Dibotentan and dapagliflozin combination for the treatment of chronic kidney disease

Abstract

To provide a pharmaceutical product for use in the treatment of chronic kidney disease (CKD) in human patients. [Solution] A pharmaceutical is provided for use in human patients with chronic kidney disease to reduce the urinary albumin-creatinine ratio (UACR) and reduce the incidence of cardiovascular or renal death, comprising the endothelin receptor antagonist (ERA) dibotentan or a pharmaceutically acceptable salt thereof, wherein dibotentan or a pharmaceutically acceptable salt thereof is administered in combination with the sodium-dependent glucose cotransporter 2 (SGLT-2) inhibitor dapagliflozin.

Description

[Technical Field]

[0001] This disclosure relates to the endothelin receptor antagonist (ERA) dibotentan in combination with the sodium-dependent glucose cotransporter 2 (SGLT-2) inhibitor dapagliflozin for use in the treatment of certain endothelin-related disorders. [Background technology]

[0002] Endothelin-1 (ET-1) is a potent vasoconstrictive peptide. It interacts with endothelin A and B receptors (ET-1). A and ET B ET-1, regulated by endothelin A (ET), is a very potent systemic vasoconstrictor and a driver of renal disease progression. In chronic kidney disease (CKD), ET-1 levels increase with urinary albumin-creatinine ratio (UACR) and severity of renal impairment (Non-patent Literature 1; Non-patent Literature 2). The pathological effects of ET-1, including proteinuria, vasoconstriction, and inflammation, are linked to endothelin A (ET). A It is thought to be predominantly driven by receptors (Non-Patent Literature 3). ET A Antagonists have demonstrated renal protective effects. In diabetic nephropathy (DKD), a 30% reduction in the urinary albumin-to-creatinine ratio (UACR) has been demonstrated (Non-Patent Literature 4; Non-Patent Literature 5). However, ET A Clinical development with receptor antagonists has been limited due to hospitalization issues related to fluid retention and heart failure (Non-Patent Literature 5). Dibotentan is a potent ET developed for the treatment of prostate cancer. A Although it is a receptor antagonist, it was discontinued in 2011 due to insufficient efficacy in phase 3 and a 17% increase in the incidence of peripheral edema compared to placebo.

[0003] SGLT-2 inhibitors reduce osmotic diuresis, increased urine volume, and fluid overload largely independent of changes in systemic sodium load as a result of diabetes. SGLT-2 inhibitors block glucose reabsorption in the kidneys, increasing glucose excretion and lowering blood glucose concentration. In addition to this well-characterized mechanism of action, SGLT-2 inhibitors lower blood pressure, reduce vascular stiffness, improve endothelial function, and possess anti-inflammatory and anti-fibrotic properties similar to those of ERA (Non-Patent Literature 6). SGLT2 inhibitors have demonstrated efficacy in DKD (Non-Patent Literature 7). Dapagliflozin was investigated for its efficacy in CKD in the DAPA-CKD clinical trial, which was recently discontinued early due to overwhelming efficacy. A post-hoc analysis of the SONAR clinical trial, presented at the 2019 US Kidney Disease Week meeting in Washington, DC, showed that ET A In a subset of DKD patients (n=14) taking both the antagonist atrasenetan and an SGLT2 inhibitor, there was an increased reduction in UACR and a decrease in weight gain induced by atrasenetan as a substitute for fluid retention compared to atrasenetan alone.

[0004] Dibotentan, N-(3-methoxy-5-methylpyrazine-2-yl)-2-[4-(1,3,4-oxadiazole-2-yl)phenyl]pyridine-3-sulfonamide has the chemical structure of formula I. [ka] Dibotentan, also known as ZD4054, is disclosed in Patent Document 1 as an entothelin receptor antagonist, along with details of its chemical synthesis. Specific inhibition of the endothelin A receptor by dibotentan has been reported in Non-Patent Document 8.

[0005] Dapagliflozin, (1S)-1,5-anhydro-1-{4-chloro-3-[(4-ethoxyphenyl)methyl]phenyl}-D-glucitol has the chemical structure of Formula II.

Chemical Formula

[0006] When the specific inhibitor of endothelin A receptor, dibotentan, is combined with the SGLT-2 inhibitor dapagliflozin, the diuretic effect of dapagliflozin is reduced by the fluid retention side effect associated with the endothelin receptor antagonist dibotentan, and as a result, both risks associated with each individual compound can be reduced.

[0007] As used herein, dapagliflozin reduces the hemodilution driven by dibotentan (hemodilution is defined as a decrease in hematocrit concentration), and thus is shown to highlight the potential regarding the combination of dibotentan and dapagliflozin to demonstrate efficacy in the treatment of certain endothelin-related diseases.

[0008] Endothelin-1, which is regulated by endothelin A and B receptors (ET A and ET B ), is a very potent systemic vasoconstrictor and a driver factor for the progression of kidney diseases.

[0009] ET A antagonist blockers improve renal function while ET BAlso removes circulating endothelin-1, ET B Blockers are not preferable.

[0010] Endothelin-related disorders are associated with increased vasoconstriction, proliferation, or inflammation caused by endothelin in many cardio-renal metabolic diseases. Examples of such endothelin-related disorders include hypertension, coronary artery disease, heart failure, renal and myocardial ischemia, and chronic kidney disease (CKD). In particular, CKD associated with hypertension or diabetes (diabetic nephropathy, DKD). ERA may be beneficial in the treatment of peripheral artery occlusive diseases, including diabetic arteriopathic disease, due to its acute (peripheral vasodilation) and chronic (improvement in vasodilation, vascular structure, and sympathetic nerve activity, antithrombotic, and anti-inflammatory) effects.

[0011] The mechanism of action of SGLT-2 is thought to involve the simultaneous inhibition of glucose and sodium uptake in the renal proximal tubules of nephrons, resulting in a reset of tubuloglomerular feedback that presumably leads to the phenomenon of glomerular hyperfiltration. The efficacy of SGLT-2 inhibitors is thought to be reduced by low plasma glucose levels or decreased glomerular filtration rate (GFR), and therefore, SGLT-2 inhibitors have an inherently low risk of developing hypoglycemia. As a result, the properties of SGLT-2 inhibitors may open up avenues for treating HF, including HFpEF, even in non-diabetic patients (Non-Patent Literature 9).

[0012] The pharmacological effects and associated side effects of SGLT-2 inhibitors include fluid volume reduction / decreased vascular volume, potentially causing dehydration, hypovolemia, orthostatic hypotension, or hypotension. Therefore, SGLT-2 inhibitors generally induce elevated hematocrit (Hot) and increased blood viscosity, markers of blood concentration, which are the putative cause of vascular damage associated with peripheral vascular disease.

