Methods and compositions for treating sepsis

Abstract

To provide a composition for treating sepsis including, for example, neonatal sepsis and sepsis associated with infection.SOLUTION: Compositions comprising improved formulations of pleconaril are provided. Preferred are compositions comprising an oral formulation of pleconaril comprising a pharmaceutically acceptable oil, a pharmaceutically acceptable ester mixture, a saturated fatty acid, a hydrofluorocarbon, and / or combinations thereof.SELECTED DRAWING: Figure 2

Description

[Technical Field]

[0001] [Related Applications] This application claims the benefit of U.S. Provisional Application No. 61 / 901,656, filed November 8, 2013, the disclosure of which is incorporated herein by reference in its entirety, and U.S. Provisional Application No. 62 / 061,391, filed October 8, 2014, the disclosure of which is incorporated herein by reference in its entirety. [Background technology]

[0002] Sepsis is a potentially life-threatening complication of infection. It occurs when an overpowering immune response is mounted against the systemic inflammatory response triggered by the infection. This inflammation can trigger a series of changes that can damage multiple organ systems, causing them to fail. If sepsis progresses to septic shock, blood pressure drops dramatically, which can lead to death. While anyone can develop sepsis, it is most common and poses the greatest threat to the elderly, young children, or those with weakened immune systems. Early sepsis treatment, usually with antibiotics and large amounts of intravenous fluids, may improve the chances of survival.

[0003] Many physicians consider sepsis to be a three-phase syndrome, beginning with septicemia, progressing to severe sepsis, and ending in septic shock. The goal is to treat sepsis during its mild stages before it becomes more severe. To be diagnosed with sepsis, a patient must exhibit at least two of the following symptoms: a change in body temperature, an elevated heart rate, an increased respiratory rate, or a probable or confirmed infection. A diagnosis of severe sepsis is made when a patient exhibits at least one of the following signs or symptoms indicating that an organ may be failing: a marked decrease in urine output, a sudden change in mental status, a low platelet count, difficulty breathing, abnormal heart rhythm, or abdominal pain. To be diagnosed with septic shock, a patient must exhibit the signs and symptoms of severe sepsis plus extremely low blood pressure that is largely unresponsive to initial fluid resuscitation.

[0004] Any type of bacterial, viral or fungal infection can cause sepsis, but the most common types include pneumonia, intra-abdominal infections, kidney infections and bloodstream infections (bacteremia).

[0005] Neonatal sepsis is sepsis in infants under 4 weeks of age, typically caused by bacteria but often by viruses. Newborns have immature immune systems, making them particularly susceptible to infection. The most severe outcome of neonatal sepsis is meningitis.

[0006] Sepsis is also a leading cause of death during the first few months of life, and approximately 13-15% of all neonatal deaths result from neonatal sepsis. The mortality rate for neonatal sepsis can be as high as 50% in infants who are not treated or whose treatment is not started promptly. As soon as sepsis is suspected, the neonate is started on antibiotic therapy while waiting for culture results to come back. Unfortunately, antibiotics do not work against sepsis caused by viral infection.

[0007] Enteroviruses (EV) (family Picornaviridae, genus Enterovirus) are among the most common viruses infecting humans. Newborns are thought to be at higher risk of infection and severe clinical symptoms due to EV infection due to their immature immune response. EV infection is common in newborns, especially during the summer and fall, and can cause a variety of symptoms, ranging from mild febrile illness to severe, potentially fatal sepsis, including multiple organ failure, referred to as "neonatal enteroviral sepsis." Along with bacterial meningitis, enteroviral meningitis is a severe manifestation of the disease. Currently, patients are provided with supportive care, but there is no specific antiviral treatment for sepsis caused by viral infection.

[0008] Severe consequences can result from systemic enteroviral infection, including meningoencephalitis, cardiovascular collapse, myocarditis, or hepatitis. Myocarditis or hepatitis carries a high mortality rate; mortality rates in neonates with isolated myocarditis have been reported at 30-50%. If severe liver failure develops, more than 80% of such patients will die within 1-3 weeks of symptom onset despite aggressive medical management.

[0009] Sepsis is more likely and more threatening in the very young or very old, in individuals with compromised immune systems, in individuals who are already seriously ill and often in hospital intensive care units, in individuals with wounds or injuries such as burns, and / or in individuals with invasive devices such as intravenous catheters or breathing tubes.

[0010] Sepsis ranges from mild to more severe. As sepsis worsens, blood flow to vital organs, such as the brain, heart, and kidneys, is impaired. Sepsis also causes blood clots to form in the organs and in the arms, legs, fingers, and toes, leading to varying degrees of organ failure and tissue death (gangrene).

[0011] Although most people recover from non-severe sepsis, the mortality rate in septic shock is approximately 50%, and severe sepsis episodes may put individuals at higher risk of future infections.

[0012] Diagnosing sepsis can be difficult because its signs and symptoms can be caused by other diseases. Physicians often request a series of tests to try to pinpoint the underlying infection. Typically, blood tests are performed to check for various factors, such as evidence of infection, clotting-related problems, abnormal liver or kidney function, impaired oxygen utilization, and / or electrolyte imbalance.

[0013] Other laboratory tests may include, for example, a urine test (for signs of bacteria), a sample of wound secretions (if the wound is found to be infected, testing a sample of the wound secretions may help indicate what type of antibiotic may work best), or a sample of respiratory secretions (if the patient is coughing up mucus (phlegm), this may be tested to determine what type of bacteria is causing the infection).

[0014] In situations where the site of infection is not obvious, a doctor may request one or more of the following imaging tests: X-ray (X-rays are good for visualizing problems in the lungs), computed tomography (CT) (infections in the appendix, pancreas, or intestines are more easily seen on a CT scan. This technique takes X-rays from various angles and combines them to show cross-sectional slices of the body's internal structures), ultrasound (i.e., useful for identifying infections in organs such as the gallbladder or uterus), magnetic resonance imaging (MRI) (MRI can be useful for identifying soft tissue infections, such as abscesses in the spine).

[0015] Early and aggressive treatment improves the chances of survival from sepsis. People with severe sepsis require close monitoring and treatment in hospital intensive care units. When patients suffer from severe sepsis or septic shock, life-saving measures may be required to stabilize respiratory and cardiac function.

[0016] Available medications for treatment include antibiotics and hypertensives. Antibiotic treatment is initiated immediately, usually even before the cause of the infection is identified. Initially, patients are given broad-spectrum antibiotics that are effective against a variety of bacteria, and antibiotics are usually administered intravenously (IV). If blood pressure remains low even after intravenous fluids are administered, patients may be given hypertensives to constrict blood vessels and help increase blood pressure. Other medications that may be administered include low-dose corticosteroids, insulin to help maintain stable blood sugar levels, drugs that modify immune system responses, and painkillers or sedatives.

[0017] As described above, enteroviruses are frequently implicated in the development of sepsis, including coxsackieviruses A1-A21, A24, and B1-B6, echoviruses (enteric cytopathic human orphan viruses) 1-7, 9, 11-21, 24-27, and 29-33, enteroviruses 68-71, 73-91, and 100-101, and polioviruses 1-3.

[0018] Enteroviruses, as well as rhinoviruses and human parechoviruses, are picornaviruses (pico, or small, RNA viruses). Human parechoviruses 1 and 2, formerly designated echoviruses 22 and 23, have now been reclassified. All enteroviruses are antigenically diverse and geographically widespread.

