layer polymer(s) and the alkaline-reactive compound in position to form the salt.

[0122] One or more enteric coating layers are applied onto the core material or onto the core material coated with the separating layer(s) by using a suitable coating technique. The enteric coating layer material can be dispersed or dissolved either in water or in a suitable organic solvent. As the enteric coating layer polymer, one or more of the following can be used individually or in combination, such as a solution or dispersion of methacrylic acid copolymer, cellulose acetate phthalate, hydroxypropylmethylcellulose phthalate, hydroxypropylmethylcellulose acetate succinate, polyvinyl acetate phthalate, cellulose acetate trimellitate, carboxymethylethylcellulose, shellac or other suitable enteric coating polymer(s).

[0123] The enteric coating layer contains a pharmaceutically acceptable plasticizer to obtain desired mechanical properties such as flexibility and hardness of the enteric coating layer, such as, but not limited to, triacetin, citrate esters, phthalate esters, dibutyl sebacate, cetyl alcohol, polyethylene glycol, polysorbate, or other plasticizers.

[0124] The amount of plasticizer is such that the mechanical properties, i.e., flexibility and hardness of the enteric coating layer(s), exemplified for example by Vickers hardness, and, if tablets are desired, the acid resistance of the enteric coating layer-coated pellets is not significantly reduced during compression of the pellets into tablets. The enteric coating layer polymer(s), plasticizer(s), and application amount of the polymer(s) are optimized for each enteric coating layer formulation to prevent granular buildup. The amount of plasticizer is typically greater than 5% by weight of the enteric coating layer polymer(s), for example, 15-50%, and even 20-50%. Additives such as dispersants, colorants, pigment polymers (e.g., poly(ethyl acrylate, methyl methacrylate)), anti-tacking agents, and anti-foaming agents may also be included in the enteric coating layer(s). Other compounds may be added to increase film thickness and reduce the diffusion of acidic gastric juices into acid-sensitive materials. The maximum thickness of the applied enteric coating is usually limited only by processing conditions and the desired dissolution profile.

[0125] Overcoating layer: Pellets coated with enteric coating layer(s) can optionally be further coated with one or more overcoating layer(s). The overcoating layer(s) should be water-soluble or rapidly disintegrate in water. The overcoating layer(s) can be applied to the enteric-coated pellets by a coating or layering procedure in a suitable device, such as a coating pan, a coating granulator, or a fluidized bed device, using water and / or organic solvents for the coating or layering process. Materials for the overcoating layer can be selected from pharmaceutically acceptable compounds, such as sugars, polyethylene glycol, polyvinylpyrrolidone, polyvinyl alcohol, polyvinyl acetate, hydroxypropyl cellulose, methylcellulose, ethylcellulose, hydroxypropylmethylcellulose, sodium carboxymethylcellulose, etc., used alone or in mixtures. Additives such as plasticizers, colorants, pigments, fillers, anti-tacking agents, and anti-static agents, such as magnesium stearate, titanium dioxide, talc, and other additives, can also be included in the overcoating layer(s). The overcoating layer may further prevent possible agglomeration of the enteric-coated pellets and may further protect the enteric coating layer from cracking during the compression process and facilitate the granulation process. The maximum thickness of the applied overcoating layer(s) is usually limited by processing conditions and the desired dissolution profile. The overcoating layer may also be used as a tablet film coating layer.

[0126] Enteric coatings for soft gelatin capsules can contain emulsions, oils, microemulsions, self-emulsifying systems, lipids, triglycerides, polyethylene glycols, surfactants, other solubilizers, and the like, and combinations thereof, to solubilize the active agent. The flexibility of soft gelatin capsules is maintained by residual water and plasticizers. Furthermore, in the case of gelatin capsules, gelatin can be dissolved in water at a rate that allows spraying to be completed in a fluidized bed or Wurster at relatively low relative humidity. Furthermore, drying should be achieved without the removal of residual water or plasticizers, which would cause the capsule shell to crack. Commercially available blends optimized for enteric coating of soft gelatin capsules include Instamodel EPD (enteric polymeric dispersion), available from Ideal Cures, Pvt. Ltd. (Mumbai, India). Enteric coated capsules can be prepared on a laboratory scale by a) rolling the capsules in a flask or dipping the capsules in a solution of enteric coating material gently heated with a plasticizer at the lowest possible temperature, or b) using a laboratory scale atomizer / fluid bed followed by drying.

[0127] For aqueous active agents, it may be particularly desirable to incorporate the drug into the aqueous phase of emulsion.This "water-in-oil" emulsion can provide a suitable biophysical environment for the drug, and provide an oil-water interface that can protect the drug from the adverse effects of pH or enzymes that can decompose the drug.In addition, this water-in-oil formulation can provide a lipid layer that can favorably interact with the lipids in the cells of living organisms, and can increase the distribution of the formulation on the cell membrane.This distribution can increase the drug of this formulation into circulation. It can increase absorption and therefore bioavailability of the drug.

[0128] In some embodiments, water-in-oil emulsions contain an oily phase composed of medium or long chain carboxylic acids or esters thereof or alcohols, a surfactant or surface active agent, and an aqueous phase containing primarily water and the active agent.

[0129] Medium and long chain carboxylic acids are C8 to C6 with up to three unsaturated bonds (and branches). 22 Examples of saturated straight-chain acids are n-dodecanoic acid, n-tetradecanoic acid, n-hexadecanoic acid, caproic acid, caprylic acid, capric acid, lauric acid, myristic acid, palmitic acid, stearic acid, arachidic acid, behenic acid, montanic acid, and melissic acid. Unsaturated monoolefin straight-chain monocarboxylic acids are also useful. Examples of these are oleic acid, gadoleic acid, and erucic acid. Unsaturated (polyolefin) straight-chain monocarboxylic acids are also useful. Examples of these are linoleic acid, ricinoleic acid, linolenic acid, arachidonic acid, and behenolic acid. Useful branched acids include, for example, diacetyl tartrate. Unsaturated olefin chains can also be hydroxylated or ethoxylated to prevent oxidation or to modify surface properties.

[0130] Examples of long chain carboxylic acid esters include, but are not limited to, glyceryl monostearate; glyceryl monopalmitate; a mixture of glyceryl monostearate and glyceryl monopalmitate; glyceryl monolinoleate; glyceryl monooleate; a mixture of glyceryl monopalmitate, glyceryl monostearate, glyceryl monooleate, and glyceryl monolinoleate; glyceryl monolinoleate; glyceryl monogadoleate; a mixture of glyceryl monopalmitate, glyceryl monostearate, glyceryl monooleate, glyceryl monolinoleate, and glyceryl monogadoleate; acetylated glycerides, such as distilled acetylated monoglyceride; propylene glycol monoesters, distilled monoglycerides, sodium stearoyl lactylate, and and silicon dioxide mixtures; d-alpha tocopherol polyethylene glycol 1000 succinate; mixtures of mono- and diglyceride esters, e.g., Atmul; calcium stearoyl lactylate; ethoxylated mono- and diglycerides; lactylated mono- and diglycerides; lactic acid esters of glycerol and propylene glycol; lactic acid esters of long-chain carboxylic acids; polyglycerol esters of long-chain carboxylic acids, propylene glycol mono- and diesters of long-chain carboxylic acids; sodium stearoyl lactylate; sorbitan monostearate; sorbitan monooleate; other sorbitan esters of long-chain carboxylic acids; succinylated monoglycerides; stearyl monoglyceryl citrate; stearyl heptanoate; cetyl esters of wax; stearyl octanoate; C8-C 30Cholesterol / labosterol esters; and sucrose long-chain carboxylic acid esters. Examples of self-emulsifying long-chain carboxylic acid esters include those from the groups of stearate, palmitate, ricinoleate, oleate, behenate, ricinolenate, myristate, laurate, caprylate, and caproate. In some embodiments, the oily phase may contain a combination of two or more long-chain carboxylic acids or their esters or alcohols. In some embodiments, medium-chain surfactants may be used, and the oily phase may be a combination of caprylic / capric triglyceride and caprylic acid C8 / C6. 10 It may contain a mixture of mono / diglycerides, glyceryl caprate or propylene glycol monocaprylate, or mixtures thereof.

[0131] Alcohols that can be used are exemplified by the hydroxyl forms of the carboxylic acids exemplified above and also by stearyl alcohol.

[0132] Surfactants or surfactants accumulate at hydrophilic / hydrophobic (water / oil) interfaces and cause surface They are long-chain molecules that can reduce surface tension. As a result, they can stabilize emulsions. In some embodiments, the surfactant can include surfactants from the Tween® (polyoxyethylene sorbate) family, surfactants from the Span® (sorbitan long-chain carboxylic acid ester) family, surfactants from the Pluronic® (ethylene or propylene oxide block copolymer) family, surfactants from the Labrasol®, Labrafil®, and Labrafac® families (each a polyglycosylated glyceride), sorbitan esters of oleic acid, stearic acid, lauric acid, or other long-chain carboxylic acids, poloxamers (polyethylene-polypropylene glycol block copolymers or Pluronic®), other sorbitan or sucrose long-chain carboxylic acid esters, mono- and diglycerides, PEG derivatives of caprylic / capric triglycerides, and mixtures thereof, or mixtures of two or more of the above. In some embodiments, the surfactant phase may comprise a mixture of polyoxyethylene (20) sorbitan monooleate (Tween 80®) and sorbitan monooleate (Span 80®).

[0133] The aqueous phase may optionally contain an active agent and a buffer suspended in water.

[0134] In some embodiments, such emulsions are coarse emulsions, microemulsions, and liquid crystal emulsions. In other embodiments, such emulsions may optionally contain penetration enhancers. In other embodiments, spray-dried dispersions or microparticles or nanoparticles containing encapsulated microemulsions, coarse emulsions, or liquid crystals may be used.

[0135] In some embodiments, the solid dosage forms described herein are non-intestinal time-delayed release dosage forms. As used herein, the term "non-intestinal time-delayed release" refers to delivery that allows drug release to occur at some generally predictable location in the intestinal tract more distally than would occur without the delayed-release modification. In some embodiments, the release delay is achieved by a coating that becomes permeable, dissolves, ruptures, and / or is no longer intact after a designed period of time. The coating of a time-delayed-release dosage form can have a certain time to erode after the drug is released (suitable coatings include polymer coatings such as HPMC and PEO), and has a core composed of a superdisintegrant(s) or osmotic agent(s) or a water-attracting agent such as a salt; a hydrophilic polymer, typically polyethylene oxide or alkylcellulose; a salt such as sodium chloride, magnesium chloride, sodium acetate, sodium citrate; or a sugar such as glucose, lactose, or sucrose; which draws water through a semipermeable membrane or a gas-generating agent such as citric acid and sodium bicarbonate, with or without an acid such as citric acid or one of the aforementioned acids incorporated into the dosage form. The semipermeable membrane is largely impermeable to the drug and osmotic agent, but is permeable to water, which penetrates at a nearly constant rate, enters the dosage form, increasing pressure, and ruptures after the swelling pressure exceeds a predetermined threshold over the desired delay time. The permeability of the drug through this membrane must be less than 1 / 10 of that of water; in one embodiment, the permeability of water must be less than 1 / 100. Alternatively, the membrane can be made porous by percolating an extractable aqueous solution over a desired delay time.

[0136] Osmotic dosage forms are described in U.S. Patent No. 3,760,984 to Theeuwes, and osmotically bursting dosage forms are described in U.S. Patent No. 3,952,741 to Baker. The osmotically bursting dosage forms can provide a single pulse of release or multiple pulses if different devices with different timing are used. The timing of the osmotic burst can be controlled by the choice of polymer and the thickness or area of ​​the semipermeable membrane surrounding the core containing both the drug and the osmotic agent or attractant. As the pressure of the dosage form increases with additional osmotic water, the membrane stretches to its rupture point, and the drug is then released. Alternatively, specific rupture areas can be created within the membrane by having thinner, weaker regions within the membrane or by adding weaker materials to areas of the coating membrane. Some preferred polymers with high water permeability that can be used as semipermeable membranes are cellulose acetate, cellulose acetate butyrate, cellulose nitrate, cross-linked polyvinyl alcohol, polyurethane, nylon 6, nylon 6.6, and aromatic nylon. Cellulose acetate is a particularly preferred polymer.

[0137] In another embodiment, the time-delay coating, which begins to delay drug release after the enteric coating is at least partially dissolved, is composed of a hydrophilic erodible polymer that gradually erodes over time upon contact with water. Examples of such polymers include cellulose polymers and their derivatives, such as, but not limited to, hydroxyalkylcellulose, hydroxymethylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, carboxymethylcellulose, and microcrystalline cellulose; polysaccharides and their derivatives; polyalkylene oxides, such as polyethylene oxide or polyethylene glycol, especially high-molecular-weight polyethylene glycol; chitosan; poly(vinyl alcohol); xanthan gum; maleic anhydride copolymers; poly(vinylpyrrolidone); starch and starch-based polymers; maltodextrin; poly(2-ethyl-2-oxazoline); poly(ethyleneimine); polyurethanes; hydrogels; cross-linked polyacrylic acid; and any combination or blend of the foregoing.

[0138] Preferred erodible hydrophilic polymers suitable for forming the erodible coating are poly(ethylene oxide), hydroxypropyl methylcellulose, and a combination of poly(ethylene oxide) and hydroxypropyl methylcellulose. Poly(ethylene oxide) is used herein to refer to a linear polymer of unsubstituted ethylene oxide. The molecular weight of the poly(ethylene oxide) polymer is about 10 5 Dalton ~ approx. 10 7 The preferred molecular weight range for poly(ethylene oxide) polymers is about 2×10 5 ~2×10 6Daltons and is commercially available from Dow Chemical Company (Midland, Mich.) called SENTRYR POLYOX™ Water-Soluble Resin, NF (National Formulary) Grade. When higher molecular weight polyethylene oxide is used, other hydrophilic agents, such as salts or sugars like glucose, sucrose, or lactose, which promote erosion or disintegration of the coating, are also included.

[0139] The time-delay dosage form may be a mechanical pill, such as an Enterion® capsule or a pH-sensitive capsule, that can release the drug after a preprogrammed time, or upon receiving a signal that can be transmitted, or once it has left the stomach.