[0013] Serum creatinine is increased, and eGFR is decreased due to the pharmacological effects of SGLT-2 inhibitors. ADibotentan, an ERA that causes effective receptor blockade, may be suitable for the treatment of endothelin-related disorders when prescribed in combination with dapagliflozin. When an ERA is combined with an SGLT-2 inhibitor, the diuretic effect and potential pharmacological effect of such an SGLT-2 inhibitor in reducing the risk of heart failure may be favorable in mitigating the most prominent side effects generally associated with ERAs, such as fluid retention and a potentially associated increased risk of congestive heart failure. While such combination therapy may result in the disclosed pharmacological effects on endothelin-related disorders, even the optimal effective dose of dibotentan, and potentially even increased doses of dibotentan, maintain a favorable side effect profile compared to the maximum tolerated dose of dibotentan alone. When dibotentan is used in combination with dapagliflozin, for example, increased doses of dibotentan that may be attainable due to reduced side effects may amplify the impact on disorders caused by the adverse effects of the endothelin paracrine system, which is widely distributed in organs. Such combination therapy may improve the benefit / risk ratio. ERA is described as lowering hematocrit (Hot) through hemodilution. Therefore, when used in combination with dapagliflozin, dibotentan may mitigate the most significant side effects commonly associated with SGLT-2 inhibitors, such as hemoconcentration due to fluid-reducing effects. ERA is described as improving blood glucose levels through various mechanisms (increased blood flow, improved insulin signaling). Therefore, when used in combination with dapagliflozin, dibotentan may have an additive or synergistic effect on blood glucose reduction. [Prior art documents] [Patent Documents]

[0014] [Patent Document 1] International Publication No. 1996040681 Pamphlet [Patent Document 2] International Publication No. 2003099836 Pamphlet

Non-Patent Literature

[0015]

Non-Patent Literature 1

Non-Patent Literature 2

Non-Patent Literature 3

Non-Patent Literature 4

Non-Patent Literature 5

Non-Patent Literature 6

Non-Patent Literature 7

Non-Patent Literature 8

Non-Patent Literature 9

Summary of the Invention

Means for Solving the Problems

[0016] In the first embodiment, dibotentan is provided for use in the treatment of chronic kidney disease (CKD) in human patients, wherein dibotentan is administered in combination with dapagliflozin.

[0017] In a further embodiment, a method is provided for treating chronic kidney disease (CKD) in a human patient requiring such treatment, comprising administering a therapeutically effective dose of dibotentan to the human patient, wherein dibotentan is administered in combination with a therapeutically effective dose of dapagliflozin.

[0018] In a further embodiment, the use of dibotentan in the manufacture of a pharmaceutical product for the treatment of chronic kidney disease (CKD) in human patients is provided, wherein dibotentan is administered in combination with dapagliflozin. [Brief explanation of the drawing]

[0019] [Figure 1] Example 1 shows the individual blood concentrations of dibotentan in Experiment 1 after oral administration of dibotentan. [Figure 2] The individual blood concentrations of dibotentan in Experiment 2, after oral administration of dibotentan alone or in combination with dapagliflozin, are shown in Example 1. [Figure 3] The individual dapagliflozin blood concentrations in Experiment 2, after oral administration of dapagliflozin alone or in combination with dibotentan, are shown in Example 1. [Figure 4] Example 1 shows the effect of dibotentan on Hct concentration in Experiment 1. [Figure 5] Example 1 shows the effect of dibotentan on body weight in Experiment 1. [Figure 6] The effects of dibotentan, dapagliflozin, and combinations on Hct in Example 1 and Experiment 2 are shown. [Figure 7] The effects of dibotentan, dapagliflozin, and combinations on body weight in Example 1 and Experiment 2 are shown. [Figure 8]The effects of dapagliflozin and dibotentan on diabetes, fluid intake, and food intake in Example 1 and Experiment 2 are shown. [Figure 9] This study demonstrates the effect of dapagliflozin on reducing UACR in patients with CKD and type 2 diabetes, or in patients without type 2 diabetes, from the DAPA CKD Phase 3 clinical trial. [Figure 10] This shows the regression and progression of UACR in patients with CKD, stratified by diabetic status, from the DAPA CKD Phase 3 clinical trial. [Modes for carrying out the invention]

[0020] In the first embodiment, dibotentan is provided for use in the treatment of chronic kidney disease (CKD) in human patients, wherein dibotentan is administered in combination with dapagliflozin.

[0021] In a further embodiment, a method is provided for treating chronic kidney disease (CKD) in a human patient requiring such treatment, comprising administering a therapeutically effective dose of dibotentan to the human patient, wherein dibotentan is administered in combination with a therapeutically effective dose of dapagliflozin.

[0022] In a further embodiment, the use of dibotentan in the manufacture of a pharmaceutical product for the treatment of chronic kidney disease (CKD) in human patients is provided, wherein dibotentan is administered in combination with dapagliflozin.

[0023] In certain embodiments, chronic kidney disease (CKD) is defined as stage 1-4 CKD as defined by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines.

[0024] In a particular embodiment, the CKD is a Stage 2-3 CKD.

[0025] In a particular embodiment, the CKD is a stage 3-4 CKD.

[0026] In a particular embodiment, CKD is a Stage 4 CKD.

[0027] In a particular embodiment, the CKD is a CKD of stage 3a or 3b.

[0028] Dibotentan, N-(3-methoxy-5-methylpyrazine-2-yl)-2-[4-(1,3,4-oxadiazole-2-yl)phenyl]pyridine-3-sulfonamide has the chemical structure of formula I. [ka]

[0029] Dibotentan is also known as ZD4054.

[0030] In the embodiment, dibotentan, or a pharmaceutically acceptable salt thereof, is administered once daily.

[0031] In this embodiment, the total daily dose of dibotentan is approximately 10 mg.

[0032] In this embodiment, the total daily dose of dibotentan is approximately 5 mg.

[0033] In this embodiment, the total daily dose of dibotentan is approximately 1.5 mg.

[0034] In this embodiment, the total daily dose of dibotentan is approximately 0.5 mg.

[0035] In this embodiment, the total daily dose of dibotentan is approximately 0.25 mg.

[0036] In the embodiment, dibotentan, or a pharmaceutically acceptable salt thereof, is in tablet form.

[0037] In some embodiments, dibotentan, or a pharmaceutically acceptable salt thereof, is administered in the form of a pharmaceutical composition comprising one or more pharmaceutically acceptable excipients. In further embodiments, the composition comprises one or more pharmaceutical diluents, one or more pharmaceutical disintegrants, or one or more pharmaceutical lubricants.

[0038] Dapagliflozin, (1S)-1,5-anhydrous-1-{4-chloro-3-[(4-ethoxyphenyl)methyl]phenyl}-D-glucitol has the chemical structure of formula II. [ka]

[0039] In the embodiment, dapagliflozin, or a pharmaceutically acceptable salt thereof, is administered once daily.

[0040] In at least one embodiment, dapagliflozin is in the form of a pharmaceutically acceptable solvate, a mixed solvate, or a complex. In some embodiments provided herein, dapagliflozin is in the form of an amorphous solid. In some embodiments provided herein, dapagliflozin is in the form of a crystalline solid. In some embodiments provided herein, dapagliflozin is in the form of (S)-propylene glycol ((S)-PG) solvate, which has the following structure: [ka]

[0041] In at least one embodiment, dapagliflozin is in the form of a pharmaceutically acceptable solvate, a mixed solvate, or a complex. In some embodiments provided herein, dapagliflozin is in the form of an amorphous solid. In some embodiments provided herein, dapagliflozin is in the form of a crystalline solid.

[0042] In some embodiments provided herein, the pharmaceutical composition is administered orally to the patient. In some embodiments provided herein, the pharmaceutical composition is administered to the patient in tablet form.