[0019] Enteroviruses are found in respiratory secretions and feces and are occasionally present in the blood and CSF of infected patients. Infection is usually transmitted by direct contact with respiratory secretions or feces, but can also be transmitted through contaminated environmental sources (e.g., water). Enterovirus disease or epidemics in the United States occur in the summer and fall. Infections transmitted by mothers during labor can result in serious, widespread neonatal infections, including hepatitis or hepatic necrosis, meningoencephalitis, myocarditis, or a combination thereof.

[0020] Intact humoral immunity and B-cell function are required for the control of enteroviral disease. Serious enteroviral infections, often manifested as slowly progressive meningoencephalitis, occur in patients with agammaglobulinemia but usually not in patients with other immunodeficiencies.

[0021] Enteroviruses cause a variety of conditions: infectious pleurisy, hand, foot, and mouth disease, herpangina, and acute poliomyelitis are almost exclusively caused by enteroviruses. Other disorders (e.g., aseptic meningitis, myopericarditis) can be caused by enteroviruses or other organisms.

[0022] Aseptic meningitis is most common among infants and children. In infants and young children, the cause is often coxsackieviruses A and B, echoviruses, or human parechoviruses. In older children and adults, aseptic meningitis can be caused by other enteroviruses and other viruses.

[0023] Myopericarditis is a cardiac infection that can occur at any age, but most patients are between 20 and 39 years of age. Patients may present with chest pain, arrhythmias, heart failure, or sudden death. Recovery is usually complete, but some patients develop dilated cardiomyopathy. Diagnosis may require reverse transcriptase (RT)-PCR of myocardial tissue. Neonatal myocarditis (cardiac infection at birth) is caused by coxsackievirus group B, several echoviruses, and human parechoviruses. It causes fever and heart failure and has a high mortality rate.

[0024] Enteroviruses are often responsible for the rash. Certain coxsackieviruses, echoviruses, and human parechoviruses often cause rashes during infection. The rash is usually nonpruritic, nonscaling, and occurs on the face, neck, chest, and extremities. They are often maculopapular or morbilliform, but are sometimes hemorrhagic, petechial, or vesicular. Fever is common. Aseptic meningitis may occur simultaneously.

[0025] Respiratory infections caused by enteroviruses present with symptoms including fever, coryza, sore throat, and, in infants and children, vomiting and diarrhea. Bronchitis and interstitial pneumonia sometimes occur in adults and children.

[0026] Other infections in which enteroviruses have been implicated include those associated with bone marrow transplantation, chronic enteroviral meningoencephalitis and agammaglobulinemia or hypogammaglobulinemia (CEMA), and rhinovirus pneumonia.

[0027] Despite advances in understanding the physiology and pathophysiology of sepsis, including neonatal sepsis, there remains a lack of compounds that are efficacious, effective, and simultaneously safe in the treatment of sepsis. These and other needs are met by the present invention. Summary of the Invention

[0028] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, the methods comprising administering to the individual a composition comprising Pleconaril. In some embodiments, the sepsis is caused by an infection, such as an enterovirus, and / or in some embodiments, the sepsis is neonatal sepsis.

[0029] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, the methods comprising administering to the individual a composition comprising pleconaril, wherein the pleconaril is administered orally, transdermally, by inhalation, intranasally, topically and via other methods of administration known to those skilled in the art.

[0030] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, wherein the composition comprising pleconaril includes a parenteral formulation of pleconaril comprising a pharmaceutically acceptable oil, a pharmaceutically acceptable ester mixture, a saturated fatty acid, a hydrofluorocarbon, and / or a combination thereof.

[0031] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, wherein the composition comprising pleconaril comprises a nanoemulsion of pleconaril.

[0032] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, wherein the composition comprises pleconaril incorporated into polymeric phospholipid micelles.

[0033] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, wherein the composition comprising pleconaril includes an oral formulation, wherein the oral formulation comprises colloidal particles of pleconaril, optionally in combination with carrier particles.

[0034] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, wherein the composition comprising pleconaril includes an oral formulation, wherein the oral formulation comprises particles of pleconaril incorporated into a cyclic oligosaccharide.

[0035] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, wherein the composition comprising pleconaril comprises an oral formulation, wherein the oral formulation comprises an oil-in-water microemulsion.

[0036] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, wherein the composition comprising pleconaril includes an oral formulation, wherein the oral formulation comprises a spray-dried emulsion of pleconaril combined with a digestible oil.

[0037] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, the methods comprising administering to the individual a composition comprising pleconaril incorporated into a sustained release composition.

[0038] Disclosed herein are methods and compositions for treating sepsis in an individual in need thereof, the methods comprising administering to the individual a composition comprising pleconaril, the composition further comprising a pharmaceutically acceptable carrier.

[0039] Disclosed herein are methods and compositions for treating sepsis in individuals in need thereof, comprising administering a composition comprising pleconaril to an individual considered to be at risk. In some embodiments, the at-risk individual includes a young child, an individual aged 65 or over, an immunocompromised individual, or an individual undergoing transplant surgery.

[0040] The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate several embodiments and, together with the description, serve to explain the principles of the invention. [Brief explanation of the drawings]

[0041] [Figure 1] 1 is a table showing maternal and neonatal characteristics of individuals enrolled in a study (Example 1) to investigate the efficacy of pleconaril as an antiviral treatment for neonatal enterovirus infection. [Figure 1a] 1 is a table showing maternal and neonatal characteristics of individuals enrolled in a study (Example 1) to investigate the efficacy of pleconaril as an antiviral treatment for neonatal enterovirus infection. [Figure 2] FIG. 1 shows viral culture results for individuals confirmed to have enterovirus. [Figure 3] Figure 1 shows the time to culture negativity for all anatomical sites (oropharynx, rectum, urine, and serum) among 19 subjects in the treatment group who had a positive culture from any site and 7 subjects in the placebo group. A subject was considered culture-negative on a particular test day only when culture assays from all sites sampled on that day were negative. DETAILED DESCRIPTION OF THE INVENTION

[0042] Additional advantages of the present invention will be in part apparent in the description which follows, and in part obvious from the description or may be learned by practice of the invention. The advantages of the present invention will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims. It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not intended to limit the invention as claimed.

[0043] Sepsis is a potentially life-threatening complication of infection that occurs as a result of the body's overwhelming immune response to infection. The resulting inflammation can trigger a series of changes that can damage multiple organ systems, causing them to fail. If left untreated or allowed to progress, sepsis can lead to septic shock, which can be fatal. While sepsis can affect anyone, it is most common and poses the greatest threat to the elderly or those with weakened immune systems. Sepsis is also a concern for newborns; neonatal septicemia is a blood infection that typically occurs in newborns up to 90 days of age.

[0044] The incidence of sepsis is on the rise in the U.S. Factors contributing to this increase include an aging population (Americans are living longer, which is increasing the proportion of the population older than 65 years old who are at highest risk), drug-resistant bacteria (many types of bacteria are becoming resistant to the antibiotics that once killed them, and these antibiotic-resistant bacteria are often the underlying cause of infections that lead to sepsis), and weakened immune systems (more Americans are living with weakened immune systems caused by drugs for HIV, cancer treatment, or transplants).

[0045] Non-poliovirus enteroviruses (EVs), comprised of Coxsackievirus A and B, echoviruses, and newer, numbered EVs, are important causes of numerous diseases, including sepsis, neonatal illness, and neonatal sepsis, with incidences that approach or exceed those of diseases caused by Streptococcus agalactiae, herpes simplex virus (HSV), and symptomatic cytomegalovirus infections. Enteroviruses are often associated with pleurisy, hand-foot-and-mouth disease, herpangina, and acute poliomyelitis, although other disorders (e.g., aseptic meningitis, myopericarditis, etc.) may be caused by enteroviruses or other organisms.