[0140] The amount of a compound of the present disclosure in a formulation can vary within the full range used by those skilled in the art. Typically, the formulation will contain, on a weight percent (wt%) basis, about 0.01 to 99.99 wt% of the BTK inhibitor compound based on the total formulation, with the remainder being one or more suitable pharmaceutical excipients. In one embodiment, the compound is present at a level of about 1 to 80 wt%.

[0141] The foregoing disclosure has been described in some detail by way of illustration and example, for purposes of clarity and understanding. Accordingly, it should be understood that the foregoing description is illustrative and not limiting. The scope of the disclosure should, therefore, be determined without reference to the above description, but should instead be determined with reference to the following appended claims, along with the full scope of equivalents to which such claims are entitled. [Example]

[0142] The following examples are provided to illustrate certain disclosed embodiments and should not be construed as limiting the scope of the present disclosure in any way. In the examples discussed below, BTK inhibitors, as defined above, may also be referred to interchangeably as "compounds" or "drugs." [Example]

[0143] Dose-finding study of a BTK inhibitor in relapsing multiple sclerosis Example 1.1 - Introduction and Overview The objective of this Phase 2b study is to identify a safe and optimal dose of a BTK inhibitor. The proposed mechanism of action of BTK inhibitors is the inhibition of the formation of new active brain lesions in MS, as measured by MRI, predicting clinical efficacy in further trials in MS patients. This study will evaluate dose-response by measuring changes in the number of gadolinium (Gd)-enhanced T1 hyperintense lesions associated with inflammation. This radiographic outcome has been established as a reliable predictive biomarker for clinical efficacy in pivotal MS studies and has been demonstrated to be a predictive biomarker (reduced ARR) for clinical efficacy in Phase 3 registration trials (Sormani et al., Ann Neurol. 2009;65(3):268-75; Sormani et al., Neurology 2010;75(4):302-9). The dose-response for lesion suppression will be assessed using a two-stage statistical approach based on four dose levels and a short-term placebo period. The efficacy of BTK inhibitors compared with placebo will be assessed by evaluating the inhibition of new active brain lesion formation, as measured by MRI. The study will also characterize the safety and tolerability of BTK inhibitors in participants with RMS.

[0144] This study will employ a number of secondary outcome measures to gather additional data regarding the potential benefit of BTK inhibitors in neuroinflammation.

[0145] Exploratory evaluations, such as analysis of serum NfL levels and advanced imaging modalities, are expected to begin to build evidence for the activity of BTK inhibitors in neuroinflammation and neurodegeneration, as well as their potential impact on remyelination and tissue preservation. Figure 1 provides a graph of the overall study design, and Table 1 shows the schedule of activities (SOA).

[0146] [Table 1-1] [Table 1-2] [Table 1-3] [Table 1-4]

[0147] The treatment objectives and evaluation items are shown in Table 2.

[0148] [Table 2-1] [Table 2-2]

[0149] Measurement appropriateness Magnetic resonance imaging (MRI) markers of inflammatory activity in the brain are collected, as in most RMS clinical trials. The primary endpoint is the number of new Gd-enhancing T1-hyperintense lesions to assess the efficacy of BTK inhibitors. Because MS results in a leaky blood-brain barrier, accumulation of Gd-enhancing agent in brain tissue is associated with inflammatory activity in MS patients. This radiographic finding has been established as a reliable predictive biomarker for clinical efficacy in MS pivotal studies. Central review is used to identify new Gd-enhancing T1-hyperintense lesions not present on previous MRI. The total number of Gd-enhancing T1-hyperintense lesions is also used as a secondary endpoint to detect effects on existing inflammatory foci. The number of new and enlarging T2 lesions, a marker of inflammatory activity and brain tissue destruction in RMS, is also assessed by central review to collect additional data on the efficacy of BTK inhibitors. The total volume of T2 lesions (MS burden) and the number of T1-hypointense lesions (black holes) are also evaluated as supportive data for efficacy.

[0150] Magnetic resonance imaging (MRI) measurements include changes in brain volume, which are considered markers of CNS degeneration but are also associated with inflammatory events in RMS patients. Several MS drugs are known to have the ability to slow brain atrophy, which will be evaluated for potential signals.

[0151] Clinical relapse is the primary clinical manifestation of RMS. Relapse-related endpoints (ARR, the proportion of relapse-free participants) are widely used as endpoints in clinical trials. Due to the short duration of this study, we do not expect significant differences in the occurrence of relapses between dose groups, and relapses, although considered rare in PPMS, will be evaluated for their clinical significance and to gather additional efficacy data.

[0152] The EDSS is widely used to measure neurological impairment in clinical trials and routine settings (Kurtzke JF, Neurology. 1983;33(11):1444-52). Although no significant changes are expected during this study, it will be used as supportive data for efficacy.

[0153] Example 1.2 - Study Design Overall design: A phase 2b, randomized, double-blind, placebo-controlled, crossover, dose-ranging study to investigate the MRI efficacy and safety of a 12-week administration of a BTK inhibitor. People diagnosed with RMS are eligible for enrollment as long as they meet all inclusion criteria and no exclusion criteria.

[0154] All participants will be centrally assigned to one of eight arms (four dose groups in each of two cohorts, in equal proportions starting from the BTK inhibitor (Cohort 1) or placebo (Cohort 2) period) using an interactive voice / web response system (IVRS / IWRS) before crossover. Within each cohort, participants will be equally randomly assigned, in a blinded manner, to one of four BTK inhibitor doses of 5, 15, 30, or 60 mg once daily. Cohort 1: Participants will receive one of the BTK inhibitor doses for the first 12 weeks, then cross over to placebo for four weeks. Cohort 2: Participants will receive a placebo for the first four weeks, then cross over to one of the BTK inhibitor doses for 12 weeks.

[0155] Upon completion of the double-blind treatment period, participants will have the option to enroll in a long-term safety (LTS) follow-up study to evaluate the safety and tolerability of the BTK inhibitor.

[0156] Participant Number: Approximately 160 participants will be screened, with approximately 120 participants (based on a 25% screening failure rate) randomized to the study intervention, and approximately 105 evaluable participants (based on an approximately 15% dropout rate, providing at least 26 participants for each BTK inhibitor dose level) completing 12 weeks of BTK inhibitor treatment. Cohort 2 participants (n = 60) will receive a placebo for 4 weeks before crossing over to the BTK inhibitor, providing data that can be used to estimate dose-response curves and compare them to placebo. This approach is based on the assumption of a theoretically constant rate of new Gd-enhanced T1-hyperintense lesions over 12 weeks under placebo. This approach minimizes placebo exposure to study participants. A brief description of the handling of placebo data and analysis, as well as additional details including sample size determination, is provided in Example 1.14.

[0157] Intervention Groups and Duration: A 4-week placebo period will be introduced after or before 12 weeks of treatment with the BTK inhibitor (Cohort 1 and Cohort 2, respectively). Participants will be randomly assigned in equal proportions to each of eight groups (four dose groups within each of two cohorts). See Table 5 for a summary of study interventions.

[0158] Rationale: This study will be blinded to dose and administration sequence. While the focus is on dose finding, the need to minimize participant exposure to placebo will also be taken into account. Therefore, a dose range will be evaluated using four doses of 5, 15, 30, and 60 mg once daily. Furthermore, to minimize placebo exposure while maintaining investigator and participant blinding, each participant will be assigned to a 4-week placebo period occurring during either the first or last 4 weeks of the study. The 4-week placebo period will be introduced after or before 12 weeks of treatment with the BTK inhibitor (Cohort 1 and Cohort 2). Participants will be randomly assigned to one of eight arms (four equal-dose groups in each of the two cohorts). The placebo administration period will be limited to 4 weeks to minimize placebo exposure, and the crossover design will allow all participants to be treated with the BTK inhibitor. This crossover design, blinded to the administration intervention, allows for objective assessment of safety events and efficacy endpoints at study baseline. The 12-week treatment period of the BTK inhibitor will allow for detection of its effect in suppressing the formation of new Gd-enhancing T1 lesions. Recent information from an evobrutinib study in patients with RMS confirms that such significant reductions in lesions are observed as early as week 12 (Merck Press release - Merck KGaA, Darmstadt, Germany, Announces Positive Phase IIB Results for Evobrutinib in Relapsing Multiple Sclerosis. March 7, 2018).

[0159] Dose Regimen: The dose range selected for this study was informed by several assessments. First, allometric modeling intended to translate BTK occupancy by BTK inhibitors in preclinical animals (mice, rats, and dogs) predicts an optimal dose range of 1–100 mg once daily in humans. Second, phase 1 multiple-dose escalation measurements of BTK occupancy in human peripheral blood mononuclear cells (PBMCs) demonstrated an asymptotic approach to receptor saturation by BTK inhibitors at a once-daily dose of 7.5 mg, with a more rapid approach to saturation at higher doses. Finally, measurements of absolute CD19+ B cell counts demonstrate a dose-dependent increase of up to 80% compared to baseline (maximum observed on day 4). The BTK-induced increase in circulating B cells is predicted from the literature because BTK inhibition alters the expression of cell surface adhesion molecules, leading to egress from lymph nodes (Burger JA et al., Nat. 2014). Rev Cancer. 2018;18(3):148-67. The dose-response relationship for this effect is greatest at approximately 30 mg once daily. Taking all these factors into consideration, a dose range of 5 to 60 mg once daily is established to provide the best opportunity for achieving an optimal dose of BTK inhibitors in RMS.

[0160] End of Study Definition: A participant is considered to have completed the study if they have completed all phases of the study, including the final visit. End of study is defined as the date of the last visit of the last participant in the study.

[0161] Example 1.3 - Study Population Example 1.3A - Selection Criteria Participants could be included in the study only if all of the following criteria applied, as shown in Table 3:

[0162] [Table 3]

[0163] Example 1.3B - Exclusion Criteria Participants will be excluded from the study if any of the following criteria apply as shown in Table 4:

[0164] [Table 4-1] [Table 4-2] [Table 4-3] [Table 4-4] [Table 4-5]

[0165] Example 1.4 - Study Intervention A study intervention is defined as any investigational intervention(s), commercially available drug(s), placebo, or medical device(s) intended to be administered to study participants according to the study protocol.

[0166] Example 1.4A - Study Intervention(s) Implemented The study interventions included IMPs and non-investigational medicinal products (NIMPs). To maintain blinding, participants received a blinded BTK inhibitor and / or placebo once daily for 4 days. Details of the interventions are provided in Table 5.

[0167] [Table 5]

[0168] NIMP:T1 contrast-enhanced MRI sequences use a radiological, signal-enhancing, intravenous (IV) contrast medium. Use a locally approved medium.

[0169] Example 1.4A1 - Measures to Minimize Bias: Randomization and Blinding All participants will be centrally assigned to one of eight groups (four dose groups in two cohorts each) using the IVRS / IWRS in a ratio equivalent to the BTK inhibitor (Cohort 1) or placebo (Cohort 2) period before crossover. Participants cannot be randomly assigned to the study more than once. Prior to the start of the study, each site will be provided with the IVRS phone number and call direction, and / or IWRS login information and instructions. Study interventions will be distributed at study visits, as summarized in the implementation schedule (Table 1). Participants must not be redistributed any return interventions to the study.

[0170] Unblinding (IVRS / IWRS): The IVRS / IWRS is programmed with unblinding directives. In the event of an emergency, the investigator has sole responsibility for determining whether unblinding of a participant's treatment assignment is warranted. In making such a decision, the participant's safety must always be the primary consideration. If the investigator determines that unblinding is warranted, the investigator should make every effort to contact the sponsor before unblinding the participant's treatment assignment, unless this would delay the participant's emergency treatment. If a participant's treatment assignment is unblinded, the sponsor must be notified within 24 hours of unblinding. The date and reason for unblinding must be recorded in the source documents and case report form, if applicable.

[0171] This study will be blinded to dose and BTK inhibitor-placebo administration sequence. Tablets and placebos at different BTK inhibitor dose levels will be identical. Due to ethical considerations, the placebo period will be limited to 4 weeks, allowing for a more objective assessment of safety events at the beginning of the study period and adding objectivity to the assessment of clinical endpoints.

[0172] The investigator will not have access to the MRI data transmitted to assess participant safety, except for findings not related to MS. The site's radiology department is responsible for reporting any non-MS findings on the MRI to the investigator in a timely manner.

[0173] An Independent Data Monitoring Committee (IDMC) will be used to regularly monitor the safety of this trial. Unblinded data will be provided to the IDMC for review by an unblinded independent statistician. Study team members, investigators, and study participants will not have access to unblinded data.

[0174] Example 1.4B - Combination Therapy Any medications or vaccines (including over-the-counter or prescription drugs, vitamins, and / or herbal supplements) received by participants at the time of enrollment or during the study will be recorded along with the reason for use, dates of administration including start and end dates, and dosing information including dose and frequency.

[0175] The same data will be collected for all pre-treatment medications received in the 4 weeks prior to enrollment, as well as for all treatments considered clinically important for assessing pre-treatment MS and MS or comorbidities. Standard treatment of MS relapses with high-dose glucocorticoids is permitted. Local guidance for such treatment should be followed.

[0176] In addition to the drugs excluded in Table 4, the following medications are prohibited throughout the study: - Other MS disease-modifying treatments - Acetylsalicylic acid (aspirin) - Antiplatelet drugs (e.g., clopidogrel) - Anticoagulants, such as warfarin, heparin, low molecular weight heparin, dabigatran, and apixaban, edoxaban, and rivaroxaban.

[0177] Paracetamol / acetaminophen, at doses up to 3g / day, will be permitted at any time during the study. NSAIDs (excluding acetylsalicylic acid) may be given at recommended doses for short periods (maximum 5 days) during the course of the study if clinically necessary for the treatment of existing medical conditions or new events. The investigator will record the use of NSAIDs (and any other concomitant medications) on the CRF.

[0178] In vitro experiments and in silico modeling have demonstrated the potential for gastric acid reducing agents to reduce the plasma exposure of BTK inhibitors. The use of proton pump inhibitors (e.g., omeprazole) should be avoided. The use of antacids (e.g., calcium carbonate) should be staggered with respect to BTK inhibitor administration, with administration occurring more than 2 hours before or after BTK inhibitor administration. The use of H2 receptor antagonists (e.g., ranitidine) should also be staggered with respect to BTK inhibitor administration, with administration of the H2 receptor antagonist occurring more than 10 hours before or 2 hours after BTK inhibitor administration. See Table 13 for a list of exemplary drugs that may affect BTK inhibitor plasma exposure via gastric acid reduction.