[0043] In some embodiments provided herein, a pharmaceutical composition containing dapagliflozin includes a dose equivalent to administering approximately 2.5 mg / day to approximately 10 mg / day of dapagliflozin to a patient. In some embodiments provided herein, a pharmaceutical composition containing dapagliflozin includes a dose equivalent to administering approximately 2.5 mg / day, approximately 5 mg / day, or approximately 10 mg / day of dapagliflozin to a patient. In some embodiments provided herein, a pharmaceutical composition containing dapagliflozin includes a dose equivalent to administering approximately 5 mg / day of dapagliflozin once daily to a patient. In some embodiments provided herein, a pharmaceutical composition containing dapagliflozin includes a dose equivalent to administering approximately 10 mg / day of dapagliflozin once daily to a patient.

[0044] In one embodiment, dibotentan is provided for use in the treatment of CKD in human patients, the treatment comprising the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with CKD. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3.

[0045] In one embodiment, a method is provided for treating CKD in a human patient requiring such treatment, comprising administering a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises the individual, sequential, or simultaneous administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with CKD. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3.

[0046] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical for the treatment of CKD in human patients is provided, the treatment comprising the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with CKD. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3.

[0047] In one embodiment, dibotentan is provided for use in reducing UACR in a human patient, comprising administering i) dibotentan and ii) dapagliflozin to the human patient individually, sequentially, or simultaneously. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0048] In one embodiment, a method is provided for reducing UACR in a human patient requiring such treatment, comprising administering a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises the individual, sequential, or simultaneous administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0049] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical for reducing UACR in human patients is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with CKD. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0050] In one embodiment, dibotentan is provided for use in reducing UACR to <300 mg / g in a human patient, comprising administering i) dibotentan and ii) dapagliflozin to the human patient individually, sequentially, or simultaneously. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0051] In one embodiment, a method is provided for reducing the UACR to <300 mg / g in a human patient requiring such treatment, which includes the administration of a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises the administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin individually, sequentially, or simultaneously to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0052] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical for reducing UACR to <300 mg / g in a human patient is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with CKD. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0053] In one embodiment, dibotentan is provided for use in reducing the risk of progression of UACR to ≥3000 mg / g in a human patient, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0054] In one embodiment, a method is provided for reducing the risk of progression to ≥3000 mg / g of UACR in a human patient requiring such treatment, which includes the administration of a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises the administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin individually, sequentially, or concurrently to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0055] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical product is provided to reduce the risk of progression of UACR to ≥3000 mg / g in a human patient, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with CKD. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0056] In one embodiment, dibotentan is provided for use in reducing the risk of eGFR decline in a human patient, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD who has type 2 diabetes. In another embodiment, the human patient is a human patient with CKD who does not have type 2 diabetes. In some embodiments, its use reduces the risk of a decline of ≥30% in eGFR. In some embodiments, its use reduces the risk of a decrease of ≥40% in eGFR.

[0057] In one embodiment, a method is provided for reducing the risk of eGFR decline in a human patient requiring such treatment, which includes administering a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises administering to the human patient an individual, sequential, or simultaneous dose of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes. In some embodiments, the method reduces the risk of a decrease of ≥30% in eGFR. In some embodiments, the method reduces the risk of a decrease of ≥40% in eGFR.

[0058] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical product to reduce the risk of eGFR decline in human patients is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD who has type 2 diabetes. In another embodiment, the human patient is a human patient with CKD who does not have type 2 diabetes. In some embodiments, its use reduces the risk of a decline of ≥30% in eGFR. In some embodiments, its use reduces the risk of a decrease of ≥40% in eGFR.

[0059] In one embodiment, dibotentan is provided for use in reducing the risk of fluid retention (edema) in a human patient, comprising administering i) dibotentan and ii) dapagliflozin to the human patient individually, sequentially, or simultaneously. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD who has type 2 diabetes. In another embodiment, the human patient is a human patient with CKD who does not have type 2 diabetes. In some embodiments, the reduction in the risk of fluid retention (edema) may be measured, for example, by a decrease in Hct or an increase in body weight.

[0060] In one embodiment, a method is provided for reducing the risk of fluid retention (edema) in a human patient requiring such treatment, which includes the administration of a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises the individual, sequential, or simultaneous administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes. In some embodiments, the reduction in the risk of fluid retention (edema) can be measured, for example, by a decrease in Hct or an increase in body weight.

[0061] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical product for reducing the risk of fluid retention (edema) in a human patient is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD who has type 2 diabetes. In another embodiment, the human patient is a human patient with CKD who does not have type 2 diabetes. In some embodiments, the reduction in the risk of fluid retention (edema) may be measured, for example, by a decrease in Hct or an increase in body weight.

[0062] In one embodiment, dibotentan is provided for use in reducing the total body water content in a human patient, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0063] In one embodiment, a method is provided for reducing total body water in a human patient requiring such treatment, comprising administering a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises the individual, sequential, or simultaneous administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0064] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical for reducing total body water content in a human patient is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0065] In one embodiment, dibotentan is provided for use in lowering blood pressure in a human patient, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0066] In one embodiment, a method is provided for lowering blood pressure in a human patient requiring such treatment, comprising administering a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises the individual, sequential, or simultaneous administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0067] In one embodiment, the use of dibotentan in the manufacture of a pharmacopoeia for lowering blood pressure in a human patient is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0068] In one embodiment, dibotentan is provided for use in reducing the risk of blood pressure elevation in a human patient, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0069] In one embodiment, a method is provided for reducing the risk of elevated blood pressure in a human patient requiring such treatment, which includes administering a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises administering to the human patient an individual, sequential, or simultaneous dose of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0070] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical product for reducing the risk of hypertension in a human patient is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD who has type 2 diabetes. In another embodiment, the human patient is a human patient with CKD who does not have type 2 diabetes.

[0071] In one embodiment, dibotentan is provided for use in reducing the incidence of a ≥40% decrease in eGFR, progression to end-stage renal disease (ESKD), and the composite endpoint of cardiovascular and renal death in human patients, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1–4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3–4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2–3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0072] In one embodiment, a method is provided for reducing the incidence of a ≥40% decrease in eGFR, progression to end-stage renal disease (ESKD), and a composite endpoint of cardiovascular and renal death in a human patient requiring such treatment, the treatment comprising the administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin individually, sequentially, or concurrently to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1–4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3–4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2–3. In a further embodiment, the human patient is a human patient with CKD who has type 2 diabetes. In another embodiment, the human patient is a human patient with chronic kidney disease (CKD) who does not have type 2 diabetes.

[0073] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical product is provided to reduce the incidence of a ≥40% decrease in eGFR, progression to end-stage renal disease (ESKD), and a composite endpoint of cardiovascular and renal death in human patients, wherein the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1–4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3–4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2–3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0074] In one embodiment, dibotentan is provided for use in reducing the incidence of reaching end-stage renal disease (ESKD) in human patients, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0075] In one embodiment, a method is provided for reducing the incidence of reaching end-stage renal disease (ESKD) in human patients requiring such treatment, which includes the administration of a therapeutically effective dose of dibotentan to a human patient, wherein the treatment comprises the administration of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin to a human patient individually, sequentially, or concurrently. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0076] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical product for reducing the incidence of reaching end-stage renal disease (ESKD) in human patients is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0077] In one embodiment, dibotentan is provided for use in reducing the incidence of cardiovascular or renal death in a human patient, comprising administering to the human patient individually, sequentially, or simultaneously: i) dibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0078] In one embodiment, a method is provided for reducing the incidence of cardiovascular or renal death in a human patient requiring such treatment, comprising administering a therapeutically effective dose of dibotentan to the human patient, wherein the treatment comprises administering to the human patient an individual, sequential, or simultaneous dose of i) a therapeutically effective dose of dibotentan and ii) a therapeutically effective dose of dapagliflozin. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0079] In one embodiment, the use of dibotentan in the manufacture of a pharmaceutical product for reducing the incidence of cardiovascular or renal death in a human patient is provided, and the treatment comprises the individual, sequential, or simultaneous administration of i) dibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a human patient with chronic kidney disease (CKD). In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 1-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3-4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 4. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 3a or 3b. In a further embodiment, the human patient is a human patient with CKD classified as a patient of stage 2-3. In a further embodiment, the human patient is a human patient with CKD having type 2 diabetes. In another embodiment, the human patient is a human patient with CKD without type 2 diabetes.