[0046] A subset of infected newborns develops severe disease manifested by hepatitis, coagulopathy, myocarditis, interstitial pneumonitis, and / or meningoencephalitis. Infants with disease onset in the first few days of life, those lacking serotype-specific transplacental neutralizing antibodies, and premature newborns are at high risk for severe illness. Hepatitis with coagulopathy and myocarditis are associated with mortality rates as high as 24–83% and 30–50%, respectively. Long-term morbidity, including persistent liver and cardiac dysfunction and neurodevelopmental failure, can occur in survivors (1–5).

[0047] To date, no antiviral therapy for neonatal EV infection is available. The mainstay of treatment is supportive care, which includes intensive cardiopulmonary and blood product support for severe infections. Small studies have suggested the potential benefit of intravenous immunoglobulin (IVIG); however, its efficacy has not yet been proven (6).

[0048] Pleconaril (3-{3,5-dimethyl-4-[3-(3-methylisoxazol-5-yl)propoxy]phenyl}-5-(trifluoromethyl)-1,2,4-oxadiazole) constituted the first of a novel class of antiviral agents designed to treat infections caused by picornaviruses. Pleconaril's rational design was based on atomic-resolution structure of the drug / virus complex, structure-activity relationship analysis, screening for metabolic stability in liver microsomes, and extensive nonclinical safety testing. Pleconaril demonstrated broad activity against human respiratory-associated picornaviruses, as demonstrated during clinical trials of an oral formulation (ViroPharma). However, oral administration of this drug at dose levels of 200–400 mg resulted in systemic exposure and adverse side effects, including induction of CYP3A, leading to adverse complications including, but not limited to, elevated steady-state plasma concentrations of theophylline and increased incidence of menstrual irregularities in women using oral contraceptives.

[0049] To date, delivery of pleconaril has also proven problematic. In its original form, delivery of pleconaril using an intranasal thixotropic formulation (ViroPharma IND Report, 2004) demonstrated that a daily dose of 12 mg (intranasal spray) of pleconaril may produce clinical / antiviral effects similar to those of a 400 mg oral formulation, without significant systemic exposure. Although thixotropic formulations become fluid upon agitation, if shear is not applied to the system, the formulation becomes viscous and is unsuitable for routine pharmaceutical use. Unfortunately, several challenges exist that limit the successful development of intranasal delivery of pleconaril. Most importantly, pleconaril is virtually insoluble in water (solubility in water is less than 20 ng / mL at 25°C) and therefore has both a low equilibrium concentration and a slow diffusion rate in relevant biospaces where the virus resides. The residence time of the drug in the frontal turbinates and pharyngeal tonsils is relatively short for intranasal sprays due to leakage and mucociliary clearance, while spraying into blocked nostrils or a nose with rhinorrhea further hinders absorption, and sneezing may also expel the drug. As a result of the above limitations, effective delivery of pleconaril has not been achieved to date, despite its therapeutic potential.

[0050] The inventors of the present invention have herein solved the problems associated with the original formulation of pleconaril (such as undesirable systemic exposure, adverse side effects, and inadequate delivery) by developing and implementing a drug design methodology that idealizes particle design, formulation, and delivery. In certain embodiments, the inventors have enabled site-specific delivery of pleconaril controlled by the size of the delivered particles (potentially bi- or trimodal distribution of pleconaril particles in the submicron range, approximately 1-50, 5-40, 10-35, and greater than 30 microns) or by the use of a novel delivery device for delivery to target areas that are sites of infection where sepsis is most likely to occur. The present invention discloses drug delivery advantageous for enhanced therapeutic activity, including significantly reduced particle size of pleconaril, wherein 90% of the particles are 1-100 microns, 1-50 microns, 1-10 microns, or less than 1 micron, constituting a nanosuspension with enhanced dissolution properties, improved therapeutic activity, and reduced drug dose, but formulated in a manner that prevents indiscriminate delivery of these particles. More specifically, it is discovered herein that such suspensions allow for lower dose levels than would be necessary to achieve the same therapeutic response as with other delivery methods (e.g., microparticulate delivery) due to reduced systemic side effects.

[0051] Disclosed herein are methods for treating sepsis in an individual in need thereof, comprising administering to the individual a composition comprising pleconaril. In some embodiments, the sepsis is caused by an enterovirus, and in other embodiments, the sepsis is neonatal sepsis. Sepsis in an individual may be associated with infection, aseptic meningitis, bone marrow transplantation, enteroviral myocarditis, chronic enteroviral meningoencephalitis, or an individual suffering from agammaglobulinemia or hypogammaglobulinemia (CEMA). Associated symptoms include, but are not limited to, elevated body temperature (e.g., above 99°F, below 100°F, 101°F, or below 97°F, such as 96.8°F or 96°F), elevated heart rate (e.g., above 80-95 beats per minute), decreased urine output, sudden changes in mental status, decreased platelet count, dyspnea, abnormal cardiac function, abdominal pain, and low blood pressure. These measurements are known to those skilled in the art. In some embodiments, symptoms of sepsis include congestive heart failure, chronic myocarditis, or dilated cardiomyopathy.

[0052] Disclosed herein are methods for treating sepsis in an individual in need thereof, comprising administering to the individual a composition comprising pleconaril, wherein the pleconaril is administered orally, transdermally, by inhalation, intranasally, topically, intravaginally, ophthalmically, intraaurally, intracerebrally, rectally, sublingually, bucally, and via parenteral, injection, intravenously, intraarterially, intramuscularly, or subendocardially.

[0053] In some embodiments, the composition comprising pleconaril comprises an oral formulation of pleconaril that comprises a pharmaceutically acceptable oil, a pharmaceutically acceptable ester mixture, and / or a combination thereof.

[0054] In some embodiments, the composition comprising pleconaril comprises an oral formulation of pleconaril comprising a nanoemulsion of pleconaril, wherein the particle size of the pleconaril includes 50-500 nm, 50-400 nm, 50-300 nm, 100-200 nm, or 100 nm. In additional embodiments, the composition further comprises a pharmaceutically acceptable surfactant.

[0055] Disclosed herein are methods for treating sepsis in an individual in need thereof, comprising administering to the individual a composition comprising pleconaril incorporated into a polymeric phospholipid micelle. In some embodiments, the polymeric phospholipid micelle comprises PEG, PEG conjugated to a hydrophobic diacylphospholipid, phosphatidylcholine, or egg phosphatidylcholine. The particle size of the polymeric phospholipid micelle may range from 5 to 100 nm, 5 to 80 nm, 10 to 50 nm, or 10 nm.

[0056] Disclosed herein is a method for treating sepsis in an individual in need thereof, the method comprising administering to the individual a composition comprising pleconaril, wherein the pleconaril comprises an oral formulation, and the oral formulation comprises colloidal particles of pleconaril, optionally combined with carrier particles. In some embodiments, the carrier particles comprise silica particles, PEG, or hydroxymethylpropylmethylcellulose. In some embodiments, the oral formulation of pleconaril described herein can be used to treat an individual over a long period of time and comprises an antiviral agent or a combination of an antiviral agent and a pharmaceutically acceptable salt thereof, wherein the formulation comprises a solid dispersion that releases the antiviral agent or agents as colloidal particles upon exposure to an aqueous environment, resulting in improved diffusion rate and bioavailability. In some embodiments, the dispersion can be made by heating the agent and carrier to a molten state and allowing it to resolidify by cooling, or by dissolving the components in a suitable solvent system and subsequently evaporating the solvent to dryness.