[0179] Based on preclinical drug metabolism studies, BTK inhibitors are substrates of CYP3A and CYP2C8 isoenzymes; therefore, plasma exposure of BTK inhibitors may be altered when coadministered with other drugs that induce or inhibit CYP3A and / or CYP2C8 metabolism. No human studies have been performed to date; therefore, drugs that strongly inhibit or induce CYP3A or CYP2C8 should be avoided, if possible. See Table 12 for a list of drugs that should not be used.

[0180] Example 1.4C - Dose Modification No dose reductions are anticipated in this study. Participants, investigators, and the sponsor team will be blinded to the assigned dose level. AEs (Examples 1.4E and 1.8) may require treatment to be interrupted or, if deemed necessary, discontinue treatment. There may be a need.

[0181] Example 1.4D - Post-Study Intervention Participants who complete the 16-week visit of this study will be offered a separate open-label LTS study. Upon completion of the double-blind treatment period, participants already enrolled in the DRI study and all subsequent participants will be given the option to enroll in an LTS follow-up study to evaluate the safety and tolerability of the BTK inhibitor.

[0182] Example 1.4E - Discontinuation of Study Intervention and Participant Discontinuation / Withdrawal Withdrawal of consent for treatment should be distinguished from (additional) withdrawal of consent for follow-up visits and from withdrawal of consent for follow-up contact with non-participants (e.g., medical record checks). Institutions should document both cases of withdrawal of consent.

[0183] Example 1.4E1 - Discontinuation of Study Intervention Definitive Discontinuation: The IMP should be continued whenever possible. If the IMP is stopped, a determination should be made as to whether it can be temporarily discontinued, and definitive IMP discontinuation should be a last resort. Any IMP discontinuation will be fully documented in the eCRF. In either case, the participant should continue to participate in the study whenever possible. Definitive intervention discontinuation is the discontinuation of any intervention accompanied by a definitive investigator decision not to re-expose the participant to the IMP at any time during the study, regardless of reason, or a definitive decision by the study participant not to re-expose the participant to the IMP. The investigator should consider discontinuing the study intervention for liver function abnormalities if the participant meets one of the conditions outlined in Section 10.6 or if the investigator believes it is in the participant's best interest. If a clinically significant finding is noted on the EDG after enrollment (including, but not limited to, a change from baseline in the QT interval corrected using the Fridericia formula [QTcF]), the investigator or qualified designee will determine whether the participant can continue in the study and whether any changes in participant management are necessary. The decision to definitively discontinue the study intervention due to ECG changes should consider review of the ECG findings by a cardiologist. This review of the printed ECG will be documented at the time of recall. Any new clinically relevant findings will be reported as an adverse event.

[0184] Please refer to the SoA (Table 1) for data to be collected at the time of intervention discontinuation (end-of-treatment visit) and follow-up, as well as any additional assessments that need to be completed. Any abnormal laboratory values ​​or ECG parameters will be immediately rechecked for confirmation after 24 hours before a decision is made to definitively discontinue the intervention for the participant involved. If the intervention is discontinued early, an end-of-treatment visit will be conducted.

[0185] Participants will be followed according to the study procedures specified in this protocol until study completion or until resolution or stabilization of AEs tracked as specified in this protocol, whichever occurs later. If possible, and after definitive discontinuation of an intervention, participants will be evaluated using the IMP, including PK samples, typically using the planned procedures on the last treatment day. Details are provided in the SoA (Table 1). All cases of definitive intervention discontinuation, if deemed confirmed, will be recorded by the investigator on the appropriate page of the eCRF.

[0186] The investigator may consider temporary discontinuation due to suspected AEs and / or abnormal laboratory values ​​and / or ECG abnormalities. For all temporary discontinuations, the investigator will record the duration of the discontinuation on the appropriate page of the eCRF. An investigator-determined temporary discontinuation represents more than one dose not administered to the participant.

[0187] Resumption of IMP intervention will be determined by the investigator in his or her best medical judgment if the event persists. Once the patient is deemed unlikely to be responsible for the IMP(s) in question and meets the study inclusion criteria, the patient will be examined under close and appropriate clinical and / or laboratory monitoring (see Table 3).

[0188] Example 1.4E2 - Participant Discontinuation / Withdrawal Participants may withdraw from the study at any time at their own request or at the discretion of the investigator for safety, behavioral, compliance, or administrative reasons. - If a participant withdraws consent for future disclosure of information, Sponsor may retain and continue to use any data collected prior to such withdrawal of consent. - If a participant withdraws from the study, the participant may request that any samples collected and samples not tested be destroyed, and the investigator must document this in the site study records - See SoA (Table 1) for data to be collected at study discontinuation and follow-up, and further assessments to be completed - If participants no longer wish to take IMP, they will be encouraged to remain in the study.

[0189] Investigators should discuss key visits with participants and emphasize that the value of all study data is important to the public health value of the study.

[0190] Participants who withdraw from the study intervention must be explicitly asked to what extent potential AEs contributed to their decision, and any information about AEs elicited must be recorded.

[0191] All study withdrawals will be recorded by the investigator on the appropriate screening eCRF and in the participant's medical record, which should document, at a minimum, the date and reason for withdrawal.

[0192] Additionally, participants may withdraw consent to participate in the study. Withdrawal of consent for the intervention should be distinguished from withdrawal of consent for follow-up visits and for contact tracing of non-participants (e.g., medical record checks). Sites should document any withdrawal of consent.

[0193] Participants who withdraw from the study cannot be re-randomized (treated) in the study. Participant and kit numbers will not be reused.

[0194] Example 1.4E3 - Untraceable Participants are considered lost to follow-up if they frequently fail to return for scheduled visits and cannot be contacted by the study site.

[0195] If a participant does not return for a required study visit, the following actions will be taken: - Sites must contact participants about the importance of maintaining their assigned visit schedule, reschedule any missed visits as soon as possible, and confirm whether participants wish to participate in the study and / or whether they should continue in the study. Before a participant is considered lost to follow-up, the investigator or designee must make every effort to re-establish contact with the participant (three attempts by phone, if possible, and, if necessary, a certified letter to the participant's last known postal address or local equivalent). These contact attempts should be documented in the participant's medical record. - Participants who remain unreachable will be considered to have withdrawn from the study.

[0196] Example 1.5 - Study Assessments and Procedures Study procedures and their timing are summarized in the SoA (Table 1). Protocol waivers or exemptions will not be permitted. Procedures performed as part of a prospective participant's routine clinical management (e.g., blood count) and obtained before signing the informed consent form (ICF) may be utilized for screening or baseline purposes, provided the procedure meets protocol-specific criteria and occurs within the timeframe defined in the SoA (Table 1). If the study intervention is discontinued prematurely, an end-of-treatment visit will be conducted. Participants will return 2–4 weeks after the early end-of-treatment visit.

[0197] Example 1.6 - Efficacy Evaluation Example 1.6A - Magnetic Resonance Imaging Assessment Head (brain) MRI with or without Gd-enhanced contrast will be performed. Baseline MRI will be performed for all participants at all study sites and will consist of T2- and T1-weighted sequences with or without Gd-enhanced contrast. Due to potential safety risks associated with deposition of certain intravenous Gd-enhanced contrast agents in the brain, these agents should be used in accordance with local recommendations / regulations (Fischer JS et al., "The Multiple Sclerosis Functional Assessment"). Composite Measure (MSFC): an integrated "An approach to MS clinical outcome assessment," National MS Society Clinical Outcomes Assessment Task Force. Multi Scler. 1999;5(4):244-50.

[0198] At each visit, new T1Gd-enhancing hyperintense signals and new and enlarging T2 lesions will be assessed according to the SoA (Table 1), and the number of lesions will be compared with the number of lesions on the previous MRI scan. Unless otherwise specified, the baseline brain MRI will be used as the reference for assessing all MRI-derived endpoints. The baseline MRI will be the last MRI performed before the randomization visit. Standardized endpoint assessment will be ensured by central review of brain MRI scans. Blinded central review will be performed for all MRI-derived endpoints. Magnetic resonance imaging reviewers will be blinded to treatment assignment and other participant data. If spinal MS lesions are suspected by the investigator, a spine MRI may be required. Spine MRIs will be assessed regionally and reported on the eCRF. Spine MRIs will not be centrally reviewed.

[0199] Magnetic resonance imaging for exploratory efficacy assessment will use regional and whole-brain volumetric assessment, additional analysis of T1 and T2 images, and sequences such as magnetic transfer ratio and susceptibility-weighted imaging.

[0200] Example 1.6B - Multiple Sclerosis Relapse Unscheduled Evaluation Visit for Suspected Multiple Sclerosis Relapse: Participants are instructed to immediately report any new neurological symptoms and any recurrence or worsening of previous symptoms to the investigator. All reported symptoms will be collected. If a participant reports symptoms that may be consistent with a relapse, an unscheduled evaluation visit with the investigator will be scheduled as soon as possible (preferably within 7 days of symptom onset). The investigator will assess whether the reported episode is consistent with the definition of an MS relapse (see Example 1.6B). If the definition of an MS relapse is met, or if there is any doubt and relapse cannot be ruled out, an EDSS assessment should be performed. Unscheduled visit activities are detailed in the SoA (Table 1); if pathology other than MS is the cause, the SoA should be adapted, and additional testing or laboratory investigations are required for safety tracking and optimal treatment decisions.

[0201] Multiple Sclerosis Relapse: For the purposes of this study, an MS relapse is defined as an acute, new neurological symptom or worsening of a previous neurological symptom accompanied by objective changes on neurological examination. Symptoms must be: Caused by MS lasts for more than 24 hours, and Present at normal body temperature (i.e., without infection, excessive exercise, or excessively high ambient temperatures).

[0202] Note: Worsening or recurrence of symptoms and signs that can reasonably be attributed to a transient disturbance of conduction in previously demyelinated pathways due to a drug (which rarely occurs within hours after injection of interferon beta), an increase in core body temperature (Uhthoff phenomenon), or systemic cytokine release (such as occurs with the administration of alemtuzumab) is not considered a relapse.

[0203] Example 1.6C - Expanded Disability Status Scale Assessment The investigator will perform EDSS assessments (Kurtzke JF, Neurology. 1983;33(11):1444-52) as indicated in the SoA (Table 1).

[0204] The investigator will assess functional systems in the context of a standard neurological examination and report these assessments according to the EDSS reporting instructions, along with information on the participant's mobility, ambulation, and assistive device use. Standard EDSS assessments of neurological symptoms in each of the seven functional domains (visual, brainstem, pyramidal [motor], cerebellar [coordination], sensory, cerebral, and bowel / bladder) will be conducted. Gait will also be assessed as part of the assessment. Fatigue will be assessed optionally but does not contribute to the EDSS score.

[0205] Example 1.7 - Safety Assessment All safety assessment time points are listed in the SoA (Table 1). Definitions of AEs and SAEs can be found in Example 1.8B. For purposes of this protocol, MS relapses (Example 1.6B) are exempt from reporting as AEs unless they meet the criteria for an SAE. Non-severe MS relapses will be collected on a special eCRF page and analyzed as efficacy endpoints. Events that are concluded as not meeting the criteria for an MS relapse as a result of the MS relapse assessment (Example 1.6B) will be reported as adverse events.

[0206] Example 1.7A - Physical Examination A complete physical examination will include, at a minimum, an evaluation of the general appearance, head and neck, abdomen, lymph nodes, skin (bruises, petechiae, and other signs of bleeding), cardiovascular system, respiratory system, gastrointestinal system, musculoskeletal system, and nervous system. Height and weight will also be measured and recorded. A brief physical examination will include, at a minimum, an evaluation of the skin, lungs, cardiovascular system, and abdomen (liver and spleen). The investigator should pay particular attention to clinical signs associated with previous serious illness. Any new findings or worsening of previous findings should be reported as a new AE. The SoA (Table 1) provides a schedule for the physical examination.

[0207] Example 1.7B - Vital Signs Temperature, pulse rate, respiratory rate, and blood pressure will be assessed. The same temperature measurement method should be used throughout the study. Blood pressure and pulse measurements will be assessed in the seated or supine position using fully automated equipment. The same positional measurements should be used throughout the study for the same participant. Manual techniques will only be used if automated equipment is not available. Caffeinated beverages should be avoided before blood pressure measurements. Blood pressure and pulse measurements will be Participants should rest for at least 5 minutes beforehand in a quiet environment without distractions (e.g., television, cell phones). Vital signs (taken before blood sampling for clinical testing) consist of one pulse, three blood pressure measurements (record three consecutive blood pressure measurements with at least one minute between each measurement), and respiratory rate. The average of the three blood pressure measurements is recorded.

[0208] Example 1.7C - Electrocardiogram A single 12-lead EDG is obtained as outlined in the SOA (Table 1) using ECG equipment that automatically calculates heart rate and measures PR, QRS, QT, and QTc intervals. Each ECG examination should incorporate at least one longer rhythm monitoring recording. The ECG is reviewed by a cardiologist for confirmation of abnormalities and clinical evaluation. See Example 1.4E for QTc withdrawal criteria and the addition of QTc values ​​that may be necessary.

[0209] Example 1.7D - Laboratory Evaluation of Clinical Safety See Example 1.16 for a list of laboratory tests to be performed, as well as the timing and frequency of the SoA (Table 1). The investigator will review the laboratory reports, document this review, and record any clinically relevant changes that occur during the study in the AE section of the eCRF. Clinically significant abnormal laboratory findings are those unrelated to the underlying disease, unless the investigator determines that the findings are more severe than expected for the participant's condition. All laboratory tests with values ​​determined to be clinically significant abnormal during study participation or within 4 weeks after the last dose of study intervention should be repeated until they return to normal or baseline values ​​or are no longer clinically significant as determined by the investigator or medical monitor. If such values ​​do not return to normal / baseline within a time period deemed appropriate by the investigator, the etiology should be identified and the sponsor notified. As defined in Example 1.16, all protocol-required laboratory evaluations will be performed in accordance with the Clinical Laboratory Manual and the SoA (Table 1). If a laboratory value from a non-protocol-specific laboratory assessment performed in the institution's local laboratory requires a change in participant management or is deemed clinically significant by the investigator (e.g., SAE or AE or dose modification), the result will be recorded on the eCRF.