[0080] In any of the above embodiments, the method and its use may also relate to a human patient receiving at least one SGLT2-I (e.g., dapagliflozin, empagliflozin, canagliflozin, etc.) alone or in combination with at least one standard-care CKD drug. In such embodiments, the standard-care CKD drugs may be ACE-Is (e.g., captopril, enalapril, and lisinopril) and / or ARBs (valsartan, losartan, and irbesartan).

[0081] In any of the above embodiments, the method and its use may be relevant to baseline patients. In some embodiments, the method and its use may be relevant to baseline patients compared to patients receiving at least one SGLT2-I, either alone or in combination with at least one standard treatment for CKD.

[0082] In one embodiment, a first pharmaceutical composition comprising dibotentan and a pharmaceutically acceptable carrier; and A second pharmaceutical composition comprising dapagliflozin and a pharmaceutically acceptable carrier. A kit including this will be provided.

[0083] Terms such as "to treat," "treatment," "the act of treating," or "to alleviate" or "the act of alleviating" refer to therapeutic means that cure, slow down, alleviate the symptoms of, and / or halt the progression of, a diagnosed medical condition or disorder. Therefore, those who require treatment include individuals who have already been diagnosed with or are suspected of having a disorder. Patients or subjects requiring treatment may include those diagnosed with CKD.

[0084] "Therapeutic dose" or "effective dose" means the amount of at least one compound of this disclosure, or a pharmaceutical composition containing at least one such compound, that is effective in producing at least one therapeutic effect when administered to a patient as a single dose or as part of a series of doses. The optimal dose can generally be determined using experimental models and / or clinical trials. The design and execution of preclinical and clinical studies for each of the therapeutic agents described herein (including when administered for prophylactic benefit) are well within the scope of the art of those skilled in the art. The optimal dose of a therapeutic agent may be determined by the patient's body mass, weight, and / or blood volume. Patients may generally be monitored for therapeutic efficacy using assays suitable for the disease, disorder, and / or condition being treated or prevented, assays that are well known to those skilled in the art and are described herein. The level of a compound administered to a patient can be monitored by determining the level of the compound (or metabolites of the compound) in patient-derived body fluids, e.g., blood, blood fractions (e.g., serum), and / or urine, and / or other biological samples. To measure the level of a compound in the course of a treatment regimen, any method practiced in the art to detect a compound or its metabolites may be used. Alternatively, the pharmacological and / or physiological effect may be prophylactic, i.e., the effect completely or partially prevents a disease or its symptoms. In this regard, the disclosed method involves administering a “prophylactic effective dose” of a drug (e.g., dibotentan or its pharmaceutically acceptable salts, solvates, mixed solvates, complexes, or prodrugs, and dapagliflozin or its pharmaceutically acceptable salts, solvates, mixed solvates, complexes, or prodrugs). A “prophylactic effective dose” means an amount effective in the dose and duration necessary to achieve the desired prophylactic outcome (e.g., prevention of CKD or disease onset).

[0085] As used herein, the terms “subject” and “patient” are interchangeable. In some embodiments, the subject is a human being.

[0086] As used herein, the term “end-stage renal disease (EKSD)” means (i) having a persistent eGFR < 15 mL / min / 1.73 m2, (ii) undergoing long-term dialysis treatment, or (iii) undergoing a kidney transplant. In some embodiments, “persistent” means confirmation of similar eGFR measurements by a second eGFR test separated by three months.

[0087] The terms “administer,” “give administration,” and “give administration,” as used herein, refer to drugs, for example, dibotentan or its pharmaceutically acceptable salts, solvates, mixed solvates, complexes, or prodrugs as described herein, and methods that may be used to enable the delivery of dapagliflozin or its pharmaceutically acceptable salts, solvates, mixed solvates, complexes, or prodrugs. Administration techniques that may be used in conjunction with the drugs and methods described herein can be found, for example, in Goodman and Gilman, The Pharmacological Basis of Therapeutics, current edition, Pergamon; and Remington's, Pharmaceutical Sciences, current edition, Mack Publishing Co., Easton, Pa. In some embodiments, dibotentan and dapagliflozin are administered orally.

[0088] The terms "pharmaceutical preparation" and "pharmaceutical composition" refer to preparations that are in a form that allows the biological activity of the active ingredient to be effective and that do not contain additional components that are unacceptably toxic to the subject to which the preparation will be administered. Such preparations may be sterile.

[0089] A "pharmaceutically acceptable carrier" refers to a non-toxic solid, semi-solid, or liquid filler, diluent, encapsulating material, formulation aid, or carrier that is customary in the art for use with a therapeutic agent comprising a "pharmaceutical composition" for administration to a subject. A pharmaceutically acceptable carrier is non-toxic to the recipient at the dose and concentration used and is compatible with the other components of the formulation. A pharmaceutically acceptable carrier is appropriate for the formulation used.

[0090] A “sterile” preparation is sterile or essentially free of living microorganisms and their spores.

[0091] As used herein, the term “prodrug” refers to, for example, esters and carbonates that can be converted to dibotentan or dapagliflozin under physiological conditions or by solvolysis. Therefore, the term prodrug includes pharmaceutically acceptable metabolic precursors of dibotentan or dapagliflozin. The term prodrug also includes covalently bonded carriers that release dibotentan or dapagliflozin in vivo when administered to a patient. Non-limiting examples of prodrugs include esters and carbonates.

[0092] Various forms of prodrugs are known in this field. Examples of such prodrug derivatives can be found in: (1) Design of Prodrugs, edited by H. Bundgaard, (Elsevier, 1985) and Methods in Enzymology, Vol. 42, pp. 309-396, edited by K. Widder, et al. (Academic Press, 1985); (2) A Textbook of Drug Design and Development, edited by Krogsgaard-Larsen and H. Bundgaard, Chapter 5 “Design and Application of Prodrugs”, H. Bundgaard, pp. 113-191 (1991); (3) H. Bundgaard, Advanced Drug Delivery Reviews, 8, 1-38 (1992); (4) H. Bundgaard, et al., Journal of Pharmaceutical Sciences, 77, 285 (1988); and (5) N. Kakeya, et al., Chem Pharm See Bull, 32, 692 (1984).

[0093] Whenever an aspect is described herein with the word “comprises,” it should be understood that similar aspects described with the terms “consist of” and / or “essentially from” are also provided. In this disclosure, “comprises,” “comprising,” “contains,” and “have,” etc., can mean “includes,” “including,” etc.; “essentially from” or “essentially from” is open-ended and allows for existences other than those enumerated, provided that the basic or novel characteristics of those enumerated are not altered by such existences, but prior art aspects are excluded.