[0057] Disclosed herein is a method for treating sepsis in an individual in need thereof, the method comprising administering to the individual a composition comprising pleconaril, wherein the pleconaril comprises an oral formulation, and the oral formulation comprises particles of pleconaril incorporated into a cyclic oligosaccharide. The cyclic oligosaccharide may include 2-hydroxypropyl-β-cyclodextrin, methyl-β-cyclodextrin, sulfobutyl-β-cyclodextrin. In some embodiments, the oral formulation described herein for treating an individual over a long period of time comprises a combination of pleconaril or an antiviral agent and a pharmaceutically acceptable salt thereof, wherein the formulation uses a cyclic oligosaccharide as a molecular encapsulating agent to incorporate the antiviral agent(s) into its hydrophobic cavity.

[0058] Disclosed herein are methods for treating sepsis in an individual in need thereof, the methods comprising administering to the individual a composition comprising pleconaril, wherein the pleconaril comprises an oral formulation, wherein the oral formulation comprises an oil-in-water microemulsion. In some embodiments, the oil in the oil-in-water microemulsion comprises a medium-chain triglyceride, a hydrogenated pharmaceutically acceptable oil, or ethyl alcohol. In some embodiments, the microemulsion is a self-microemulsifying formulation. In some embodiments, the particle size of the microemulsion is 1 to 100 nm, 5 to 90 nm, 5 to 50 nm, or 8 to 12 nm.

[0059] Disclosed herein is a method for treating sepsis in an individual in need thereof, the method comprising administering to the individual a composition comprising pleconaril, wherein the pleconaril comprises an oral formulation, wherein the oral formulation comprises a spray-dried emulsion of pleconaril combined with a digestible oil. In one embodiment, the digestible oil comprises soybean oil, sesame oil, cottonseed oil, safflower oil, tocopherol-containing oil, and / or tocotrienol-containing oil. In another embodiment, the composition further comprises lecithin.

[0060] Disclosed herein are methods for treating sepsis in an individual in need thereof, the methods comprising administering to the individual a composition comprising pleconaril, wherein the pleconaril is incorporated into a sustained-release composition. In one embodiment, the composition is incorporated into a biodegradable gel. In another embodiment, the biodegradable gel is a biodegradable thermal gel. In one embodiment, the biodegradable gel comprises lactic acid, glycolic acid, PEG 1000, or 1450. In one embodiment, treatment can be sustained by incorporating pleconaril and a pharmaceutically acceptable salt thereof into a biodegradable thermal gel, wherein the gel is made from materials known to those skilled in the art, such as lactic acid, glycolic acid, PEG 1000, or 1450. Once injected, the thermal gel becomes a sustained-release formulation that provides treatment for 1 to 6 weeks and increases solubility by 200 to 1000 times.

[0061] Disclosed herein are methods for treating sepsis in an individual in need thereof, the methods comprising administering to the individual a composition comprising pleconaril, the composition further comprising a pharmaceutically acceptable carrier. In some embodiments, the composition comprising pleconaril comprises 1-600 mg, 1-500 mg, 1-300 mg, 5-200 mg, 10-100 mg, or 10-40 mg of pleconaril.

[0062] Disclosed herein is a method for treating sepsis in an individual in need thereof, the method comprising administering a composition comprising pleconaril to an individual considered to be at risk.In some embodiments, the individual at risk includes young children, individuals over 65 years old, individuals with compromised immune systems, or individuals undergoing transplant surgery.In some embodiments, the individual at risk is suffering from rhinovirus pneumonia.

[0063] Disclosed herein are compositions comprising improved formulations of pleconaril. In some embodiments, the compositions comprise parenteral formulations of pleconaril comprising a pharmaceutically acceptable oil, a pharmaceutically acceptable ester mixture, a saturated fatty acid, or a combination thereof. In some embodiments, the formulation comprises a nanoemulsion of pleconaril, wherein the particle size of the pleconaril comprises 50-500 nm, 50-400 nm, 50-300 nm, 100-200 nm, or 100 nm. In other embodiments, the composition further comprises a pharmaceutically acceptable surfactant.

[0064] Disclosed herein are compositions comprising an improved formulation of pleconaril, wherein the composition comprising pleconaril is incorporated into polymeric phospholipid micelles. In one embodiment, the polymeric phospholipid micelles include PEG, PEG conjugated with a hydrophobic diacylphospholipid, phosphatidylcholine, or egg phosphatidylcholine. In another embodiment, the particle size of the polymeric phospholipid micelles includes 5-100 nm, 5-80 nm, 10-50 nm, or 10 nm.

[0065] Disclosed herein are compositions comprising improved formulations of pleconaril, wherein the compositions comprising pleconaril include oral formulations, and the oral formulations include colloidal particles of pleconaril, optionally combined with carrier particles. In some embodiments, the carrier particles include silica particles, PEG, or hydroxymethylpropylmethylcellulose.

[0066] Disclosed herein are compositions comprising improved formulations of pleconaril, wherein the pleconaril-containing compositions comprise particles of pleconaril incorporated into cyclic oligosaccharides. In some embodiments, the cyclic oligosaccharides include 2-hydroxypropyl-β-cyclodextrin, methyl-β-cyclodextrin, and sulfobutyl-β-cyclodextrin.

[0067] Disclosed herein are compositions comprising an improved formulation of pleconaril, wherein the composition comprising pleconaril comprises an oil-in-water microemulsion. In one embodiment, the oil in the oil-in-water microemulsion comprises a medium-chain triglyceride, a hydrogenated pharmaceutically acceptable oil, and ethyl alcohol. In another embodiment, the microemulsion is a self-microemulsifying formulation. In one embodiment, the particle size of the microemulsion is 1 to 100 nm, 5 to 90 nm, 5 to 50 nm, or 8 to 12 nm.

[0068] Disclosed herein is a composition comprising an improved formulation of pleconaril, wherein the composition comprising pleconaril comprises an oral formulation, wherein the oral formulation comprises a spray-dried emulsion of pleconaril combined with a digestible oil. In some embodiments, the digestible oil comprises soybean oil, sesame oil, cottonseed oil, safflower oil, tocopherol-containing oil, and / or tocotrienol-containing oil. In additional embodiments, the composition further comprises lecithin.

[0069] Disclosed herein is a composition comprising an improved formulation of pleconaril, wherein the composition comprising pleconaril is incorporated into a sustained-release composition. In some embodiments, the composition comprising pleconaril is incorporated into a biodegradable gel. In some embodiments, the biodegradable gel comprises lactic acid, glycolic acid, PEG 1000, or 1450.

[0070] Disclosed herein are compositions comprising improved formulations of pleconaril, wherein the pleconaril-containing compositions further comprise a pharmaceutically acceptable carrier. In some embodiments, the pleconaril-containing compositions contain 1-600 mg, 1-500 mg, 1-300 mg, 5-200 mg, 10-100 mg, or 10-40 mg of pleconaril per dose, and are administered according to methods and protocols known to those skilled in the art, for example, once, twice, or three times daily for a predetermined period of time or until sepsis symptoms are alleviated. The compositions disclosed herein further comprise a pharmaceutical salt of pleconaril. Additionally, the compositions disclosed herein reduce CYP induction of antiviral agents.