[0210] Example 1.7E - Suicide Risk Monitoring BTK inhibitors are considered CNS active; therefore, routine suicide risk monitoring is performed. The Columbia-Suicide Severity Rating Scale (C-SSRS) and a thorough clinical evaluation of complaints are used to assess suicide risk. Any clinically significant observations or events are reported as AEs. The C-SSRS is a tool used to assess participants' lifetime suicidality and track suicide-related events throughout the study. A structured interview prompts recollection of suicidal ideation, including the intensity of actual and potentially lethal thoughts, behaviors, and attempts. The investigator or a qualified designee will administer the scale at the time points indicated in the SoA (Table 1).

[0211] Example 1.8 - Adverse Events and Serious Adverse Events Example 1.8A - Adverse Events of Particular Interest An AESI is an AE (serious or non-serious) of scientific and medical concern specific to the sponsor's product or program that requires the investigator to continuously monitor and immediately notify the sponsor. Further investigation may be required to characterize and understand such events. Adverse events of particular interest can be added, modified, or removed during the study through protocol amendments. - Acute hypersensitivity / anaphylaxis - Pregnancy in female participants enrolled in the study and in female partners of male participants enrolled in the IMP / NIMP study; Pregnancy occurring in a female participant enrolled in a clinical study or in the female partner of a male participant enrolled in a clinical study. This will only qualify as an SAE if it meets one of the severity criteria (see Example 1.8B). If a female participant becomes pregnant, the IMP should be discontinued. Follow-up of pregnancies in female participants or female partners of male participants is mandatory until the outcome is determined (see Example 1.17). - Symptomatic overdose (serious or non-serious) involving IMP / NIMP: An overdose (accidental or intentional) involving IMP / NIMP was an event suspected by the investigator or spontaneously notified by the participant (not based on systematic pill counts), defined as at least a doubling of the dose within the intended treatment interval, adjusted according to the study drug. Of note, asymptomatic overdose was reported as a standard AE. - ALT elevation: Any elevation in ALT >3×ULN.

[0212] Other project-specific AESI ECG observation of a QTc of 500 ms or greater or a clinically significant arrhythmia (e.g., atrial fibrillation, atrial flutter) confirmed by a cardiologist, including serious infection, especially any opportunistic infection; serious hemorrhagic events, including symptomatic bleeding in a critical area or organ, such as central nervous system or intraocular hemorrhage, resulting in an SAE; thrombocytopenia, platelet count <100 × 10 9 / L.

[0213] AEs will be reported by the participant (or, where appropriate, the caregiver, proxy, or legal representative of the participant).

[0214] The investigator and any eligible designee will be responsible for detecting, documenting, and recording events that meet the definition of an AE or SAE and will remain responsible for tracking any serious AEs, AEs considered related to the study intervention or procedure, or AEs that cause the participant to discontinue the study intervention (see Example 1.4E).

[0215] A definition of AE or SAE can be found in Example 1.8B.

[0216] Example 1.8B - Adverse Events: Definitions and Procedures for Recording, Assessing, Tracking, and Reporting Adverse Event (AE): An AE is any untoward medical occurrence in a participant or clinical trial participant that is transiently associated with the use of the study intervention, whether or not it is causally related to the study intervention. Thus, an AE can be any untoward, unintended sign (including abnormal laboratory values), symptom, or disease (new or worsening) transiently associated with the use of the study intervention.

[0217] Events that meet the AE definition: Any abnormal clinical laboratory value (e.g., hematology, clinical chemistry, or urinalysis) or other safety assessment (e.g., ECG, radiological tests, vital sign measurements), including any deterioration from baseline, that in the investigator's medical and scientific judgment is considered clinically important (i.e., unrelated to progression of the underlying disease). - A worsening of a chronic or intermittent pre-existing condition, including an increase in the frequency and / or severity of the condition. - A new condition detected or diagnosed after administration of the study intervention was detected or diagnosed even though it may have been present before the start of the study. - Signs, symptoms, or clinical sequelae of a suspected drug-drug interaction. - Signs, symptoms, or clinical sequelae suspected of overdose of either the study intervention or concomitant medication.

[0218] Lack of efficacy or failure of the expected pharmacological action itself is reported as an AE or SAE and is captured in the efficacy evaluation.

[0219] Events that do not meet the AE definition: - Clinically significant abnormal laboratory findings or other abnormal safety assessments related to the underlying disease, unless the investigator determines that the participant's condition is more severe than expected. - The disease / disorder being studied or the expected progression, signs, or symptoms of the disease / disorder being studied, except for a disease / disorder that is more severe than expected for the participant's condition. - Medical or surgical procedure (e.g., endoscopy, appendectomy): The condition leading to the procedure is an AE. - Situations in which no undesirable medical events occurred (social and / or convenience hospitalization). - Estimated day-to-day fluctuations in pre-existing disease(s) or condition(s) present or detected at the start of the study that will not worsen

[0220] If an event is not an AE according to the definition above, it will not be an SAE even if the serious condition (e.g., hospitalization for signs / symptoms of the disease under study, death due to disease progression) is met.

[0221] Serious Adverse Events (SAEs): An SAE is any untoward medical event occurring at any dose: a) leading to death; b) life-threatening (the term "life-threatening" refers to an event / side effect in which the participant was at risk of death at the time of the event / side effect, not an event / side effect that, if more severe, could hypothetically have resulted in death); c) Requires hospitalization or results in an extension of an existing hospitalization (Generally, hospitalization means that the participant is admitted to a hospital or emergency room for observation and / or treatment that was not appropriate in a physician's office or outpatient clinic (usually including at least an overnight stay). A complication that occurs during hospitalization is an AE. An event is serious if the complication extends the hospital stay or meets any other serious criteria. If there is any doubt about whether a "hospitalization" occurred or was necessary, the AE should be considered serious. Hospitalization for elective treatment of a pre-existing condition that did not worsen from baseline is not considered an AE); d) resulting in permanent impairment / incapacity (the term impairment means a significant impairment of a person's ability to perform normal life functions). This definition is not intended to include relatively minor medically significant experiences such as uncomplicated headache, nausea, vomiting, diarrhea, flu, and accidental trauma (e.g., sprained ankle), which may interfere with or prevent daily life functioning but do not constitute a substantial interruption; e) have a congenital anomaly / birth defect; f) Other circumstances, such as significant medical events that are not immediately life-threatening and may not result in death or hospitalization, but may compromise the participant or require medical or surgical intervention to prevent any of the other outcomes listed in the definition above. These events should generally be considered serious. Examples of such events include invasive or malignant cancer, emergency department or intensive home treatment for allergic bronchospasm, blood disorders or seizures not resulting in hospitalization, and the development of drug dependence or abuse.

[0222] Recording and tracking AEs and / or SAEs Recording AEs and SAEs: If an AE / SAE occurs, record all relevant documentation. The investigator will review documents (e.g., hospital progress notes, laboratory reports, and diagnostic reports) and record all relevant AE / SAE information in the eCRF. It is not permitted for the investigator to send a copy of the participant's medical record to the sponsor's representative instead of completing the AE / SAE eCRF page. Medical records may need to be submitted as additional data for reporting SAEs and AESIs. In such cases, they will be anonymized by replacing the participant's name and initials with the participant number for this study. The sponsor may also request copies of medical records for specific cases. In this case, all participant identifiers, except for the participant number, will be recorded on the copies of the medical records before submitting them to the sponsor. The investigator will attempt to confirm the diagnosis of the event based on signs, symptoms, and / or other clinical information. Whenever possible, the diagnosis (not individual signs / symptoms) will be documented as the AE / SAE.

[0223] Intensity Rating: AEs / SAEs reported during the study will be rated for intensity and assigned to one of the following categories: - Mild: An event that is easily tolerated by the participant, causes minimal discomfort, and does not interfere with daily activities. - Moderate: An event that causes sufficient discomfort to interfere with daily life. - Severity: An event that interferes with daily life. AEs rated as severity should not be confused with SAEs. Severity is a category used to rate the intensity of an event; both AEs and SAEs can be rated as severe.

[0224] An event was defined as "serious" if it met at least one of the predefined outcomes, as described in the SAE definition, and not "serious" if it was assessed as severe.

[0225] Assessment of Causality: Investigators are obligated to assess the relationship between the study intervention and the occurrence of each AE / SAE. A "reasonable possibility" of relationship conveys that facts, evidence, and / or arguments exist that suggest a causal relationship, rather than that a relationship cannot be ruled out. Investigators will use clinical judgment to determine relevance. Alternative causes, such as underlying disease(s), concomitant therapies, and other risk factors, as well as the temporal relationship of the event to the administration of the study intervention, will be considered and investigated. Investigators will also refer to the Investigator Brochure (IB) and / or product information for marketed products in their assessment.

[0226] For each AE / SAE, the investigator will document in the medical record that they have reviewed the AE / SAE and made an assessment of causality. In some cases, an SAE may occur and the investigator may need to include minimal information in their initial report to the sponsor. However, it is very important that investigators always assess the causality of all events before initially sending SAE data to the sponsor. Investigators may change their opinion about causality in light of follow-up information and send a follow-up report of the SAE with an updated causality assessment. The causality assessment is one of the criteria used to determine regulatory reporting requirements.

[0227] Tracking of AEs and SAEs: The investigator is obligated to perform or arrange for additional measurements and / or evaluations, if medically indicated or requested by a representative of the monitoring team, to clarify as fully as possible the nature and / or causality of an AE or SAE. This may include additional clinical tests or investigations, histopathological examination, or consultation with other medical professionals. New or updated information will be recorded in the originally completed eCRF. If a participant dies during study participation or the approved follow-up period, the investigator will provide a copy of the autopsy findings, including histopathological examination, to the sponsor's representative. New or updated information will be recorded in the originally completed eCRF. The investigator will submit any updated SAE data to the sponsor within 24 hours of receiving the information.

[0228] Reporting SAEs: Report SAEs to the sponsor via the electronic data collection tool. The primary mechanism for reporting SAEs to the sponsor is the electronic data collection tool. If the electronic system is unavailable for more than 24 hours, sites will use a paper SAE data collection tool (see herein). Sites will enter SAE data into the electronic system when it becomes available. After the study is completed at a given site, the electronic data collection tool will be taken offline, preventing the entry of new data or changes to existing data. If a site receives a new SAE from a study participant or updated data on a previously reported SAE after taking the electronic data collection tool offline, the site can report this information to the sponsor via a paper SAE report (see Example 1.8C) or by telephone.

[0229] SAEs reported to the sponsor via a Case Report Form (CRF): Facsimile transmission of the case report form for the SAE is the preferred method of transmitting this information to the sponsor. In rare circumstances where a facsimile machine is not available, telephone notification is acceptable, along with a copy of the SAE data collection tool sent by overnight mail or courier. Initial notification by telephone does not replace the need for the investigator to complete and sign the SAE CRF page within the designated reporting period.

[0230] Example 1.8 Duration and Frequency for Collecting Information on C-AE and SAE All AEs (including SAEs) will be collected from the signing of the ICF until the EOT at the times specified in the SOA (Table 1). All SAEs and AESIs will be recorded and reported to the sponsor or designee within 24 hours as directed in Example 1.8B. The investigator will submit the latest SAE data to the sponsor within 24 hours of obtaining it. The investigator is under no obligation to actively seek the occurrence of AEs or SAEs after the end of study participation. However, if the investigator learns of any SAE, including death, at any time after the participant has discontinued the study and determines that the event is reasonably related to the study intervention or participation, he or she will promptly notify the sponsor. Methods for recording, evaluating, and assessing the causality of AEs and SAEs, as well as procedures for preparing and sending SAE reports, are described in Example 1.8B. Provide for 1.8B.

[0231] Example 1.8D-AE and SAE Detection Method Care should be taken to avoid bias when detecting AEs and / or SAEs. Open-ended and non-directed verbal questioning of participants is the preferred method for inquiring about the occurrence of AEs.

[0232] Example 1.8 Tracking E-AE and SAE After the first AE / SAE report, investigators are expected to actively follow each participant at subsequent visits / contacts. At the pre-specified study end date, all SAEs and non-serious AESIs (as defined in Example 1.8B) will be tracked until they have resolved, stabilized, or are otherwise accounted for, or the participant is lost to follow-up (as defined in Example 1.4E3).

[0233] Example 1.8F-Pregnant Details of all pregnancies in female participants and female partners of male participants will be collected after the start of the study intervention and until the final study visit. If a pregnancy is reported, the investigator must notify the sponsor within 24 hours of learning of the pregnancy and follow the procedures outlined in Example 1.17. Abnormal pregnancy outcomes (e.g., spontaneous abortion, fetal death, stillbirth, congenital anomaly, ectopic pregnancy) will be considered SAEs.

[0234] Example 1.8G - Cardiovascular and Mortality Events Observation of atrial fibrillation, atrial flutter, QTc >500 ms, or other clinically significant arrhythmias is an AESI in this study and is subject to expedited reporting to the sponsor. All other cardiovascular events will be reported according to standard safety reporting and safety oversight practices (including data review by the IDMC). Central review of ECGs will be conducted to ensure consistency of ECG assessment. Fatal events will be reported according to standard SAE reporting rules to clarify the cause of death and report the diagnosis of the fatal event as an SAE.

[0235] Example 1.8H - Multiple Sclerosis Relapse Report Multiple sclerosis relapses, as determined from the assessments described in Example 1.6B, as well as all efficacy endpoints, are exempt from being reported as AEs unless they meet the definition of an SAE. Hospitalization for MS relapse, if routinely performed at the institution (e.g., high-dose IV methylprednisolone), will not be considered a severity criterion for this study. Other neurological worsening symptoms that do not meet the definition of an MS relapse will be reported as an AE per general safety reporting rules.

[0236] Example 1.8I - Reporting of Safety Findings from Magnetic Resonance Imaging Magnetic resonance imaging scans should be reviewed locally for any non-MS pathology. In the case of such findings, the MRI report should be submitted to the investigator for appropriate safety reporting. If available, report the pathology diagnosis as the cause of such MRI findings or the findings themselves as AEs until a diagnosis is clarified. Multiple sclerosis findings on MRI do not need to be reported unless they are considered abnormal and therefore a definite safety finding.