[0094] Unless otherwise specified or made clear from the context, the term "or" as used herein is understood to be inclusive.

[0095] As used herein, when the terms “about” and “approximately” are used to modify a number or range of numbers, deviations of up to 10% above and 10% below that value or range remain within the intended meaning of the listed value or range. Whenever an aspect is described herein with the words “about” or “approximately” along with a number or range, it should be understood that other similar aspects referring to that particular number or range (without “about”) are also provided. [Examples]

[0096] Experimental Procedure Example 1 The effects of dapagliflozin and dibotentan on hematocrit (Hct) concentration in male Wistar rats on a 4% salt diet were investigated. In Experiment 1, dibotentan was administered orally once daily at doses of 30, 100, or 300 mg / kg for 14 days. On day 7, all three doses of dibotentan resulted in a significant decrease in Hct concentration compared to the solvent (p<0.05). On day 14, a significant decrease in Hct concentration compared to the solvent (p<0.05) was observed for the higher doses of dibotentan (100 mg / kg and 300 mg / kg), but not for the lower dose (30 mg / kg).

[0097] In Experiment 2, Hct concentrations were measured in male Wistar rats fed a 4% salt diet after 7 days of administration of dibotentan (30 or 100 mg / kg) or dapagliflozin (3.0 mg / kg) alone or in combination. Dibotentan (30 or 100 mg / kg) significantly reduced Hct concentrations. Co-administration of dapagliflozin (3.0 mg / kg) and dibotentan (30 mg / kg) resulted in Hct concentrations that were not significantly different from those in solvent-treated animals. Co-administration of dapagliflozin (3.0 mg / kg) and dibotentan (100 mg / kg) attenuated the effect of dibotentan on Hct concentrations, as revealed by one-way ANOVA and post-hoc Tukey test (dibotentan -4.00 ± 0.87 vs. dibotentan + dapagliflozin -1.72 ± 0.68). # (p<0.05). Dibotentan did not affect the effect of dapagliflozin on urinary glucose excretion.

[0098] Materials and methods Formulation for dibotentan alone: ​​30% (w / w) TEG, 2% (w / w) EtOH, 0.5% (w / w) HPMC, 10000 cps, 0.1% (w / w) Tween 80, suspension in 67.4% purified water. Formulation for dapagliflozin alone: ​​30% (w / w) TEG, 2% (w / w) EtOH, 0.5% (w / w) HPMC 10000 cps, 0.1% (w / w) Tween 80, solution in 67.4% purified water. Formulation for the combination of dibotentan and dapagliflozin: 30% (w / w) TEG, 2% (w / w) EtOH, 0.5% (w / w) HPMC, 10000 cps, 0.1% (w / w) Tween 80. Suspension / solution in 67.4% purified water.

[0099] The test was divided into two experiments.

[0100] In the first experiment (Experiment 1), the effect of dibotentan on hematocrit (Hct) concentration was determined when dibotentan was administered orally via (po)QD for 14 days. Three days prior to the first administration of the test drug, animals were randomized to the following groups based on body weight (BW): 1) solvent, 2) dibotentan (30 mg / kg), 3) dibotentan (100 mg / kg), and 4) dibotentan (300 mg / kg). Animals were weighed daily before administration throughout the experiment. Blood samples (20 μL) for bioanalysis were collected from conscious animals via the tail vein 4 and 24 hours after the first administration, and from anesthetized animals via the postorbital pathway 24 hours after the last administration. Blood samples (100 μL) were collected via the tail vein 1-2 hours after administration on days 7 and 14 for Hct concentration and hemoglobin (Hb) measurement. Between the 9th and 10th doses, 24-hour urine samples were collected for measurement of urinary glucose, urine volume, and electrolytes. The animals were slaughtered 24 hours after the last dose. On the day of slaughter, the animals were anesthetized with 5% isoflurane, and blood was collected via the postorbital pathway (in a heparin-coated microvette, Sarsted), centrifuged at 3,500 rpm at 4°C for 10 minutes, plasma was collected, and stored at -80°C before analysis. The animals were then euthanized by removal of the heart. Both the heart and kidneys were removed and weighed. From the right kidney, 4 mm thick tissue sections were collected and fixed in 4% formaldehyde for subsequent histological analysis, and portions of renal cortical tissue and cardiac tissue were collected for gene expression analysis.

[0101] In the second experiment (Experiment 2), the effects of dibotentan and dapagliflozin (alone or in combination) on Hct concentration and Hb were determined. 72 animals were randomized to the following groups for BW and Hct concentrations 2-3 days prior to administration of the test drugs: 1) solvent, 2) dibotentan (30 mg / kg), 3) dibotentan (100 mg / kg), 4) dapagliflozin (3 mg / kg), 5) dibotentan (30 mg / kg) + dapagliflozin (3 mg / kg), and 6) dibotentan (100 mg / kg) + dapagliflozin (3 mg / kg). For practical reasons, the study was conducted in two consecutive timeframes with 36 animals (6 animals / group) in each timeframe. The compounds were administered for 7 days at poQD. Blood samples for bioanalysis were collected 4 and 24 hours after the first dose and 24 hours after the final dose for Hct concentration and Hb analysis on days 3 and 7, as described for Experiment 1. 24-hour urine was collected between the third and fourth doses. 24-hour food and water intake was measured between days 2–3 and 6–7. Using two animals per cage, the food and water intake per animal in the cage was assessed by dividing the total food and water intake for the cage by two.

[0102] The researchers were blinded to the treatment assignment of the animals during terminal blood collection and sample analysis.

[0103] Blood and urine concentrations of dibotentan and dapagliflozin were determined by biochemical analysis using liquid chromatography with mass spectrometry detection (LC-MS / MS).

[0104] Whole blood samples for the bioanalysis of dapagliflozin and dibotentan were prepared according to the same procedure. 20 μL of whole blood was precipitated with 150 μL of acetonitrile containing an internal standard, rapidly vortexed, and then centrifuged at 3220 g and 4°C for 20 minutes. The supernatant was transferred to a new deep-well plate and diluted 1:1 with water prior to LC-MS analysis. Calibration samples and blanks by matrix matching were processed in the same manner as the test samples. The dibotentan sample was further diluted two and three times in a 1:10 ratio with 33% acetonitrile to ensure that all diluted samples were reliably detectable within the calibration range.

[0105] The sample concentration is determined by weighted linear regression (1 / X) using Waters TargetLynx software version XS V4.2 SCN986. 2 The matrix spike calibration standards were determined for dapagliflozin in the range of 0.010 μM to 10.0 μM and for dibotentan in the range of 0.75 μM to 376 μM by applying the specified method. The calibration sample residues showed an equal dispersion distribution. The bias of the analysis was <15% across the concentration ranges for both analytes.

[0106] The samples were analyzed using reversed-phase high-pressure liquid chromatography with rapid gradient elution. The compounds were detected using a Waters Xevo TQ-S triple quadrupole mass spectrometer (Waters Corporation, Milford, MA, USA). Chromatographic separation was performed at 40°C using an ACQUITY BEH C18 1.8 μM, 2.1 x 50 mm column. Mobile phase A was 2% acetonitrile and 0.2% formic acid (A) in water, and mobile phase B was 0.2% formic acid (B) in acetonitrile. Separation was achieved using the following elution gradients: 0 min to 1.5 min, gradient from 4% B to 95% B; 1.5 min to 2.3 min, maintained at 95% B; 2.3 min to 2.4 min, 95% B to 4% B, and maintained at 4% B up to 2.7 min. The flow rate was 0.7 mL / min. Dibotentan eluted after 0.82 minutes and was detected in positive electrospray mode using multiple reaction monitoring during the transition (425.3 m / z > 139.25 m / z).