[0071] Disclosed herein are compositions comprising improved formulations of pleconaril, where the compositions comprising pleconaril include, but are not limited to, abacavir, acyclovir, acyclovir, adefovir, amantadine, aprenavir, ampligen, arbidol, atazanavir, atripla, balavir, boceprevir, cidofovir, combivir, dolutegravir, fluticasone, fluoxetine ... Dolutegravir, Darunavir, Delavirdine, Didanosine, Docosanol, Edozudine, Efavirenz, Emtricitabine, Efuvirtide, Entecavir, Ecoliver, Famciclovir, Fomivirsen, Fosamprenavir, Foscarnet, Fosfonet, Fusion Inhibitors Inhibitors, Ganciclovir, Ibacitabine, Imunovir, Idoxuridine, Imiquimod, Indinavir, Inosine, Integrase inhibitor, Interferon type III, Interferon type II, Interferon type II), Interferon, Lamivudine, Lopinavir, Loviride, Maraviroc, Moroxydine, Methisazone, Nelfinavir, Nevirapine, Nexavir, Nucleoside analogues, Oseltamivir (Tamiflu®), Peginterferon alfa-2a, Penciclovir, Peramivir, Podophyllotoxin, Protease inhibitors, Raltegravir, Reverse transcriptase inhibitors inhibitor, Ribavirin, Rimantadine, Ritonavir, Pyramidine, Saquinavir, Sofosbuvir, Stavudine, Synergistic enhancer (antiretroviral agent), Telaprevir, Tenofovir, Tenofovir disoproxiland / or one or more additional antiviral agents, including, for example, disoproxil, tipranavir, trifluridine, trizivir, tromantadine, Truvada, traporved, valaciclovir (Valtrex®), valganciclovir, vicriviroc, vidarabine, viramidine, zalcitabine, zanamivir (Relenza®), or zidovudine.

[0072] Also disclosed herein is the use of the disclosed compositions as research and / or investigational tools in the development and standardization of in vitro and in vivo test systems for evaluation in experimental animals such as cats, dogs, rabbits, monkeys, rats, and mice as part of the search for novel therapeutic approaches for the treatment of sepsis.

[0073] definition Unless expressly stated otherwise, it is not intended that any method or embodiment defined herein be construed as requiring that its steps be performed in a particular order. Thus, if a method claim does not specifically state in the claim or detailed description that the steps are to be limited to a particular order, no order is intended to be implied in any way. This also applies to other possible, implicit bases of interpretation, including, for example, logical considerations regarding the arrangement of steps or operational flow, the simple meaning derived from grammatical structure or division, or the number or type of embodiments described in the specification.

[0074] As used in this specification and the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise.

[0075] As used herein, the term "or" means any one of a particular list and includes any combination of parts of that list.

[0076] Ranges can be expressed herein as from "about" one particular value and / or to "about" another particular value. When such a range is stated, a further embodiment includes from the one particular value and / or to the other particular value. Similarly, when numerical values ​​are expressed as approximations, by use of the antecedent "about," it is to be understood that the particular value forms a further embodiment. It will be further understood that the endpoints of each of the ranges are significant both in relation to the other endpoint, and independently of the other endpoint. There are a number of values ​​disclosed herein, and it is also to be understood that each of these values ​​is also disclosed herein as "about" that particular value in addition to that value. For example, if the value "10" is disclosed, then "about 10" is also disclosed. It is also to be understood that each unit between two individual units is also disclosed. For example, if 10 and 15 are disclosed, then 11, 12, 13, and 14 are also disclosed.

[0077] References in the specification and final claims to parts by weight of a particular element or ingredient in a composition indicate the weight relationship between the element or ingredient and other elements or ingredients in the composition or description in which the parts by weight are recited. Thus, in a compound containing 2 parts by weight of component X and 5 parts by weight of component Y, X and Y are present in a weight ratio of 2:5, and are included in such ratio regardless of whether additional components are included in the compound.

[0078] Weight percent (wt.%) of an ingredient is based on the total weight of the formulation or composition in which the ingredient is included, unless specifically stated otherwise.

[0079] As used herein, the term "optional" or "optionally" means that the event or circumstance described below may or may not occur, and that the description includes instances when the event or circumstance occurs and instances when it does not occur.

[0080] As used herein, the term "subject" refers to the target of administration, e.g., an animal. Thus, the individual in the methods disclosed herein can be a vertebrate, such as a mammal, fish, bird, reptile, or amphibian. Alternatively, the individual in the methods disclosed herein can be a human, a non-human primate, a horse, a pig, a rabbit, a dog, a sheep, a goat, a cow, a cat, a guinea pig, or a rodent. The term does not denote a particular age or sex. Thus, it is intended to include adult and newborn individuals, as well as fetuses, whether male or female. In some embodiments, the individual is a mammal. A patient refers to an individual suffering from a disease or disorder. The term "patient" includes human and animal individuals. In some embodiments of the disclosed methods, the individual has been diagnosed as needing treatment for cardiac dysfunction, e.g., a cardiac ischemia / reperfusion event, prior to the administering step.

[0081] As used herein, the term "treatment" refers to the medical management of an individual or patient with the intent to cure, ameliorate, stabilize, or prevent a disease, pathological condition, or disorder, such as injured myocardium. This term includes active treatment, i.e., treatment specifically directed at ameliorating the disease, pathological condition, or disorder, and causal treatment, i.e., treatment directed at eliminating the causes associated with the disease, pathological condition, or disorder. In addition, this term includes palliative treatment, i.e., treatment designed for the relief of symptoms rather than cure of the disease, pathological condition, or disorder; preventive treatment, i.e., treatment aimed at minimizing or partially or completely inhibiting the progression of the associated disease, pathological condition, or disorder; and supportive treatment, i.e., treatment used to supplement another specific therapy directed at ameliorating the associated disease, pathological condition, or disorder. In various embodiments, the term encompasses any treatment of an individual, including a mammal (e.g., a human), and includes (i) preventing the disease from occurring in an individual who may be affected but has not yet been diagnosed with the disease, (ii) inhibiting the disease, i.e., halting its progression, or (iii) palliating the disease, i.e., causing regression of the disease. In some embodiments, the disease, pathological condition, or disorder is heart failure, such as a cardiac ischemia / reperfusion event.

[0082] As used herein, the terms "prevent" or "preventing" mean to prevent, avert, obviating, forestalling, stopping, or hindering something from happening, especially by prior action. Where reduce, inhibit, or prevent is used herein, it is to be understood that the use of the other two words is also expressly disclosed, unless specifically indicated otherwise.

[0083] As used herein, the term "diagnosed" means subject to a physical examination by a skilled person, such as a physician, and found to have a condition that can be diagnosed or treated by the compositions or methods disclosed herein. For example, "diagnosed with sepsis" means subject to a physical examination by a skilled person, such as a physician, and found to have a condition that can be diagnosed or treated by a compound or composition that alleviates or ameliorates sepsis. Such a diagnosis can be related to a disorder such as sepsis, as described herein.

[0084] As used herein, phrases such as "identified to be in need of treatment for a disorder" refer to the selection of an individual in need of treatment for a disorder. For example, an individual may be identified as being in need of treatment for a disorder (e.g., a disorder associated with sepsis or neonatal sepsis) based on an earlier diagnosis by a skilled person and then be placed on treatment for the disorder. It is contemplated that the identification may, in some embodiments, be performed by a person different from the person making the diagnosis. It is also contemplated that, in further embodiments, the administration may be performed by the person subsequently performing the administration.

[0085] As used herein, the terms "administering" and "administration" refer to any method for providing a pharmaceutical preparation to an individual. Such methods are known to those skilled in the art and include, but are not limited to, intracardiac, oral, transdermal, inhalation, intranasal, topical, intravaginal, ocular, intraaural, intracerebral, rectal, sublingual, buccal, and parenteral administration, such as injectable, intravenous, intraarterial, intramuscular, and subcutaneous administration. Administration can be continuous or intermittent. In various embodiments, the preparation can be administered pharmaceutically; i.e., to treat an existing disease or condition. In further various embodiments, the preparation can be administered prophylactically; i.e., to prevent a disease or condition.