[0237] Example 1.9 - Overdose Treatment The sponsor does not recommend any specific treatment for overdose. In the event of an overdose, the investigator should: - Immediately contact the medical monitor. Participants will be closely monitored for any AEs / SAEs and laboratory abnormalities until the study intervention is no longer systemically detectable and activity ceases (for at least 9 days). - If possible, obtain plasma samples for PK analysis within 1 day of the last dose of the study intervention, or later if requested by the medical monitor (determined on a case-by-case basis). - Document the amount of overdose on the eCRF, as well as the duration of the overdose.

[0238] Decisions regarding discontinuation or modification of medication will be made by the investigator in consultation with the medical monitor based on the participant's clinical assessment.

[0239] Example 1.10 - Pharmacokinetics Example 1.10A - Sampling Time Samples for BTK inhibitor PK analysis will be collected 1 hour (±0.5 hours) post-dose for all participants in both cohorts at visits at weeks 1, 4, 8, 12, and 16. Additional PK samples will be collected 3 hours (±0.5 hours) post-dose for all participants in both cohorts at visits at weeks 4 and 12. Data from the most recent meal prior to PK sampling will be provided on the eCRF.

[0240] Example 1.10B - Pharmacokinetics Handling Procedure A total of 2 mL of blood will be collected for each PK sample. The total PK blood volume per participant and the total number of samples collected in the study are presented in Table 6.

[0241] [Table 6]

[0242] Example 1.10C - Bioanalytical Methods BTK inhibitors are assayed by a validated LC / MS method.

[0243] Example 1.10D-PK parameters BTK inhibitor concentrations at selected time points after IMP ingestion are reported using descriptive statistics. max , t max Additional pharmacokinetic parameters such as , AUC, etc. were estimated using population pharmacokinetic methods.

[0244] Example 1.11 - Pharmacodynamics Example 1.11A - Sampling Time Venous blood samples collected for PBMCs will be used for lymphocyte subset analysis to measure BTK occupancy at baseline (pre-dose) and 1 hour (±0.5 hours) post-dose of the BTK inhibitor at the 12-week and 16-week visits (as part of a biomarker substudy).

[0245] Example 1.11B - Bioanalytical Methods for Pharmacodynamic Parameters Peripheral blood mononuclear cells are prepared from whole blood to determine BTK occupancy. Descriptive statistics are used to report BTK occupancy at selected time points.

[0246] Example 1.12 - Pharmacogenetics Participants who consent to participate in the genetic analysis component of this study will have a 6 mL blood sample drawn for DNA isolation. Participants who do not wish to participate in the genetic study will still be eligible to participate in the study. Samples will be collected to investigate allelic variants of drug-metabolizing enzymes and / or drug transporters as intrinsic factors associated with PK or PD variability of BTK inhibitors (Example 1.18).

[0247] If DNA extraction is unsuccessful, participants can be asked to provide a supplemental genetic blood sample.

[0248] Example 1.13 - Biomarkers Plasma and serum samples for biomarker studies will be collected from all participants in this study as specified in the SoA (Table 1). Samples from all participants will be tested for neurofilament light chain and chitinase-3-like 1 protein and immunoglobulin levels to assess their association with observed clinical responses. Blood samples for PBMC isolation will also be collected in all participants from sites selected for their ability to rapidly send them to a central laboratory for processing. Peripheral blood mononuclear cell samples will be used to assess BTK receptor occupancy, for selected lymphocyte subset analysis throughout the study, as well as other potential biomarkers (Example 1.11B). Approximately 50 mL of blood will be collected for all of these samples.

[0249] Example 1.14 - Statistical Considerations Example 1.14A - Statistical Hypothesis The primary objective of this study was to evaluate the dose-response relationship based on the primary endpoint (number of new Gd-enhancing T1-hyperintense lesions detected by brain MRI) at the end of 12 weeks of BTK inhibitor treatment. The null hypothesis was a flat no-dose-response curve for the primary endpoint, with a dose-response signal instead.

[0250] Example 1.14B - Sample Size Determination In this study, 120 participants will be equally randomly assigned to one of four BTK inhibitor doses in two cohorts (60 participants in each of Cohorts 1 and 2). Cohorts 1 and 2 represent different treatment sequences, and participants will each cross over to the BTK inhibitor or placebo in a blinded manner.

[0251] Sixty participants in Cohort 2 began with a 4-week placebo run-in, which served as placebo data for the primary endpoint analysis, based on the assumption that the monthly mean number of new Gd-enhanced T1-hyperintense lesions remained constant over the 12 weeks of placebo treatment. Assuming that 15% of participants failed the primary endpoint at the end of the 12-week BTK inhibitor treatment, 105 participants (26 per BTK inhibitor dose) were randomized to six pre-specified dose-response curves (two E) using the two-stage MCP-Mod. max The power to detect a maximum reduction of 85% was at least 83% for the following models: quadratic, linear, logistic, and exponential. This calculation assumes a within-subject correlation between 4-week placebo and 12-week BTK inhibitor measurements in Cohort 2 of -0.9 to 0.9, a placebo mean number of new Gd-enhanced T1-hyperintense lesions after 4 weeks of ≥1, and a dispersion parameter of 2. This power was calculated using the package DoseFinding from the Comprehensive R Archive Network (CRAN) (Bornkamp B, Pinheiro J, Bretz F. Package 'DoseFinding', January 4, 2018) and six candidate curves considered for dose-response modeling in a negative binomial regression framework.

[0252] Example 1.14C-Analysis Population For analytical purposes, the following populations are defined as shown in Table 7:

[0253] [Table 7]

[0254] Example 1.14D - Statistical Analysis Efficacy analysis Primary Analysis: The dose-response relationship between BTK inhibitors and the primary endpoint, the number of new Gd-enhancing T1-hyperintense lesions detected on brain MRI at the end of 12 weeks of BTK inhibitor treatment, was assessed in a modified intention-to-treat (mITT) population by a two-stage multiple comparisons method using a modeling technique (MCP-Mod). The first step of this approach tests the efficacy signal (compared to the null hypothesis of a flat no-dose-response curve) in a procedure that controls for type I error. To account for uncertainty in the dose-response shape, six candidate models were considered: two E max Model (ED 50 = 10 mg, ED 50 = 30 mg), linear, quadratic, logistic, and exponential models are considered to cover a variety of potential dose-response profiles. The second stage is dose estimation of the dose-response curve if an efficacy signal is established in the first stage.

[0255] A negative binomial regression model with covariates of baseline Gd-enhanced T1-hyperintense lesion counts, treatment, and cohort (Cohort 1 or Cohort 2) was used to evaluate the mean number of new Gd-enhanced T1-hyperintense lesions in each of the four dose groups at the end of 12 weeks of BTK inhibitor treatment and at the end of 4 weeks of placebo. The 4-week post-randomization placebo data from Cohort 2 (i.e., Week 4 data from Cohort 2) was used as the Week 12 placebo data, assuming that the rate of Gd-enhanced T1-hyperintense lesion formation remains constant if participants receive placebo over the 12 weeks. Participants in Cohort 2 contributed placebo data (Week 4) and data for the four BTK inhibitor doses (Week 16). Therefore, to account for potential correlation between measurements from the 4-week placebo period in Cohort 2 and the subsequent 12-week BTK inhibitor treatment period, a generalized estimating equation (GEE) approach was used to fit a negative binomial model that accounts for within-participant correlation via repeated-fit statements in SAS PROC GENMOD. A negative log-transformation of the mean lesion counts entered into the MCP-Mod method was performed. The null hypothesis of a flat dose-response curve (i.e., no dose-response relationship) at the end of 12 weeks of BTK inhibitor treatment for the primary endpoint was evaluated for each of the six candidate dose-response models, along with a two-sided contrast test controlling for family-wise error rates at alpha = 0.05. If significant results were obtained in Step 1, the generalized Akaike information criterion (AIC) was used to select the best-fit model from the six predefined candidate models.

[0256] The primary analysis will be based on the combined data from Cohorts 1 and 2 for each dose of BTK inhibitor (i.e., data on the number of new Gd-enhanced T1-hyperintense lesions at week 12 in Cohort 1 and week 16 in Cohort 2). Data from Cohort 1 and Cohort 2 will also be explored separately, as needed.

[0257] Secondary endpoint analysis: For the secondary endpoint of the number of Gd-enhanced T1-hyperintense lesions at the end of 12 weeks of BTK inhibitor treatment, we used a similar negative binomial model and MCP-Mod approach. Because it is reasonable to assume a constant lesion formation rate over 12 weeks under placebo for the total number of Gd-enhanced T1-hyperintense lesions, we used the week 4 data from Cohort 2 as the week 12 placebo data, taking into account within-participant correlations, and utilized the same approach as for the primary endpoint. Descriptive summary statistics over time are presented for each dose of the four BTK inhibitors.

[0258] Descriptive summary statistics for the number of new or enlarging T2 lesions over time (4, 8, 12, and 16 weeks) are provided for each of the four BTK inhibitor doses. Additionally, a similar MCP-Mod approach will be explored where it is considered reasonable to extrapolate week 4 data to week 12 placebo data from cohort 2.

[0259] The primary efficacy analysis will be based on the mITT population. For endpoints assessed by change from baseline, baseline values ​​will be defined as the last measurement collected on or before the randomization visit (Day 1) prior to the start of the first dose of study intervention.

[0260] Data from Cohorts 1 and 2 will be combined in the primary analysis (i.e., data on new Gd-enhanced T1 hyperintense lesion counts at week 12 for Cohort 1 and week 16 for Cohort 2). Descriptive statistics will be summarized over time (weeks 4, 8, 12, and 16) for each cohort, as appropriate. The Cohort 1 summary will include descriptive statistics for the 4-week placebo period after 12 weeks of BTK inhibitor treatment. Additional efficacy analyses will be described in the SAP.

[0261] [Table 8-1] [Table 8-2]

[0262] Safety analysis All safety analyses will be performed on the safety population. All safety summaries will be descriptive. No statistical significance tests will be performed on safety data. Safety endpoints are listed in Table 9.

[0263] Baseline values ​​are generally defined as the last value available before the first dose of the randomized study intervention. Safety data for the first 4 weeks after randomization (if participants in Cohort 2 receive placebo) will be summarized separately for BTK inhibitor and placebo. 4 weeks for Cohort 1 Safety data during the placebo period (i.e., 4 weeks) will be summarized separately and presented for the BTK inhibitor dose groups and overall. Safety data for BTK inhibitor treatment will be provided by dose group, time on BTK inhibitor, and overall.

[0264] For safety variables, the following observation periods will be defined and used to classify AEs, determine on-treatment PCSA values, and final treatment values ​​for clinical laboratory and vital sign parameters: The pre-treatment period is defined as the period from the signed ICF to the first administration of the randomized study intervention. For the purposes of defining "treatment-emergent," the on-treatment period is defined as the period from the first administration of the randomized study intervention to the final clinic visit. The treatment period is further defined as follows: - "Weeks 1-4" is defined as the period from the first dose of randomized study treatment to the administration of study treatment at week 4. In Cohort 1, this is 4 weeks of BTK inhibitor treatment, and in Cohort 2, this is 4 weeks of placebo treatment. - "BTK inhibitor treatment period" is defined as weeks 1-12 for Cohort 1 and weeks 4-16 for Cohort 2. Note: Participants in weeks 1-4 of Cohort 1 are also included in the 12-week BTK inhibitor treatment period. - The "placebo / post-BTK inhibitor dosing period" is defined as weeks 12-16 in Cohort 1. This is 12 weeks of BTK inhibitor treatment followed by 4 weeks of placebo treatment.

[0265] The analysis of AEs focused on treatment-emergent adverse events (TEAEs). A treatment-emergent AE is defined as an AE that developed, worsened, or became severe during treatment. A treatment-emergent adverse event (TEAE) is defined as an AE that developed, worsened, or became severe during treatment.

[0266] The following definitions apply to laboratory test, ECG, and vital sign results: - Potentially Clinically Significant Abnormal (PCSA) values ​​are defined as abnormal values ​​that the sponsor considers to be medically significant according to predefined criteria / thresholds based on literature review and are defined by the sponsor with respect to laboratory tests and vital signs. The potentially clinically significant abnormality criterion is determined by determining which participants had at least one PCSA during the treatment period, taking into account all assessments performed during the treatment period, including unscheduled or repeat assessments. The number of all such participants is the numerator for the on-treatment PCSA percentage.

[0267] [Table 9-1] [Table 9-2]

[0268] Individual PK concentrations will be summarized descriptively by visit. Additional data will be provided as described in Example 1.10D. PK parameters, as well as population PK and PD analyses, will be presented in separate documents.

[0269] Example 1.15 - Interim Analysis If deemed necessary due to slower-than-expected recruitment, an interim analysis will be conducted once at least 44 participants have completed 16 weeks of the study (12 weeks of BTK inhibitor treatment and 4 weeks of placebo). If the study is rapidly recruiting because the time to the final analysis is too short (i.e., less than 3–4 months) for an interim analysis to be worthwhile, an interim analysis will not be conducted. The purpose of the interim analysis is to explore efficacy signals and optimize the Phase 3 study design. The criteria for conducting an interim analysis (e.g., recruitment rate) and the decision on whether to conduct an interim analysis before finalizing the SAP are specified in advance in the business document. If an interim analysis is conducted, it will explore the reduction in the number of new Gd-enhanced T1 hyperintense lesions (in the 60 mg group only or in the 60 mg and 30 mg groups combined) compared to placebo (using placebo data from 4 weeks after randomization in Cohort 2), as well as the potential dose-response curve. The interim analysis will be conducted by an unblinded, independent statistician. Because the study will not be stopped early to make a claim of efficacy based on this potential exploratory interim analysis, no alpha adjustment will be made at the final analysis if an interim analysis is performed. The SAP will be described in more detail if there is one planned interim analysis.

[0270] The IDMC will be used to monitor the safety of the study.

[0271] Example 1.16 - Clinical Testing Details of the clinical tests are provided in Table 10. Additional tests will be performed at any time during the trial if deemed necessary by the investigator or required by local regulations.

[0272] [Table 10-1] [Table 10-2]

[0273] Example 1.17 - Contraception Guidance and Pregnancy Information Collection Women of childbearing potential (WOCBP): Women are considered fertile after menarche until after menopause, unless permanently infertile.