[0107] The samples were analyzed by reverse-phase high-pressure liquid chromatography with rapid gradient elution. The compounds were detected using a Waters Xevo TQ-S triple quadrupole mass spectrometer (Waters Corporation, Milford, MA, USA). Mobile phase A was 1M ammonium acetate / acetonitrile / water (0.1 / 2 / 97.5, v / v / v), and mobile phase B was 1M ammonium acetate / acetonitrile (0.1 / 99.5, v / v). Separation was performed by an ACQUITY BEH C18 1.8 μM, 2.1 x 50 mm column from Waters using the following gradients: 0 min to 2.5 min, gradient from 4% B to 60% B; 2.5 min to 2.9 min, 60% B to 95% B; 2.9 min to 3.4 min, maintained at 95% B; and 3.4 min to 3.5 min, mobile phase B was returned to 4% B and maintained at 4% B until 4 min. The flow rate was 0.6 mL / min, and the column temperature was 40°C. Dapagliflozin eluted after 2.19 minutes, and the transition (407.1 > 329.07 for dapagliflozin) was observed. 13It was detected in negative electrospray mode with respect to the C6-dapagliflozin internal standard (413.0 > 335.13).

[0108] Bioanalysis of dibotentan in rat urine: 50 μL of PBS containing 5% BSA was added to 50 μL of urine sample, followed by 500 μL of acetonitrile containing nifedipine as an internal standard. The sample was vortexed for 1 minute and centrifuged at 2400 g at 4°C for 5 minutes. 400 μL of supernatant was transferred to a new plate and dried under heated nitrogen. The sample was reconstituted in 100 μL of deionized water / formic acid (100 / 0.2, v / v), mixed by vortexing, and centrifuged before analysis. Calibration samples by matrix matching, quality control samples, and blanks were processed in the same manner as the test samples.

[0109] Samples were analyzed on an Acquity i-class UPLC system (Waters, Milford, MA, USA) connected to an API 4500 (Sciex LLC, Framingham, MA, USA). Mobile phase A was acetonitrile with 0.2% formic acid, and mobile phase B was water with 0.2% formic acid. Separation was performed on an Acquity UPLC BEH C18 column (50 mm x 2.1 mm, 1.7 μm particle size, Waters) using the following gradients: 0 min to 1.5 min, 5% A to 100% A; 1.5 min to 2.0 min, 100% A to 100% A; 2.0 min to 2.5 min, 100% A to 5% A. The flow rate was 0.75 mL / min, and the column temperature was 60°C. Dibotentan (425.1 m / z > 361.2 m / z) was analyzed in positive ionization mode with a source temperature of 700°C and an ion spray voltage of 5000 V.

[0110] The limit of quantification (LLOQ) was 0.010 μM, and the bias of the analysis was <15%, with a CV% of 13.6%, except for the lowest QC-standard with a bias of 21.0%.

[0111] Bioanalysis of dapagliflozin in rat urine: 50 μL of PBS containing 5% BSA was added to a 50 μL urine sample, followed by 500 μL of acetonitrile / formic acid (100 / 0.5, v / v) containing nifedipine as an internal standard. The sample was vortexed for 1 minute and centrifuged at 2400 g at 4°C for 5 minutes. 450 μL of the supernatant was transferred to a new plate and dried under heated nitrogen. The sample was reconstituted in 400 μL of 1 M ammonium acetate / water / formic acid (20 / 75 / 5, v / v / v) and mixed by vortexing. The sample was further purified by solid-phase extraction (SPE) using a SOLA HRP (10 mg) SPE plate (ThermoFisher Scientific, Waltham, MA, USA) on a liquid handling robot. The plates were conditioned with 450 μL of methanol followed by 450 μL of 1 M ammonium acetate / water / formic acid (20 / 75 / 5, v / v / v). The samples were loaded onto SPE plates and washed with 450 μL of 1 M ammonium acetate / water / formic acid (20 / 75 / 5, v / v / v) and 450 μL of acetonitrile / water (95 / 5, v / v). The samples were eluted twice with 250 μL of acetonitrile / deionized water / acetic acid (80 / 20 / 1, v / v / v) and dried under a stream of heated nitrogen. The samples were reconstituted in 100 μL of deionized water, mixed by vortexing, and centrifuged before analysis. Calibration samples by matrix matching, quality control samples, and blanks were processed in the same manner as the test samples.

[0112] Samples were analyzed on an Acquity i-class UPLC system (Waters, Milford, MA, USA) connected to an API 4500 (Sciex LLC, Framingham, MA, USA). Mobile phase A was 1M ammonium acetate / acetonitrile / water (0.5 / 95 / 4.5, v / v / v), and mobile phase B was 1M ammonium acetate / acetonitrile / water (0.5 / 25 / 74.5, v / v / v). Separation was performed on an Acquity UPLC HAS T3 column (50 mm x 2.1 mm, 1.8 μm particle size, Waters) using the following gradients: 0 min to 3.0 min, 5% A to 50% A; 3.0 min to 3.5 min, 50% A to 100% A; 3.5 min to 4 min, 100% A to 5% A. The flow rate was 0.45 mL / min, and the column temperature was 25°C. The acetate adduct of dapagliflozin (467.2 m / z > 329.0 m / z) was used for quantification and was analyzed in negative ionization mode with a source temperature of 750°C and an ion spray voltage of -4500 V. The LLOQ was 0.010 μM, and the CV and bias were generally <5% (the lowest QC - standard material was 0.03 μM, CV was 10.3%).

[0113] Plasma and urinary albumin, creatinine, glucose, urea, potassium, and sodium levels were analyzed using an ABX Pentra 400 instrument (Horiba Medical, Irvine, California, USA) according to the manufacturer's protocol.

[0114] For Hct and Hb analysis, 100 μl of blood was collected from the rat tail vein and measured using a CG8 cartridge with an iSTAT instrument (Abbott Point of Care Inc, Abbott Park, IL, USA).

[0115] Data for each measured feature were confirmed to be normally distributed, and logarithmic transformation was applied to non-normally distributed data using R where necessary. Since data were classified by single-factor dibotentin administration or combination therapy, one-way ANOVA was used to analyze single-time-point-time-measured features (GraphPad version 8 or R statistics package emmeans), and a linear mixed-effects model in R (nlme package) was used to analyze data for multiple indicators related to body weight. Differences between groups were tested using either Dunnett's test (R emmeans package or GraphPad v8) when comparing treatment groups to solvent groups, or Tukey comparisons (R emmeans package or GraphPad v8) for specific pairwise comparisons of treatment groups. All model hypotheses were confirmed using model diagnostic plots in R statistics. Results are expressed as mean ± standard error of the mean (SEM) for pharmacodynamic parameters and mean ± standard deviation (SD) for compound concentrations in blood and urine. Significance was set at p<0.05.

[0116] result Dibotentan concentrations exceeding LLOQ were measured in all blood samples collected from animals that received dibotentan 4 or 24 hours after the first dose, or 24 hours after the last dose, to confirm exposure to dibotentan (Tables 1 and 2, Figures 1 and 2).