[0086] As used herein, the term "contacting" means bringing together a disclosed compound and a cell, target receptor, or other biological entity in such a manner that the compound can affect the activity of the target (e.g., receptor, transcription factor, cell, etc.) either directly (i.e., by interacting with the target itself) or indirectly (i.e., by interacting with another molecule, cofactor, or protein on which the activity of the target depends, etc.).

[0087] As used herein, the term "determining" can mean measuring or ascertaining the quantity or amount or change in the expression and / or activity level of, e.g., a nucleotide or transcript or polypeptide associated with an enterovirus. For example, determining the amount of a disclosed enterovirus transcript or polypeptide in a sample as used herein can refer to steps one of skill in the art can take to measure or ascertain some quantifiable value of the transcript or polypeptide in a sample. Those of skill in the art are familiar with methods for measuring the amount of the disclosed nucleotides, transcripts, polypeptides, etc.

[0088] As used herein, the term "level" refers to the amount of a target molecule in a sample, such as a sample from an individual. The amount of a molecule can be determined by any method known in the art and will depend, to some extent, on the type of molecule (i.e., gene, mRNA, cDNA, protein, enzyme, etc.). Those skilled in the art are familiar with quantification methods for nucleotides (e.g., genes, cDNA, mRNA, etc.) and proteins, polypeptides, enzymes, etc. It should be understood that the amount or level of a molecule in a sample need not be measured as an absolute value, but can be determined as a relative value (e.g., when compared to a control or sham or untreated sample).

[0089] As used herein, "effective amount" and "effective amount" refer to an amount sufficient to achieve a desired result or to alleviate undesired symptoms. For example, a "therapeutically effective amount" refers to an amount sufficient to achieve a desired therapeutic result or to alleviate undesired symptoms, but generally insufficient to cause adverse side effects. The specific therapeutically effective dose level for any particular patient will depend on various factors, such as the disorder being treated and the severity of the disorder; the specific composition being applied; the patient's age, weight, mental health, sex, and diet; the time of administration; the route of administration; the excretion rate of the specific compound being applied; the duration of treatment; the specific compound being applied; drugs used in combination or simultaneously; and factors well known in the pharmaceutical arts.

[0090] By "modulate" is meant to change by increasing or decreasing. As used herein, a "modulator" can refer to a composition that can increase or decrease the expression or activity level of a gene or a gene product, such as a peptide. Modulation in expression or activity need not be complete. For example, expression or activity can be modulated by about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%, 99%, 100%, or any percentage therebetween, compared to a control cell in which the expression or activity of the gene or gene product is not modulated by the composition.

[0091] As used herein, "antiviral agents" refers to antiviral agents known to those of skill in the art, such as, but not limited to, Abacavir, Aciclovir, Acyclovir, Adefovir, Amantadine, Aprenavir, Ampligen, Arbidol, Atazanavir, Atripla, Balavir, Boceprevirert, Cidofovir, Combivir, Dolutegravir Dolutegravir, Darunavir, Delavirdine, Didanosine, Docosanol, Edozudine, Efavirenz, Emtricitabine, Enfuvirtide, Entecavir, Ecoliver, Famciclovir, Fomivirsen, Fosamprenavir, Foscarnet, Fosfonet, Fusion Inhibitors Inhibitors, Ganciclovir, Ibacitabine, Imunovir, Idoxuridine, Imiquimod, Indinavir, Inosine, Integrase inhibitor, Interferon type III, Interferon type II, Interferon type II), Interferon, Lamivudine, Lopinavir, Loviride, Maraviroc, Moroxydine, Methisazone, Nelfinavir, Nevirapine, Nexavir, Nucleoside analogues, Oseltamivir (Tamiflu®), Peginterferon alfa-2a, Penciclovir, Peramivir, Podophyllotoxin, Protease inhibitors (Pharmacology), Raltegravir, Reverse transcriptase inhibitors transcriptase inhibitor, Ribavirin, Rimantadine, Ritonavir, Pyramidine, Saquinavir, Sofosbuvir, Stavudine, Synergistic enhancer (antiretroviral), Tea tree oil, Telaprevir, Tenofovir, Tenofovir disoproxildisoproxil, tipranavir, trifluridine, trizivir, tromantadine, Truvada, traporved, valaciclovir (Valtrex®), valganciclovir, vicriviroc, vidarabine, viramidine, zalcitabine, zanamivir (Relenza®), and zidovudine.

[0092] As used herein, "EC 50 " is intended to mean the concentration or dose of a substance (e.g., a compound or drug) required for a 50% increase or activation of a biological process or component of a process, e.g., a protein, subunit, organelle, ribonucleoprotein, etc. 50 EC also refers to the concentration or dose of a substance that is required for a 50% increase or activation in vivo, as further defined elsewhere herein. Alternatively, EC 50The term "response" may refer to the concentration or dose of a compound that induces a response intermediate between the baseline and maximum response. Responses can be measured in an in vitro or in vivo system that is convenient and appropriate for the biological response of interest. For example, responses can be measured in vitro using cultured endothelial cells or in ex vivo organ culture using isolated cells. Alternatively, responses can be measured in vivo using appropriate research models, such as rodents, including mice and rats. The mice or rats can be inbred strains with phenotypic characteristics of interest, such as susceptibility to sepsis. Where appropriate, responses can be measured in transgenic or knockout mice or rats, in which a gene or genes have been introduced or knocked out appropriately to reproduce a disease process.

[0093] As used herein, "IC 50 " means the concentration or dose of a substance (e.g., a compound or drug) required for 50% inhibition or reduction of a biological process or component of a process, e.g., a protein, subunit, organelle, ribonucleoprotein, etc. 50 IC also refers to the concentration or dose of a substance that is required for 50% inhibition or reduction in vivo, as further defined elsewhere herein. Alternatively, IC 50The term "inhibitory concentration" also refers to the inhibitory concentration (IC) or half-maximal (50%) inhibitory dose of a substance. Responses can be measured in in vitro or in vivo systems that are convenient and appropriate for the biological response of interest. For example, responses can be measured in vitro using cultured cardiac cells for disorders such as myopericarditis, or in ex vivo organ culture systems using isolated cardiac cells (e.g., cardiomyocytes, vascular smooth muscle cells, epithelial cells, etc.). Alternatively, responses can be measured in vivo using appropriate research models, such as rodents, including mice and rats. The mice or rats can be inbred strains with phenotypic characteristics of interest, such as susceptibility to sepsis. Where appropriate, responses can be measured in transgenic or knockout mice or rats, in which a gene or genes have been introduced or knocked out as appropriate to recapitulate a disease process.