[0274] The following categories of women are not considered WOCBP: 1) Before menarche, 2) Premenopausal women who have undergone hysterectomy, bilateral salpingectomy, or bilateral oophorectomy; 3) Postmenopausal women. - Postmenopausal status is defined as the absence of menstruation for 12 months without other medical causes. In women not using hormonal contraception or hormone replacement therapy (HRT), elevated postmenopausal FSH concentrations can be used to confirm postmenopausal status. However, a single FSH measurement is insufficient if there is no amenorrhea for 12 months. - Women taking HRT and whose menopausal status is in doubt must use one of the non-estrogenic, highly effective methods of contraception if they wish to continue HRT during the study, otherwise they must discontinue HRT so that their postmenopausal status can be confirmed before study enrollment.

[0275] Contraception guidance · Male participants Male participants with a female partner of childbearing potential will be eligible to participate if they agree to choose one of the following options by three months after the final dose of the study intervention: · Agree to avoid and be abstinent from penile-vaginal intercourse as a normal and preferred lifestyle (long-term abstinence and sustained). Agree to use a male condom in combination with a partner-provided contraceptive method, as described in Table 11, with a failure rate of less than 1% per year when engaging in penile-vaginal intercourse with a woman of non-currently pregnant potential. Additionally, male participants must refrain from donating sperm for the duration of the study and for six months after the final dose of the study intervention. Male participants with pregnant or breastfeeding partners must agree to abstain from penile-vaginal intercourse or use a male condom during each penile penetration event for 3 months after their final dose. · Female participants Because definitive reproductive toxicity studies conducted with BTK inhibitors have not yet been conducted, investigators are instructed to take appropriate precautions during exposure of WOCBPs in this clinical trial. Female participants of childbearing potential are eligible to participate if they agree to consistently, accurately, and use dual contraception methods, including highly effective methods, as described in Table 9, from the time of enrollment through two months after the last study dose. Additionally, WOCBPs are required to refrain from egg donation during the study and for two months after the last dose of the study intervention.

[0276] [Table 11]

[0277] Pregnancy testing: WOCBP will be included only if a sensitive serum pregnancy test is negative after menstruation is confirmed. Additional pregnancy tests will be performed at monthly intervals during the intervention period and one month after the last dose of study intervention, as needed locally. Pregnancy tests will be performed if a menstrual cycle is missed or if pregnancy is suspected.

[0278] Pregnancy Information Collection: Pregnant Male Participant Partners - The investigator will attempt to collect pregnancy information for any male participant's female partner who becomes pregnant while the male participant is participating in this study. This only applies to male participants receiving a BTK inhibitor. After obtaining the required signed informed consent directly from the pregnant female partner, the investigator will record the pregnancy information on the appropriate form and submit it to the sponsor within 24 hours of learning of the partner's pregnancy. The female partner will also be followed to determine the outcome of the pregnancy. Information regarding the maternal and fetal status will be forwarded to the sponsor. Generally, the follow-up period is within 6-8 weeks from the expected date of delivery. Pregnancy terminations will be reported regardless of fetal status (presence or absence of anomalies) or indication for treatment.

[0279] Pregnant Female Participants - The investigator will collect pregnancy information for any female participant who becomes pregnant during participation in this study. Information will be recorded on the appropriate form and submitted to the sponsor within 24 hours of learning of the participant's pregnancy. Participants will be followed to determine the outcome of the pregnancy. The investigator will collect follow-up information for the participant and newborn and forward that information to the sponsor. Generally, follow-up is not required to extend beyond 6-8 weeks from the expected delivery date. Pregnancy termination will be reported regardless of fetal status (presence or absence of anomalies) or indication for treatment. All pregnancy complications or terminations will be reported as AEs or SAEs. Spontaneous abortions are always considered SAEs and will be reported as such. Any SAEs related to post-study pregnancies that the investigator determines are reasonably related to the study intervention will be reported to the sponsor. Investigators are under no obligation to proactively solicit this information from previous study participants, but may learn of SAEs through spontaneous reporting. Female subjects who become pregnant during study participation will discontinue the study intervention and withdraw from the study.

[0280] Example 1.18 - Genetics DNA Uses / Analysis Genetic variations may influence participants' response to study interventions, susceptibility to disease, and disease severity and progression. Variability in response to study interventions may result from genetic determinants affecting drug absorption, distribution, metabolism, and excretion; drug mechanism of action; disease etiology; and / or molecular subtype of the disease being treated. Therefore, where local regulations and IRB / IEC permit, blood samples for DNA analysis will be collected from consenting participants.

[0281] DNA samples are used for research interventions or studies related to MS and related diseases. They may also be used to develop tests / assays, including diagnostic tests, related to research interventions and indications. Genetic studies may consist of analysis of one or more candidate genes or genome-wide genetic markers (as appropriate). DNA samples are analyzed to investigate allelic variants of drug-metabolizing enzymes and / or drug transporters as intrinsic factors associated with PK or PD variability of BTK inhibitors. Additional analyses may be performed if they are hypothesized to be useful for further understanding clinical data. Samples may be analyzed as part of multiple research evaluations of genetic factors involved in response to BTK inhibitors or as part of this class of research intervention to understand the disease or related conditions.

[0282] Example 1.19 - List of Exemplary Prohibited Drugs The following drugs are strong inducers or inhibitors of CYP3A or CYP2C8 hepatic enzymes (as listed by the University of Washington Drug Interaction Database Program (www.druginteractioninfo.org)) and should not be administered during the study period because they may alter the kinetics of BTK inhibitors through interactions with P450-mediated metabolism. The list provided is not exhaustive and should be reviewed for any product information for any drugs intended for concomitant use. Please note that you should refer to

[0283] [Table 12]

[0284] [Table 13]

[0285] [Table 14-1] [Table 14-2] [Example]

[0286] Results of a dose-finding and safety study of a BTK inhibitor in relapsing multiple sclerosis The inventors provide herein the results of the dose-finding and safety study described in Example 1. The inventors determined the dose-response relationship of BTK inhibitors to reduce the number of new active brain lesions, including the number of new gadolinium (Gd)-enhancing T1-hyperintense lesions. The inventors also evaluated the efficacy of BTK inhibitors on disease activity, as assessed by imaging, by measuring the number of new or enlarging T2 lesions and the total number of Gd-enhancing T1-hyperintense lesions. The inventors also evaluated the safety and tolerability of the BTK inhibitor dose-response.

[0287] As described in Example 1, this study was a multicenter study involving a total of 40 active centers in Europe and North America. All participants were administered an interactive voice / Patients were centrally assigned to one of eight arms (four dose groups in each of two cohorts, in equal proportions starting from the BTK inhibitor (Cohort 1) or placebo (Cohort 2) period before crossover) using a web response system.

[0288] Within each cohort, participants were equally randomly assigned to receive one of four BTK inhibitor doses of 5, 15, 30, or 60 mg once daily in a blinded manner.

[0289] Cohort 1: Participants received one of the BTK inhibitor doses for the first 12 weeks, then crossed over to placebo for four weeks.

[0290] Cohort 2: Participants received a placebo for the first 4 weeks and then crossed over to one of the BTK inhibitor doses for 12 weeks.

[0291] All brain scans were reviewed and interpreted by one or more treatment-blinded, rater-blinded radiologists at an independent central center, thereby avoiding bias and ensuring standardized endpoint assessment.

[0292] Diagnosis and inclusion criteria: Participants were aged 18–55 years, diagnosed with RMS according to the 2017 revision of the McDonald diagnostic criteria, and had at least one documented relapse within the previous year, or two or more documented relapses within the past two years, or one or more documented active Gd-enhancing brain lesions on MRI scans in the six months prior to screening.

[0293] Primary and secondary endpoints Efficacy: Primary: Number of new gadolinium (Gd)-enhancing T1 hyperintense lesions at the end of 12 weeks of BTK inhibitor treatment, as detected by brain MRI.

[0294] Secondary: · Number of new or enlarging T2 lesions at the end of 12 weeks of BTK inhibitor treatment; Number of Gd-enhanced T1 hyperintense lesions at the end of 12 weeks of BTK inhibitor treatment

[0295] Safety: Adverse events (AEs), serious adverse events (SAEs), and potentially clinically significant abnormalities in laboratory tests, electrocardiograms (ECGs), or vital signs during the study period

[0296] Statistical methods: Primary endpoint analysis: The primary analysis was based on the pooled data from Cohorts 1 and 2 for each dose of BTK inhibitor (i.e., data on the number of new Gd-enhanced T1 hyperintense lesions at week 12 in Cohort 1 and week 16 in Cohort 2).

[0297] The dose-response relationship between BTK inhibitors and the primary endpoint, the number of new Gd-enhancing T1-hyperintense lesions as detected on brain MRI after 12 weeks of BTK inhibitor treatment, was assessed in the modified intent-to-treat (mITT) population by a two-stage multiple comparison procedure using a modeling technique (MCP-Mod). The first stage of this procedure tested for efficacy signals (compared to the null hypothesis of a flat no-dose-response curve) in a procedure that controlled for type 1 error. To account for uncertainty in the dose-response shape, six candidate models were evaluated, including E2 max Model (ED 50 = 10 mg, ED 50 A variety of dose-response models were considered, including linear, quadratic, logistic, and exponential models (=30 mg), covering potential dose-response profiles. In the second phase, efficacy signals were established in the first phase, and therefore dose-response models were considered. Response curves were estimated.

[0298] In MCP-Mod step 1, a negative binomial regression model with baseline Gd-enhanced T1-hyperintense lesion activity (presence / absence) and treatment covariates was used to assess the mean number of new Gd-enhanced T1-hyperintense lesions in each of the four dose groups at the end of 12 weeks of BTK inhibitor treatment and after 4 weeks of placebo. MRI assessments were excluded from the analysis if participants had received systemic corticosteroids within 30 days prior to the MRI assessment date. The 4-week postrandomization placebo data from Cohort 2 (i.e., week 4 data from Cohort 2) were used as the week 12 placebo data in the analysis, assuming a constant rate of Gd-enhanced T1-hyperintense lesion formation if participants had received placebo over the 12 weeks. Participants in Cohort 2 contributed placebo data (week 4) and data for all four BTK inhibitor doses (week 16). The 4-week placebo runout data from Cohort 1 were not included in the analysis. Therefore, to account for potential correlation between measurements from the 4-week placebo period in Cohort 2 and the subsequent 12-week BTK inhibitor treatment period, a generalized estimating equation (GEE) approach was used to fit a negative binomial model accounting for within-participant correlation using the "REPEATED" statement in SAS PROC GENMOD. A negative logarithmic transformation of the mean lesion counts was entered into the MCP-Mod method. The null hypothesis of a flat dose-response curve (i.e., no dose-response relationship) at the end of 12 weeks of BTK inhibitor treatment for the primary endpoint was jointly assessed for each of the six candidate dose-response models using a control test controlling the family-wise error rate with a two-sided alpha of 0.05. Test statistics and adjusted p-values ​​were provided for all six candidate models.

[0299] In MCP-Mod step 2, all candidate models with an adjusted p-value <0.05 in step 1 were fitted. The generalized Akaike information criterion (AIC) and model parameters were provided. The best-fit model was selected as the model with the smallest generalized AIC. The dose for the phase 3 program was then estimated from the final selected model.

[0300] Additionally, based on the negative binomial regression model described above, the relative reduction in the mean number of new Gd-enhanced T1-hyperintense lesions compared to the placebo group and the corresponding 95% confidence intervals (CIs) were provided for each of the four BTK inhibitor dose groups.

[0301] We also provided descriptive statistics for the observed number of new Gd-enhancing T1-hyperintense lesions over time for the four BTK inhibitor dose groups (Weeks 4 / 8, 8 / 12, and 12 / 16 for Cohort 1 / Cohort 2) and the placebo group (Week 4 for Cohort 2).

[0302] Secondary endpoint analysis: For each secondary endpoint, a similar negative binomial model and MCP-Mod approach were used. Because it is reasonable to assume that the rate of lesion formation remains constant over 12 weeks under placebo treatment, we used the same approach as for the primary endpoint, i.e., cohort 2 week 4 data was used as placebo data at week 12, while accounting for within-participant correlations. Descriptive summary statistics over time were provided for each of the four BTK inhibitor dose groups.

[0303] All safety summaries were descriptive and were conducted in the safety population. Safety data for the first 4 weeks after randomization (when Cohort 2 participants received placebo) are summarized by BTK inhibitor and placebo treatment. Safety data during the BTK inhibitor treatment period (from the first dose of BTK inhibitor) were summarized by BTK inhibitor dose group and overall.

[0304] Population characteristics: 130 patients were randomly assigned. Baseline participant demographics were generally well balanced across the eight treatment arms (two cohorts of four treatment arms each). The median age of participants was 36.3 years (range: 19-55 years). The majority of participants were women (91; 70.0%). Of note, 119 of 130 participants (91.5%) were white.

[0305] A total of 130 participants were diagnosed with RMS (128 with relapsing RMS and 2 with secondary progressive MS), with a mean EDSS score of 2.50, a median time from initial diagnosis of 3.5 years, and a median time from first MS symptom of 4.9 years. 127 participants (97.7%) had at least one relapse in the year before screening, and 61 participants (46.9%) had highly active disease (HAD) confirmed by one relapse in the year before screening, one or more Gd-enhancing lesions on MRI within 6 months before screening, or nine or more T2 lesions at baseline or two or more relapses in the year before screening.

[0306] 129 of 130 patients completed the treatment period. One participant permanently discontinued treatment after week 12 due to refusal to meet contraceptive needs.

[0307] Table 15 provides detailed patient demographics. Tables 16A-16B summarize patient demographics and baseline characteristics. Table 17 provides details on exposure duration for each group, and Table 18 provides details on exposure by dose for each group.

[0308] Efficacy Results: Primary Efficacy Endpoint: The study met its primary objective and demonstrated a dose-response relationship for the BTK inhibitor as evidenced by a reduction in the number of new active Gd-enhancing T1-hyperintense brain lesions detected by brain MRI after 12 weeks of treatment.

[0309] Table 19 provides a summary of the relative reduction in new Gd-enhancing T1-hyperintense brain lesions vs. placebo after 12 weeks of treatment, as also shown in Figure 2A. Table 20 shows the MCP-Mod of new Gd-enhancing T1-hyperintense brain lesions after 12 weeks of treatment. MCP-Mod assessment was performed as described above in the Statistical Methods section.