[0117] [Table 1]

[0118] [Table 2]

[0119] Dapagliflozin concentrations exceeding LLOQ were measured in all blood samples collected from animals that received dapagliflozin 4 hours or 24 hours after the first dose, or 24 hours after the last dose, to confirm exposure to dapagliflozin (Figure 3, Table 2). In Experiment 2, dibotentan concentrations exceeding LLOQ were measured in all urine samples collected overnight between days 3 and 4 from animals that received dibotentan (Table 3), and dapagliflozin concentrations exceeding LLOQ were measured in all urine samples from animals that received dapagliflozin (Table 3).

[0120] [Table 3]

[0121] In Experiment 1, quantifiable concentrations of dibotentan were detected in six blood samples from control animals on day 14. The apparent concentrations of dibotentan in these positive samples were at least 13 times lower than the mean blood concentration in the low-dose group (30 mg / kg) (using solvent animals with the highest observed concentration (0.54 μM) compared to the mean (7.39 μM) in the 30 mg / kg group). In Experiment 2, no concentrations of dibotentan or dapagliflozin above LLOQ were found in blood samples from control animals, but concentrations of dibotentan above LLOQ were detected in five urine samples from control animals. The amount of dibotentan excreted in the urine of these samples was at least 190 times less than the average amount excreted in the group treated with the lowest amount of dibotentan in urine (30 mg / kg dibotentan + 3 mg / kg dapagliflozin).

[0122] In Experiment 2, the blood concentration of dibotentan 24 hours after the last dose was 3 to 4 times lower in the group that received dibotentan in combination with dapagliflozin compared to the group that received dibotentan alone.

[0123] Dibotentan resulted in a significant (p<0.05) decrease in Hct concentration compared to the solvent at all doses on day 7 (30 mg / kg, 100 mg / kg, and 300 mg / kg) and at 100 mg / kg and 300 mg / kg on day 14 (Figure 4).

[0124] Body weight was measured daily for each dose of dibotentan (30, 100, and 300 mg / kg) and compared to the solvent. There was no difference in body weight change between any of the groups treated with dibotentan and the solvent (Table 4, Figure 5). On day 10, the animals' body weight decreased due to placement in metabolic cages.

[0125] [Table 4]

[0126] Dibotentan resulted in a significant decrease in Hb compared to the solvent at all three doses on day 7 (30, 100, and 300 mg / kg) and at the two higher doses on day 14 (100 and 300 mg / kg) (Table 5).

[0127] [Table 5]

[0128] As shown in Table 6, there were no changes in plasma Na, K, glucose, and urea levels in response to different doses of dibotentan compared to the solvent.

[0129] [Table 6]

[0130] As shown in Table 7, there were no changes in urine volume, Na, K, urea, creatinine, and glucose levels for different doses of dibotentan compared to the solvent.

[0131] [Table 7]

[0132] Fourteen days after dibotentan treatment, there was an increase in kidney weight with or without tibial length standardization for the 300 mg / kg dose compared to the solvent, and an increase in heart weight for the 100 mg / kg dibotentan dose, but this increase was not statistically significant after tibial length standardization (Table 8).

[0133] [Table 8]

[0134] Hct data were analyzed using a linear mixed-effects model to estimate the marginal mean and standard deviation within the solvent and treatment groups, estimated overall for day 3, day 7, and the entire trial for post-hoc comparisons. The treatment groups were compared to the solvent to determine whether they had an effect on Hct compared to the solvent-treated control group (Dunnet's test), and the dibotentan treatment groups were compared to the dibotentan + dapafliglozin group (using Tukey's test) to determine whether the combination therapy reduced the effect of dibotentan on Hct.

[0135] There was no significant difference in absolute Hct levels between the groups at baseline (Figure 6A). On day 3, dibotentan (30 mg / kg and 100 mg / kg), administered with or without dapagliflozin (3 mg / kg), reduced Hct compared to the solvent (Figure 6B, Table 9A). On day 7, dibotentan (30 mg / kg and 100 mg / kg) reduced Hct compared to the solvent, and when administered co-administered with dapagliflozin (3 mg / kg), both doses resulted in similar Hct levels to the solvent (Figure 6C, Table 9B). Overall, dibotentan 100 mg / kg + dapagliflozin resulted in higher Hct levels than dibotentan 100 mg / kg alone (Table 9C).

[0136] [Table 9]

[0137] On day 7, dibotentan monotherapy at 30 mg / kg and 100 mg / kg induced a decrease in Hct, but this effect was lost when dibotentan was combined with dapagliflozin (Figure 6C, Table 9B).

[0138] [Table 10]

[0139] [Table 11]

[0140] Dapagliflozin is known to increase weight loss (Hansen et al., Endocr Pract. 2014;20(11):1187-1197). To evaluate the effect of combination therapy on weight loss, body weight was measured daily and compared using a linear mixed-effects model. Animals treated with the solvent gained weight during the treatment period, as expected, and dapagliflozin monotherapy prevented this BW increase compared to the solvent (p<0.05), while dibotentan alone or in combination with dapagliflozin did not (Figure 7, Table 10).

[0141] [Table 12]

[0142] As expected, animals treated with the solvent gained body weight during the treatment period. Dapagliflozin monotherapy prevented this BW increase compared to the solvent (p<0.05), while dibotentan alone or in combination with dapagliflozin did not (Figure 7).

[0143] Dapagliflozin increased urinary glucose excretion, while zibtentan had no effect (Figure 8A). Co-administration of zibtentan did not alter the dapagliflozin-mediated increase in urinary glucose (Figure 8A). Water and food intake were not altered by zibtentan compared to the solvent. Dapagliflozin treatment increased water and food intake compared to the solvent, as shown in Figures 8B and 8C. Animals co-administered with dapagliflozin and zibtentan showed a significant increase in water and food intake compared to the solvent, to levels similar to those observed in animals administered with dapagliflozin alone (Figures 8B and 8C, respectively).

[0144] [Table 13]

[0145] Plasma Na, K, glucose, and urea concentrations did not change with treatment with dibotentan, dapagliflozin, or a combination thereof, compared to the solvent, as shown in Table 12. Zibo (100 mg / kg) monotherapy or Zibo (100 mg / kg) in combination with Dapa (3 mg / kg) significantly increased plasma creatinine compared to the solvent, as shown in Table 12 (p<0.05).

[0146] [Table 14]

[0147] 24-hour urine volume and urea excretion were increased in all dapagliflozin treatment groups, with or without concomitant administration of dibotentan. No difference was observed in the dibotentan monotherapy group compared to the solvent. As shown in Table 13, no changes in Na, K, and creatinine were observed in any of the treatment groups compared to the solvent.

[0148] [Table 15]

[0149] Seven days after treatment, kidney weight increased in the Zibo 100 mg / kg + Dapa 3 mg / kg group compared to the solvent. Cardiac weight increased in the Zibo 30 mg / kg group compared to the solvent alone, with or without normalization to tibial length, as shown in Table 14.

[0150] [Table 16]

[0151] The endothelial receptor A antagonist, dibotentan, significantly reduced Hct levels in male Wistar rats fed a 4% salt diet. Concurrent administration of the SGLT-2 inhibitor dapagliflozin for 7 days significantly reduced the effect of dibotentan on Hct levels. Dapagliflozin also attenuates the dibotentan-induced reduction in hematocrit in rats.