[0094] The term "pharmaceutically acceptable" refers to a material that is not biologically or otherwise undesirable, i.e., does not cause unacceptable levels of undesirable biological effects or interact in a deleterious manner. As used herein, the term "pharmaceutically acceptable carrier" refers to sterile aqueous or non-aqueous solutions, dispersions, suspensions, or emulsions, and sterile powders for reconstitution into sterile injectable solutions or dispersions immediately prior to use. Examples of suitable aqueous or non-aqueous carriers, diluents, solvents, or vehicles include water, ethanol, polyols (e.g., glycerol, propylene glycol, polyethylene glycol, etc.), carboxymethylcellulose, and suitable mixtures thereof, vegetable oils (e.g., olive oil), and injectable organic esters such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of coating materials such as lecithin, by maintaining the required particle size in the case of dispersions, and by the use of surfactants. These compositions may also contain auxiliary agents such as preservatives, wetting agents, emulsifying agents, and dispersing agents. Prevention of microbial action can be ensured by the inclusion of various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, sorbic acid, etc. It may also be desirable to include isotonic agents, such as sugars and sodium chloride. Delayed absorption of injectable dosage forms can be achieved by including agents, such as aluminum monostearate and gelatin, which delay absorption. Injectable depot preparations can be made by forming microencapsulated matrices of drugs in biodegradable polymers, such as polylactide-polyglycolide, polyorthoesters, and polyanhydrides. Depending on the ratio of drug to polymer and the properties of the specific polymer used, the rate of drug release can be controlled. Injectable depot preparations can also be prepared by entrapping drugs in liposomes or microemulsions that are compatible with body tissues.Injectable formulations can be sterilized, for example, by filtration through a bacteria-retaining filter, or by incorporating sterilized agents in the form of a sterile solid composition that can be dissolved or dispersed in sterile water or other sterile injectable medium immediately before use. Suitable inert carriers can include, for example, sugars such as lactose. Preferably, at least 95% by weight of the particles of the active ingredient have an effective particle size in the range of 0.01 to 10 μm.

[0095] Disclosed are compounds used to prepare the compositions of the invention and the compositions themselves used in the methods disclosed herein. These and other materials are described herein, and even if specific reference to various individual and collective combinations and permutations of each of these compounds is not explicitly disclosed, it should be understood that combinations, subsets, interactions, groups, etc. of these materials are included in the disclosure, each specifically contemplated and described herein. For example, if a particular compound is disclosed and described, and many modifications that can be made to many molecules comprising said compound are described, each combination and permutation of the compound, and modifications that are possible unless specifically indicated otherwise, are expressly included in the contemplated list. Thus, if types of molecules A, B, and C are disclosed, and similarly, examples of types of molecules D, E, and F and molecular combination AD are disclosed, each is considered individually and collectively, even if each is not individually listed, i.e., the combinations AE, AF, BD, BE, BF, CD, CE, and CF are considered to be disclosed. Similarly, any subsets or combinations of these are also disclosed. Thus, for example, a subset of AE, BF, and CE would also be considered disclosed. This concept applies to all aspects of this application, including, but not limited to, steps in methods of making and using the compositions of the invention. Thus, where there are various additional steps that may be performed, it should be understood that each of these additional steps may be performed with any particular embodiment or combination of embodiments of the methods of the invention.

[0096] The present invention may be understood more readily by reference to the following detailed description of the invention and the examples included therein.

[0097] All documents cited herein are incorporated by reference to disclose and describe the methods and / or materials in connection with which the documents are cited. The documents cited herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein should be construed as an admission that the present invention is not entitled to antedate such document by virtue of prior invention. Further, the dates of publication provided herein may be different from the actual publication dates, which may require independent confirmation. [Example]

[0098] The following examples are put forth so as to provide those of skill in the art with a complete disclosure and description of how the compounds, compositions, articles, devices, and / or methods claimed herein may be made and evaluated, and are intended to be purely exemplary of the invention and in no way to limit the scope of what the inventors regard as their invention. However, those of skill in the art should, in light of the present disclosure, appreciate that many changes can be made in the specific embodiments which are disclosed and still obtain like or similar results without departing from the spirit and scope of the invention.

[0099] Efforts have been made to ensure accuracy with respect to numbers (e.g., amounts, temperatures, etc.), but some errors and deviations may be included. Unless otherwise indicated, parts are parts by weight, temperature is in °C or is at ambient temperature, and pressure is at or near atmospheric.

[0100] Example 1 Design and Implementation of a Study to Investigate the Efficacy of Pleconaril as an Antiviral Treatment for Neonatal Enterovirus Infection 1. Study Population Sixty-one subjects were enrolled: 43 randomly assigned to the treatment group and 18 to the placebo group (Figure 1). Of these, 43 (70%) were confirmed EV positive, i.e., 31 in the treatment group and 12 in the placebo group. The study was terminated prematurely due to expiration of study reagents. The frequency of premature treatment discontinuation and protocol discontinuation did not differ between study groups (9% vs. 28%, p = 0.11, and 56% vs. 72%, p = 0.27, respectively); however, there were differences in reasons for protocol discontinuation (p = 0.04): 10 of 43 (23%) subjects died in the treatment group vs. 8 of 18 (44%) in the placebo group, and 9 of 43 (21%) subjects were lost to follow-up in the treatment group vs. 1 of 18 (6%) in the placebo group. Neonates with suspected EV sepsis (hepatitis, coagulopathy, and / or myocarditis) were enrolled between June 1999 and December 2010 at 19 centers.

[0101] 2. Study Design A 2:1 drug:placebo randomization with varying block sizes was used. Randomization codes were available only to the biostatistician at the coordinating center. Subjects initially received 5.0 mg / kg / dose of a 40 mg / mL liquid formulation of pleconaril (ViroPharma, Inc., Exton, PA) or a matching placebo identical in composition but containing no active study drug. The liquid formulation expired on May 31, 2002, after which the formulation was changed by the manufacturer to a 40 mg / mL suspension. Subjects received 8.5 mg / kg / dose of pleconaril suspension (shown to provide similar drug exposure as 5.0 mg / kg / dose of pleconaril liquid) or a matching placebo. Both the pleconaril formulation and matching placebo were administered orally or via orogastric tube in 1.0 mL of breast milk or formula every 8 hours for 7 days to subjects who were otherwise NPO. Subjects were permitted to receive antibiotics, acyclovir, cardiac medications, and IVIG. In subjects with documented disease etiology other than EV infection after enrollment, the study drug / placebo was discontinued.

[0102] 3. Sample size and statistical analysis Consistent with the expectation that approximately 67% of enrolled subjects would be confirmed with EV infection, a target sample size of 45 subjects with confirmed EV disease was selected to provide sufficient power to detect a 96% to 70% reduction in oropharynx shedding virus at day 5. Subjects with confirmed EV disease (culture- or PCR-positive) were included in virologic and clinical efficacy analyses, all enrolled subjects were included in safety studies, and pleconaril recipients for whom pharmacokinetic data were available (whether EV-infected or not) were included in pharmacokinetic analyses. Survival analyses were performed for all enrolled groups and for subjects with confirmed EV disease.

[0103] Fisher's exact test was used to compare categorical factors, and the Kruskal-Wallis test and Mann-Whitney test were used for continuous factors, with medians and ranges shown. Kaplan-Meier curves and log-rank statistics were used to assess differences in incubation duration, PCR positivity, and survival rates between study groups. Changes from baseline in the degree of toxicity and the incidence of side effects were compared using the chi-square test.

[0104] Example 2 Virologic Efficacy of Pleconaril Nineteen subjects in the treatment group and seven subjects in the placebo group were culture-positive at any site during the treatment period, and 31 subjects in the treatment group and 12 subjects in the placebo group were PCR-positive at any site during the treatment period. All culture-positive subjects were also PCR-positive. Six of 24 EV-confirmed subjects (25%) in the treatment group and three of 10 (30%) in the placebo group had positive oropharyngeal cultures on day 1, and no subjects shed culturable virus from the oropharynx on day 5 (Figure 2). The median time for oropharyngeal cultures to remain negative was 3.0 days in both the treatment and placebo groups. Among subjects with positive cultures from any site, those in the treatment group became culture-negative faster at all sites than those in the placebo group (a trend was observed (p=0.008)): the median time to culture negativity among culture-positive subjects in the treatment group was 4.0 days compared with 7.0 days in the placebo group (Figure 3). A similar pattern was observed in urine (median time to remain culture-negative = 4.0 days vs. 7.0 days, respectively; p=0.005; Figure 3), but not in other individual sites.