[0310] Figure 2B shows MCP-Mod step 2, assessing the estimated dose-response curve for novel Gd-enhanced T1-hyperintense brain lesions. To account for potential correlations in Cohort 2 between measurements during the run-in and treatment periods, a generalized estimating equations approach (GEE) was used to fit a model accounting for within-subject correlations. The mean lesion counts at week 12 of BTK inhibitor treatment and week 4 of placebo were estimated from a negative binomial regression model to account for potential correlations between measurements during the 4-week placebo period and the subsequent 12-week BTK inhibitor treatment period in Cohort 2. MRI assessments were excluded from the analysis if participants had received systemic corticosteroids within 30 days prior to the MRI assessment date.

[0311] As shown in Figure 2A and Table 19, the observed mean (SD) numbers of new Gd-enhanced T1-hyperintense lesions at 12 weeks posttreatment were 1.03 (2.50) in the placebo group, 1.39 (3.20) in the BTK inhibitor 5 mg group, 0.77 (1.48) in the BTK inhibitor 15 mg group, 0.76 (3.31) in the BTK inhibitor 30 mg group, and 0.13 (0.43) in the BTK inhibitor 60 mg group. A negative binomial regression model adjusting for baseline Gd-enhanced T1-hyperintense lesion activity showed that the relative reduction in lesions at week 12 compared with placebo was statistically significant in the 60 mg dose group (85.02%; 95% CI [28.02%, 96.88%]; nominal p = 0.0178) but not in the lower dose groups. Of note, 90.3% of participants in the BTK inhibitor 60 mg dose group had evaluable MRI data. 0% (28 of 31) had no new Gd-enhancing T1 hyperintense lesions at the end of 12 weeks of treatment. An exponential model was selected as the best-fit dose-response curve and is shown in Figure 2B.

[0312] Key secondary efficacy endpoints: Table 21 provides a summary of the relative reduction in the number of new or enlarging T2 lesions after 12 weeks of treatment versus placebo, as also shown in Figure 3A. Table 22 shows the MCP-Mod for the number of new and enlarging T2 lesions after 12 weeks of treatment, as also shown in Figure 3B. Table 23 provides a summary of the relative reduction in the number of total T2 Gd-enhanced T1 hyperintense lesions after 12 weeks of treatment versus placebo. Table 24 shows the MCP-Mod for the total number of Gd-enhanced T1 hyperintense lesions after 12 weeks of treatment. 12 weeks of treatment represents week 12 for Cohort 1 with BTK inhibitor treatment, week 16 for Cohort 2 with BTK inhibitor treatment, and week 4 for Cohort 2 placebo. MRI assessments were excluded from analysis if participants were receiving systemic corticosteroids within 30 days of the MRI assessment date. MCP-Mod 1 did not claim significance.

[0313] As shown in Table 21 and Figure 3A, for the secondary endpoint of number of new and enlarging T2 lesions at the end of 12 weeks of BTK inhibitor treatment, the observed mean (SD) values ​​were 2.12 (5.16) in the placebo group, 1.90 (3.97) in the BTK inhibitor 5 mg group, 1.32 (1.83) in the BTK inhibitor 15 mg group, 1.30 (4.90) in the BTK inhibitor 30 mg group, and 0.23 (0.62) in the BTK inhibitor 60 mg group. The 60 mg group, unlike the other dose groups, demonstrated a statistically significant adjusted relative reduction in the number of new and enlarging T2 lesions compared to the placebo group (89.34%; 95% CI: [68.39%, 96.41%]; nominal p = 0.0001). Of participants in the BTK inhibitor 60 mg group with evaluable MRI data, 87.1% (27 of 31) were free of new and enlarging T2 lesions at the end of 12 weeks of treatment. A linear model was selected as the best-fit dose-response curve, which is shown in Figure 3B.

[0314] As shown in Table 23, for the secondary endpoint of number of Gd-enhanced T1-hyperintense lesions at 12 weeks of BTK inhibitor treatment, the observed mean (SD) values ​​were 1.36 (3.52) for the placebo group, 1.77 (4.10) for the 5 mg BTK inhibitor group, 0.87 (1.59) for the 15 mg BTK inhibitor group, 1.18 (4.87) for the 30 mg BTK inhibitor group, and 0.29 (0.86) for the 60 mg BTK inhibitor group. No statistically significant relative reduction in the number of lesions was observed with any of the BTK inhibitor doses tested compared with placebo. However, a higher proportion of participants in the 60 mg BTK inhibitor group (87.1%, 27 of 31) with evaluable MRI data were free of Gd-enhanced T1-hyperintense lesions at the end of 12 weeks of treatment compared with the placebo group (74.6%, 44 of 59).

[0315] Safety Results: The BTK inhibitor was well tolerated over the 12 weeks of treatment. Table 25A provides a summary of treatment-emergent adverse events during the weeks 1-4 period. Table 25B provides a summary of adverse events during the 4-week period. Table 25C provides a summary of adverse events during the 12-week period. Table 26 provides a summary of treatment-emergent adverse events during the BTK inhibitor treatment period. Table 27 provides a summary of treatment-emergent serious adverse events during the BTK inhibitor treatment period. Table 28 provides a summary of treatment-emergent adverse events of particular interest during the weeks 1-4 period. Table 29 provides a summary of treatment-emergent adverse events of particular interest during the BTK inhibitor treatment period. Table 30 provides a summary of adverse events that occurred in more than two patients on medication during the 12 weeks of treatment.

[0316] As shown in Table 17, the mean duration of BTK inhibitor exposure was 82.1, 81.5, 83.6, and 82.1 days in the 5, 15, 30, and 60 mg BTK inhibitor groups, respectively, and 28.0 days in the placebo group over the first 16 weeks. The mean exposure time to the BTK inhibitor across dosing groups was 82 days.

[0317] No deaths were reported in this study. One treatment-emergent SAE was reported in a participant in Cohort 1 treated with 60 mg of the BTK inhibitor. The event, an MS relapse, occurred in a 32-year-old female participant approximately 8 weeks after initiating treatment with the BTK inhibitor. The participant had difficulty speaking and was unable to ingest liquids without drooling. No swallowing problems were reported in the hospital records. She was admitted 2 days after symptom onset to rule out the possibility of a stroke. The event was assessed as severe by the investigator. MS relapse was confirmed, treatment continued without interruption, and the participant completed the study and was successfully enrolled in a long-term extension study.

[0318] All reported TEAEs were mild or moderate in intensity, except for one severe TEAE reported in the 60 mg BTK inhibitor group, the SAE of severe MS relapse described above.

[0319] No TEAEs led to permanent treatment discontinuation. The percentages of participants experiencing TEAEs during weeks 1-4 were 34.8%, 31.3%, 18.8%, 12.5%, and 31.3% in the placebo group and the 5, 15, 30, and 60 mg groups, respectively. The percentages of participants with TEAEs were similar across the four BTK inhibitor groups throughout the treatment period (57.6%, 53.1%, 54.5%, and 50.0% in the 5, 15, 30, and 60 mg BTK inhibitor groups, respectively).

[0320] The most frequently reported TEAEs (>3 total events) by the primary SOC during weeks 1–4 (placebo-controlled) were headache (4 events in the placebo group, 3 events in the BTK inhibitor 5 mg group, 2 events in the BTK inhibitor 15 mg group, and 1 event in the BTK inhibitor 60 mg group), upper respiratory tract infection (1 event in each treatment group, including placebo), and nausea (1 event in the placebo group, 2 events in the BTK inhibitor 5 mg group, and 1 event in the BTK inhibitor 30 mg group).

[0321] As shown in Table 30, the most frequently reported TEAEs by the primary SOC during the 12-week BTK inhibitor treatment period were headache (1 event in the BTK inhibitor 5 mg group, 3 events in the BTK inhibitor 15 mg group, 1 event in the BTK inhibitor 30 mg group, and 4 events in the BTK inhibitor 60 mg group), upper respiratory tract infection (2 events in the BTK inhibitor 5 mg group, 2 events in the BTK inhibitor 15 mg group, 1 event in the BTK inhibitor 30 mg group, and 1 event in the BTK inhibitor 60 mg group), nasopharyngitis (1 event in the BTK inhibitor 5 mg group, 1 event in the BTK inhibitor 30 mg group, and 3 events in the BTK inhibitor 60 mg group), back pain (1 event in the BTK inhibitor 5 mg group, 1 event in the BTK inhibitor 15 mg group, and 2 events in the BTK inhibitor 30 mg group), and peripheral edema (2 events in the BTK inhibitor 5 mg group and 2 events in the BTK inhibitor 60 mg group). , gastroenteritis (one case in the BTK inhibitor 5 mg group and two cases in the BTK inhibitor 60 mg group), respiratory tract infection (one case in the BTK inhibitor 15 mg group, one case in the BTK inhibitor 30 mg group, and one case in the BTK inhibitor 60 mg group), muscle spasms (one case in the BTK inhibitor 30 mg group and two cases in the BTK inhibitor 60 mg group), oropharyngeal pain (one case in the BTK inhibitor 5 mg group, one case in the BTK inhibitor 30 mg group, and one case in the BTK inhibitor 60 mg group), alopecia (one case in the BTK inhibitor 5 mg group, one case in the BTK inhibitor 15 mg group, and one case in the BTK inhibitor 60 mg group), increased alanine aminotransferase (one case in the BTK inhibitor 5 mg group, one case in the BTK inhibitor 30 mg group, and one case in the BTK inhibitor 60 mg group), and accidental overdose (three cases in the BTK inhibitor 60 mg group). Each of the three participants who experienced alopecia had a medical history that could have contributed to this event.

[0322] As shown in Table 29, two AESIs (alanine aminotransferase increases >3 × ULN) were reported in this study, one during 30 mg BTK inhibitor treatment and one during 60 mg BTK inhibitor treatment. In both cases, the liver enzyme elevations were transient, IMP was not discontinued, liver enzymes returned to normal, and participants completed the study. The investigators assessed the events in the participant receiving 60 mg as mild and complicated by reported pruritus, while the other participant's events were moderate and uncomplicated. One participant (60 mg group) had ALT levels above the ULN (34 U / L) at screening and randomization (48 U / L and 50 U / L, respectively) and reached >3×ULN levels (107 U / L) at the week 4 visit. ALT gradually decreased, reaching normal levels (28 U / L) by week 12. The other participant (30 mg group) had an ALT level >3×ULN (105 U / L) at the week 8 visit, and the level returned to normal (32 U / L) within 4 days. Both participants were female.

[0323] PCSA-related changes in vital signs (systolic blood pressure, weight), labs (hemoglobin ≤115 g / L [men]; ≤95 g / L [women], hematocrit ≤0.37 v / v [men]; ≤0.32 v / v [women], ALT >3 × ULN, bilirubin >1.5 × ULN), and ECG (e.g., heart rate <50 beats / min, heart rate >90 beats / min, heart rate >100 beats / min, PR >200 msec, QRS >110 msec, QTc Bazett >450 msec, QTc Fridericia >450 msec) were reported across treatment groups and were not dose-related.

[0324] conclusion This study met its primary objective and demonstrated a dose-response relationship for BTK inhibitors, as revealed by a reduction in the number of new active Gd-enhancing T1-hyperintense brain lesions detected by brain MRI after 12 weeks of treatment. The difference was statistically significant in the 60 mg BTK inhibitor group compared with placebo, while the differences in the other BTK inhibitor treatment groups were not statistically significant compared with placebo. Consistently, efficacy in disease activity was also demonstrated by a reduction in the number of new and enlarging T2-hyperintense lesions detected by brain MRI after 12 weeks of 60 mg BTK inhibitor treatment, but not with the 5, 15, and 30 mg BTK inhibitor doses. However, the data did not demonstrate a statistically significant reduction in the total number of Gd-enhancing T1-hyperintense lesions after 12 weeks of BTK inhibitor treatment, regardless of the dose tested.

[0325] No direct correlation was found between the dose of BTK inhibitor administered and the number of TEAEs. The most common events (preferred terms) observed in participants in the BTK inhibitor treatment arm were headache, upper respiratory tract infection, and nasopharyngitis. The number of AESIs and PCSAs observed across dose groups was low. No new risks were identified in this study.

[0326] These findings indicate that BTK inhibitor treatment within a range of doses was well tolerated and effective in reducing MRI lesions in patients with relapsing MS.

[0327] [Table 15-1] [Table 15-2]

[0328] [Table 16-1] [Table 16-2]

[0329] [Table 17]

[0330] [Table 18]

[0331] [Table 19]

[0332] [Table 20]

[0333] Table 21

[0334] Table 22

[0335] Table 23

[0336] Table 24-1 Table 24-2

[0337] Table 25

[0338] Table 26

[0339] Table 27

[0340] Table 28

[0341] Table 29

[0342] Table 30

[0343] [Table 31]

[0344] [Table 32]

[0345] [Table 33] [Example]

[0346] The role of BTK was investigated using primary mouse microglial cells.

[0347] Preparation of primary mouse microglial cells Postnatal mouse brain collection Primary cultures of microglia were obtained from the brains of C57BL / 6 postnatal mice. Mice were anesthetized with CO2 and subsequently decapitated with sterile scissors. Brains were harvested and the meninges were removed. Brains were placed in ice-cold complete DMEM / F12 medium and kept on ice until processing.

[0348] Brain tissue processing Brains were removed from the medium by filtering through a 40 μm cell strainer. Brains were transferred to warm (37°C) 0.25% trypsin (2 mL / brain) and incubated at 37°C with rotation for 30 minutes. The dissociation reaction was stopped with an equal volume of complete DMEM / F12. The tissue was centrifuged at 300 × g for 7 minutes. The tissue pellet was washed three times with complete DMEM / F12 and centrifuged at 300 × g for 7 minutes. After the final wash, the tissue pellet was resuspended in complete DMEM / F12 (approximately 1 mL / brain), triturated until no clumps were visible, and then filtered through a 70 μm cell strainer. Cells were distributed into T150 tissue culture flasks (1 flask / mouse) with complete DMEM / F12 to a final volume of up to 35 mL per flask. Cells were given complete medium changes every 3–4 days until isolation, beginning on day 5.

[0349] Isolation of microglial cells After 11–14 days in culture, cells were washed with PBS, treated with 5 mL of 0.25% trypsin, and disrupted in 10 mL of complete DMEM / F12. The single-cell suspension was filtered through a 70 μm cell strainer, centrifuged at 200 × g for 6 min, and 1 × 10 8Cells were resuspended in isolation medium at 1000 cells / mL. Up to 4 mL of cells were transferred to a 14 mL polystyrene FACS tube. 50 μl / mL of rat serum was added to each sample, and the samples were incubated for 5 minutes. Selection cocktails were prepared by mixing equal volumes of cocktails A and B (for a 1 mL sample, 25 μl of cocktail A was mixed with 25 μl of cocktail B) and incubating for 5 minutes. The EasySep (Stemcell Technologies, Vancouver, CA) selection cocktail provided with the kit (50 μL per 1 mL of cells) was added to the FACS tube, mixed well with a pipette tip, and incubated for 5 minutes. The EasySep RapidSpheres provided with the kit were vortexed for 30 seconds, and 80 μL was added per mL of cells, mixed with a pipette tip, and incubated for 3 minutes at room temperature. Isolation medium was added to fill the sample to the indicated volume (5 mL for samples <3 mL and 10 mL for samples ≥3 mL). The tube was placed in the EasySep Magnet for 5 minutes. In one fluid movement, unlabeled cells were poured off in the buffer solution, and the tube, still in the magnet, was inverted for 2-3 seconds. The tube was removed from the magnet, and the appropriate amount of isolation medium was added and left for an additional 5 minutes. The magnetic separation / washing process was repeated four times to remove all unlabeled cells. After the final wash, the labeled CD11b+ microglial cells were resuspended in serum-free NbActiv1 medium, counted, and resuspended at the desired concentration.

[0350] In vitro signature method After isolation, microglia were plated at 1 million cells per well in 12-well plates and allowed to rest for 24 hours. Microglia were pretreated with 2.5 μM BTK inhibitor for 30 minutes. After pretreatment, aggregated / conjugated IgG (50 μg / mL) was added to the stimulator cells, and the cells were incubated for 6 or 24 hours. Cells were lysed in 200 μL of Qiazol and sent for RNA isolation and sequencing (Genewiz, South Plainfield, NJ).

[0351] Analysis of RNASeq library data was performed within Omicsoft's Array Studio platform following standard RNAseq protocols. Generally, sequencing reads were quality checked, and samples were mapped to the mouse mm10 reference genome using ENSEMBL.R89 gene models. Expression measurements (transcripts) were collected as both FPKM and counts. For sets of 4x biological replicates (groups), a low-count filter was applied, retaining only groups with transcript counts greater than 15 in at least two replicates. A low-count filter was applied to the FPKM count data. Additionally, only transcripts that mapped to coding genes were retained. After applying these filters, 12,790 transcripts were obtained. FPKM transcripts remained. FPKM data were normalized to the 75th percentile. A value of 1 was added to all samples before log2 transformation.

[0352] T-tests were performed to compare treatment with IgG alone and treatment with IgG and the BTK inhibitor after 6 and 24 hours, respectively. In all comparisons, differentially expressed genes (DEGs) were determined to be transcripts that met the following criteria: fold change >1.2 or <-1.2 and p-value <0.05 (fc1.2, p0.05).

[0353] The 6-hour BTKi gene signature was established by identifying DEGs that were increased in the activated state after treatment with a BTK inhibitor, and the 24-hour BTKi gene signature was established by identifying DEGs that were increased in the activated state after treatment with a BTK inhibitor, as shown in Figure 4.

[0354] The FPKM comparison of RGS1 mRNA at 24 hours is shown in Figure 5A.

[0355] In vivo treatment of naive mouse microglia Primary mouse microglia were prepared from postnatal mice as described above and treated with 2.5 μM BTKi inhibitor for 6 and 24 hours. RNA was isolated and analyzed by quantitative real-time PCR (Taqman, Thermo Fisher). Relative expression levels compared to the control after 6 hours are shown in Figure 5B (t-test, * p<0.05).

[0356] In vivo mouse studies Naive C57B16 mice were administered an oral solution of BTK inhibitor or vehicle (100% PEG200) daily for 5 days. Mice were sacrificed on day 5, 1 hour after the final dose, and perfused with PBS before brain isolation. RNA was isolated from brains using the Rneasy Lipid Tissue RNA Isolation Kit (Qiagen). RGS1 was quantified using real-time PCR and Taqman probes (Figure 6; one-way ANOVA). ** p<0.01).

[0357] Human brain single-nucleus RNAseq library preparation Patient samples and processing Cryopreserved postmortem brain specimens were obtained from the UCLA Brain Bank or the Cleveland Clinic Rapid Autopsy Program. Tissue specimens consisted primarily of subcortical white matter, with smaller portions of surrounding gray matter. Nuclear suspensions were prepared from homogenized tissue according to previously described methods with modifications. Briefly, approximately 200–400 mg of tissue was processed on ice in nuclear isolation buffer consisting of 240 mM sucrose, 24 mM KCl, 4.8 mM MgCl, 9.59 mM Tris (pH 8.0), 0.97 μM DTT, 0.1% (v / v) Triton X-100, 1× protease inhibitor (Fisher, PI78429), 0.4 units / μL RNAseIn (Fisher, PR-N2511), and 0.2 units / μL Superasin (Fisher, AM2694) in nuclease-free water. First, the sample was placed in a Petri dish containing buffer and minced using a razor blade. Next, the tissue suspension was homogenized using a glass Dounce homogenizer, and the homogenate was filtered through a 100-micron cell strainer. A crude nuclear suspension was prepared from the homogenate by one or two rounds of washing (Nuclei PURE storage buffer, Sigma, S9183) and centrifugation (700 g, 4 °C, 3 min). Next, nuclei were labeled with a nucleic acid-binding dye (DAPI, 1:500), washed once more with nuclear isolation buffer, and pelleted by centrifugation (700 g, 4 °C, 2 min). The final nuclear suspension was prepared by resuspending the crude pellet in nuclear isolation buffer and sorting DAPI+ events into collection buffer (0.5% UltraPure BSA and 1x Superasin in PBS) using a BD Influx cell sorter.

[0358] Single nucleus RNAseq library preparation Isolated nuclei were subjected to snRNA-seq using the Chromium Single Cell 3' Library Kit with Chromium Controller v2 chemistry according to the manufacturer's instructions (10x Genomics). Libraries were sequenced using Nextseq500 (Illumina).

[0359] Single-nucleus RNAseq data processing Sample demultiplexing, barcoding, and single-cell counting were performed using the Cell Ranger analysis pipeline (10x Genomics). RNAseq reads were mapped to the human reference genome using pre-mRNA annotations comprising both exons and introns. Subsequent data analysis was performed using R / Bioconductor and the Partek Single Cell Toolkit (Partek). For quality control, nuclei with high mitochondrial content, high UMI, and high gene counts per cell were removed. Data were normalized using a scaling factor of 1,000,000.

[0360] result As shown in Figure 4, the gene expression signature of microglia was altered by IgG activation, which was normalized by BTK inhibition. As shown in Figure 4, RGS1 was identified as one of the upregulated genes in this BTK-dependent microglial signature. RGS1 (regulator of G protein signaling 1) functions as a negative regulator of the G protein signaling pathway and is involved in various inflammatory diseases. RGS1 has been identified as a risk factor for MS and has also been found to be enriched in microglia (International Multiple Sclerosis Genetics Consortium, Science 365:6460 (2019)).

[0361] As shown in Figure 5A, when comparing mRNA expression in mouse microglia after in vivo treatment with IgG alone and IgG plus a BTK inhibitor, RGS1 mRNA expression was upregulated by IgG treatment and blocked by the BTK inhibitor. As shown in Figure 5B, treatment of naive mouse microglia with a BTK inhibitor reduced RGS1 mRNA levels.

[0362] The BTK inhibitor also reduced RGS1 expression in vivo. When naive mice were treated with the BTK inhibitor once daily for 5 days, a reduction in RGS1 mRNA expression was observed at various doses (0.6, 6, and 24 mg / kg), as shown in Figure 6. These results indicate that BTK regulates constitutive RGS1 brain expression, which may be indicative of BTK activity in vitro and in vivo.

[0363] Figure 7A shows that single-cell RNA-seq datasets from secondary progressive MS (SPMS) microglia identify various CNS cells, including microglia (open circles). When specific genes in the single-cell mRNA sequencing dataset were examined, RGS1 was one of the most upregulated genes in SPMS microglia (Table 31 and Figure 7B).

[0364] [Table 34]

[0365] The upregulation of RGS1 suggests that BTK may be active in these microglia, and suggests that RGS1 may also have functional relevance distinct from the progressive MS microglial phenotype. [Example]

[0366] The effect of food intake on BTK inhibitors was investigated. The clinical trial of Example 1 was conducted, and the results were analyzed to compare patients treated with the BTK inhibitor in the fasted state with patients treated in the fed state. Samples were obtained and analyzed from the two groups to evaluate the pharmacokinetic parameters described in Example 1.10 above.

[0367] Results confirmed that administration of the BTK inhibitor in the fed state substantially increased the median area under the curve (AUC) compared with administration in the fasted state. Patients with higher AUC (higher exposure to the BTK inhibitor) had few or no new Gd-enhanced T1 hyperintense lesions.

Claims

1. 1. A method of treating relapsing forms of multiple sclerosis (RMS), comprising administering to a subject in need thereof a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

2. 1. A method for reducing the number of new gadolinium (Gd)-enhanced T1 hyperintense lesions, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS) in need thereof.

3. 1. A method of reducing the number of new or enlarging T2 lesions, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS) in need thereof.

4. 1. A method for reducing the total number of gadolinium (Gd)-enhanced T1 hyperintense lesions, comprising administering a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject with relapsing multiple sclerosis (RMS) in need thereof.

5. 1. A method of reducing relapse rate in a subject with multiple sclerosis (MS), comprising administering to a subject in need thereof a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one.

6. 6. The method of any one of claims 1 to 5, wherein the BTK inhibitor is administered at a dose of about 5 mg to about 60 mg.

7. The method of any one of claims 1 to 6, wherein the dose is 5 mg.

8. The method of any one of claims 1 to 6, wherein the dose is 15 mg.

9. The method of any one of claims 1 to 6, wherein the dose is 30 mg.

10. The method of any one of claims 1 to 6, wherein the dose is 60 mg.

11. 11. The method of any one of claims 1-10, wherein administration of the BTK inhibitor inhibits the formation of new active brain lesions as measured by MRI.

12. The method of any one of claims 1 to 11, wherein the dose is once a day.

13. 13. The method of any one of claims 1 to 12, wherein the dose is administered once daily with food.

14. 13. The method of any one of claims 1-6, 8, and 11-12, wherein a dose of 15 mg is administered once daily with food.

15. 13. The method of any one of claims 1-6, 9, and 11-12, wherein a dose of 30 mg is administered once daily with food.

16. 13. The method of any one of claims 1-6 and 10-12, wherein a dose of 60 mg is administered once daily with food.

17. 17. The method of any one of claims 1 to 16, wherein administration of a BTK inhibitor reduces RGS1 expression in brain cells.

18. 18. The method of claim 17, wherein the brain cells comprise microglia.

19. 19. The method of any one of claims 1-18, wherein administration of the BTK inhibitor reduces the number of new gadolinium (Gd)-enhancing T1 hyperintense lesions as measured by MRI.

20. 20. The method of claim 19, wherein the number of new Gd-enhancing T1 hyperintense lesions is less than one.

21. 20. The method of claim 19, wherein no new Gd-enhancing T1 hyperintense lesions form after 12 weeks of BTK inhibitor treatment.

22. 22. The method of any one of claims 1-2 or 4-21, wherein administration of the BTK inhibitor reduces the number of new or enlarging T2 lesions as measured by MRI.

23. 23. The method of claim 22, wherein the number of new or enlarging T2 lesions is less than or equal to two.

24. 23. The method of claim 22, wherein after 12 weeks of BTK inhibitor treatment, no new or enlarging T2 lesions form.

25. 25. The method of any one of claims 1-3 or 5-24, wherein administration of the BTK inhibitor reduces the total number of Gd-imaging T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

26. 26. The method of any one of claims 1-5 or 16-25, wherein the dose is 60 mg and one or zero new Gd-enhancing T1-hyperintense lesions are formed after 12 weeks of BTK inhibitor treatment.

27. 27. The method of claim 26, wherein no new Gd-enhancing T1 hyperintense lesions form after 12 weeks of BTK inhibitor treatment.

28. 28. The method of any one of claims 1-5 or 16-27, wherein the dose is 60 mg and the number of new or enlarging T2 lesions is less than or equal to 2 after 12 weeks of BTK inhibitor treatment.

29. 29. The method of any one of claims 1-5 or 16-28, wherein the dose is 60 mg and administration of the BTK inhibitor reduces the total number of Gd-imaging T1 hyperintense lesions after 12 weeks of BTK inhibitor treatment.

30. 30. The method of any one of claims 1 to 29, wherein the BTK inhibitor compound is administered as monotherapy.

31. 31. The method of any one of claims 1 to 30, wherein the RMS is selected from clinically isolated syndrome (CIS), relapsing-remitting multiple sclerosis (RRMS), and relapsing secondary-progressive multiple sclerosis (R-SPMS).

32. The method of any one of claims 1 to 31, wherein the subject is a human.

33. 1. A method of treating relapsing multiple sclerosis (RMS), comprising administering 60 mg of a BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one to a subject in need thereof, wherein 12 weeks after the BTK administration, no new Gd-imaging T1 hyperintense lesions are formed.

34. 1. A BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one for use in a method for treating relapsing forms of multiple sclerosis (RMS) in a subject in need thereof.

35. 1. A BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one for use in a method for reducing the number of new or enlarging T2 lesions in a subject with relapsing multiple sclerosis (RMS).

36. 1. A BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one for use in a method for reducing the total number of gadolinium (Gd)-imaging T1 hyperintense lesions in a subject with relapsing multiple sclerosis (RMS).

37. 1. A BTK inhibitor comprising (R)-1-(1-acryloylpiperidin-3-yl)-4-amino-3-(4-phenoxyphenyl)-1H-imidazo[4,5-c]pyridin-2(3H)-one for use in a method of reducing relapse rate in a subject with multiple sclerosis (MS).

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