[0105] Example 3 Clinical Efficacy of Pleconaril Of all enrolled subjects, 10 of 43 (23%) in the treatment group and 8 of 18 (44%) in the placebo group died, with cumulative survival over 2 months being greater in the treatment group (p=0.02). Of subjects with confirmed EV, 7 of 31 (23%) in the treatment group and 5 of 12 in the placebo group died, with a trend toward higher cumulative survival in the treatment group. Cumulative survival in the treatment group continued to exceed that of the placebo group for over 18 months (p=0.07 among all subjects and p=0.23 among subjects with confirmed EV).

[0106] 1. Materials and Methods Specimens for EV culture and nucleic acid amplification (PCR) were obtained from the oropharynx, rectum, urine, and serum on days 1–5, 7, 10, and 14. Plasma for pharmacokinetic analysis was obtained on day 1 (2, 4, and 8 hours after study drug administration) and days 3 and 7 (predose and 2 and 4 hours after administration). Hematology and chemistry tests were performed on study days 1, 3, 5, 7, 10, and 14, and urine analysis on days 1 and 7. Persistent abnormalities were addressed at visits at 2, 6, 12, 18, and 24 months. Side effects were recorded at each evaluation, and their relationship to study treatment was determined by the site physician.

[0107] The primary endpoint was the proportion of patients with positive viral cultures from the oropharynx 5 days after initiation of study drug. Secondary endpoints included duration of positive cultures from the oropharynx, rectum, urine, and serum; changes in laboratory values ​​reflecting resolution or progression of EV disease or drug toxicity; duration of hospitalization; time to resolution of organ abnormalities; survival; and pleconaril pharmacokinetics. Tertiary endpoints included duration of blood products (freshly frozen plasma, packed red blood cells, platelets, other products) and inotropic support.

[0108] Example 4 Safety Analysis of Pleconaril Eighty-six percent of subjects enrolled in the treatment group and 94% in the placebo group experienced adverse events, of which only 3% and 18%, respectively, experienced events judged to be possibly / probably related to treatment. The distribution of number and severity of events / subject was similar between groups. Only one subject (placebo group) experienced a serious adverse event considered possibly / probably related to treatment. Other than the identification of herpes simplex virus as the cause of illness (3 subjects) or death (5 subjects), no subjects withdrew from treatment due to adverse events.

[0109] As shown in the examples above, viral cultures had unexpectedly low yields. Indicators of potential virologic efficacy were positive; the time to negative cultures from all sites combined was shorter in the pleconaril group, and the duration of PCR positivity from OP was shorter in the pleconaril group. In addition, differences in survival suggest potential clinical efficacy. The similar AE profile between groups and the rarity of AEs attributable to study treatment indicate safety. Pleconaril concentrations were IC after D1. 90 The concentration at D1 was 41% and the IC 90 The smaller response rate suggests the need for a loading dose. The efficacy signal and absence of safety concerns demonstrate the efficacy of pleconaril for the treatment of neonatal EV disease.

[0110] TIFF2026004455000002.tif112157

Claims

1. A composition comprising an improved formulation of pleconaril.

2. 10. The composition of claim 1, comprising an oral formulation of pleconaril comprising a pharmaceutically acceptable oil, a pharmaceutically acceptable ester mixture, a saturated fatty acid, a hydrofluorocarbon, and / or combinations thereof.

3. 10. The composition of claim 1, wherein the formulation comprises a nanoemulsion of pleconaril, and the particle size of the pleconaril comprises 50-500 nm, 50-400 nm, 50-300 nm, 100-200 nm, or 100 nm.

4. 10. The composition of claim 1, wherein the composition comprising pleconaril is incorporated into a polymeric phospholipid micelle, the polymeric phospholipid micelle comprising PEG, PEG conjugated to a hydrophobic diacyl phospholipid, phosphatidylcholine, or egg phosphatidylcholine, and the particle size of the polymeric phospholipid micelle comprises 5-100 nm, 5-80 nm, 10-50 nm, or 10 nm.

5. 2. The composition of claim 1, wherein the composition comprising pleconaril comprises an oral formulation, the oral formulation comprising colloidal particles of pleconaril, optionally combined with carrier particles, the carrier particles comprising silica particles, PEG, or hydroxymethylpropylmethylcellulose.

6. 10. The composition of claim 1, wherein the composition comprising pleconaril comprises an oral formulation, wherein the oral formulation comprises particles of pleconaril incorporated into a cyclic oligosaccharide, wherein the cyclic oligosaccharide comprises 2-hydroxypropyl-β-cyclodextrin, methyl-β-cyclodextrin, or sulfobutyl-β-cyclodextrin.

7. 10. The composition of claim 1, wherein the composition comprising pleconaril comprises an oral formulation, the oral formulation comprises an oil-in-water microemulsion, the oil in the oil-in-water microemulsion comprises a medium-chain triglyceride, a hydrogenated pharmaceutically acceptable oil, or ethyl alcohol, and the particle size of the microemulsion is 1-100 nm, 5-90 nm, 5-50 nm, or 8-12 nm.

8. 10. The composition of claim 1, wherein the composition comprising pleconaril comprises an oral formulation, the oral formulation comprising a spray-dried emulsion of pleconaril combined with a digestible oil.

9. The composition of any one of claims 1 to 8, further comprising a pharmaceutically acceptable salt of pleconaril.

10. 10. The composition of any one of claims 1 to 9, wherein the formulation is designed for delivery via oral, transdermal, inhalation, intranasal, topical, intravaginal, ocular, intraaural, intracerebral, rectal, sublingual, buccal, and parenteral, injectable, intravenous, intraarterial, intramuscular, or subendothelial administration, and wherein the composition comprising pleconaril is optionally incorporated into a sustained release composition.

11. 11. The composition of any one of claims 1 to 10, wherein the formulation is selected from the group consisting of abacavir, acyclovir, adefovir, amantadine, amprenavir, ampligen, arbidol, atazanavir, atripla, baravir, boceprevir, cidofovir, combivir, dolutegravir, darunavir, delavirdine, didanosine, docosanol, edzudin, efavirenz, emtricitabine, enfuvirtide, entecavir, ecoliver, famciclovir, fomivirsen, fosamprenavir, foscarnet, phosphonet, fusion inhibitors, ganciclovir, ibacitabine, immunovir, idoxuridine, imiquimod, indinavir, inosine, integrase inhibitors, interferon type III, interferon type II, interferon type I, interferon, lamivudine, lopinavir, loviride, maraviroc, mogamulizumab, thiazolinone ... The composition further comprises one or more additional antiviral agents, including roxyzine, methisazone, nelfinavir, nevirapine, nexavir, a nucleoside analog, oseltamivir (Tamiflu®), peginterferon alfa-2a, penciclovir, peramivir, podophyllotoxin, a protease inhibitor, raltegravir, a reverse transcriptase inhibitor, ribavirin, rimantadine, ritonavir, pyramidine, saquinavir, sofosbuvir, stavudine, a synergistic enhancer (antiretroviral agent), telaprevir, tenofovir, tenofovir disoproxil, tipranavir, trifluridine, trizivir, tromantadine, Truvada, Trapolbed, valacyclovir (Valtrex®), valganciclovir, vicriviroc, vidarabine, viramidine, zalcitabine, zanamivir (Relenza®), or zidovudine.

Images