[0152] Example 2 The effect of dapagliflozin on albuminuria was investigated in patients with chronic kidney disease (CKD) who have or do not have type 2 diabetes. In this analysis from the Phase 3 DAPA CKD clinical trial, the efficacy of dapagliflozin was evaluated to determine whether treatment with dapagliflozin reduces the level of albuminuria in patients with CKD.

[0153] In this clinical trial, the estimated glomerular filtration rate was 25-75 mL / min / 1·73m². 24304 patients with urinary UACR levels of 200–5000 mg / g were randomized to receive either dapagliflozin (10 mg) or placebo. Changes in albuminuria were assessed as the mean change in logarithmically transformed UACR from baseline to the end of the study. Additional endpoints included regression of UACR stage, defined as a transition from overt albuminuria (≥300 mg / g) to microalbuminuria or microalbuminuria-negative (<300 mg / g), and progression of UACR stage, defined as a transition from <3000 mg / g to ≥3000 mg / g.

[0154] In the overall population, the median (25th–75th percentile) UACR was 965 (472–1903) mg / g (compared to placebo, which had a median UACR of 934 (482–1868)). Compared to placebo, dapagliflozin reduced UACR by 29.3% in patients with and without type 2 diabetes (95% confidence interval [CI], 25.2–33.1%; p<0.001). When stratified by diabetes status, dapagliflozin reduced the UACR by 35.1% (95% confidence interval [CI], 30.6–39.4%; p<0.001) in patients with type 2 diabetes compared to placebo, and by 14.8% (95% confidence interval [CI], 5.9–22.9%; p<0.001) in patients without type 2 diabetes.

[0155] Among 3860 patients with a baseline UACR ≥ 300 mg / g, dapagliflozin increased the likelihood of UACR stage regression (hazard ratio [HR] 1.81; 95% CI, 1.60–2.05). Among 3820 patients with a baseline UACR < 3000 mg / g, dapagliflozin reduced the risk of UACR stage progression ([HR] 0.41; 95% CI, 0.32–0.52). Albuminuria regression and progression were further stratified by diabetic status and are shown in Figures 9 and 10. As shown by this analysis, treatment with dapagliflozin reduced UACR in patients with CKD, regardless of diabetic status.

[0156] Example 3 Preclinical studies of dapagliflozin in combination with dibotentan are underway to demonstrate the efficacy of both monotherapy and combination therapy against specific biomarkers indicating renal and cardiovascular function in male Dahl salt-sensitive (DSS) rats.

[0157] Example 3 will evaluate the effects of dibotentan alone and dibotentan and dapagliflozin combination on body weight, blood pressure (mean arterial pressure - MAP, systolic blood pressure - SBP, and diastolic blood pressure - DBP), heart rate, urinary proteinalbumin and creatinine, serum creatinine, hematology, cardiac echocardiography, LV diameter and wall thickness, shortening rate and ejection fraction, and kidney (left and right), heart and lung weight and tibia length in DSS 7-9 week old rats on a 4% salt diet over a 7-week trial. Treatment will be initiated 12 days after the start of the 4% salt diet.

[0158] Preparation for the solvent: 30% (w / w) PEG400, 2% (w / w) EtOH, 0.5% (w / w) HPMC (10000 cps), 0.1% (w / w) Tween 80, and 67.4% purified water.

[0159] Formulation for dibotentan alone: ​​Suspension in 30% (w / w) PEG400, 2% (w / w) EtOH, 0.5% (w / w) HPMC 10000 cps, 0.1% (w / w) Tween 80, and 67.4% purified water.

[0160] Formulation for dapagliflozin in combination with dibotentan: suspension / solution in 30% (w / w) PEG400, 2% (w / w) EtOH, 0.5% (w / w) HPMC 10000 cps, 0.1% (w / w) Tween 80, and 67.4% purified water.

[0161] The effects of dibotentan alone and dapagliflozin alone on body weight, blood pressure (MAP, SBP, and DBP), heart rate, urinary proteinalbumin and creatinine, serum creatinine, hematology, cardiac echocardiography, and LV diameter and wall thickness, shortening rate and ejection fraction, as well as kidney (left and right), heart, and lung weight and tibia length, will be determined according to the three groups summarized in Table 15 below.

[0162] [Table 17]

[0163] Whole blood samples (20 μL) from groups B and C will be collected at weeks 3 and 6 to assess PK. An additional 200 μL of whole blood sample will be collected at week 1 to assess hematological Hct and MCV (via Horiba ABX Micros ESV60). Urine will be collected at weeks 1, 3, and 6 to assess clinical chemistry for serum creatinine and urinary proteinalbumin and creatinine (via RX Daytona®). Echocardiographic images will be obtained from rats under light anesthesia with 1-2% isoflurane using a VisualSonics Vevo 3100® ultrasound echocardiography system and an MX201 15 MHz microscan transducer. Left ventricular M-mode (short-axis) images will be collected for LVEDD, LVESD, AWT, PWT, FS, and EF. The left kidney, lung, and heart will be collected, decapsulated, and weighed. The tibia will be measured for length and imaged using X-rays.

[0164] Clinical chemistry and hematological data, echocardiographic data, and body weight and tissue weight (normalized to tibial length) will be analyzed using one-way ANOVA (GraphPad Prism version 7.0a). Statistical significance between groups will be tested using Dunnett's test. Blood pressure analysis will be evaluated as mean ± SEM of MAP, SBP, DBP, and heart rate in line graph format.

[0165] Example 4 The clinical trial of the combination of dapagliflozin and dibotentan (ZENITH-CKD) is ongoing as a phase 2b, multicenter, randomized, double-blind, placebo-controlled, parallel-group dose-finding study to evaluate the efficacy, safety, and tolerability of dibotentan and dapagliflozin in participants with CKD who have an eGFR of 20–60 mL / min / 1.73m2.

[0166] Test design The trial will be conducted in two parts, Part A and Part B. In both trial parts, participants will be randomized to receive 12 weeks of treatment followed by 2 weeks of observation. All variable factors will be collected to validate inclusion criteria as well as additional demographic data such as race / ethnicity, serum creatinine, and height. All analyses (with the exception of the interim analysis in Part A) will include data from both parts of the trial.

[0167] Participants who meet the eligibility criteria will receive background topical SoC therapy and will be randomized to one of the treatments described in Part A or Part B. To maintain blinding, participants will receive both the effective and placebo trial intervention on each dosing day when receiving Zibo / Dapa monotherapy. Participants accepting only placebo will receive placebos for both trial interventions.

[0168] In Part A, 132 eligible participants are planned to be recruited and randomized into four treatment arms, each containing 33 participants: - Dibotentan 5mg + Dapagliflozin 10mg once daily. - Dibotentan 5mg once daily. - Dapagliflozin 10 mg once daily. - Placebo, once a day.

[0169] An interim analysis of Part A data will be conducted when approximately 30 participants in each arm (120 participants) have completed 6 weeks of treatment to assess changes in fluid-related scales (weight gain or BNP). If fluid-related scales meet the specified criteria in at least 5 participants in the dibotentan 5 mg monotherapy arm, that arm will be discontinued for the remainder of the trial.

[0170] If the specified discontinuation criteria for the dibotentan 5 mg monotherapy arm are not met in the interim analysis at week 6 of treatment, the available Part A data will be used for a second interim analysis to assess changes in humoral scales when all randomized Part A participants complete 12 weeks of treatment. If the humoral scales meet the specified criteria in at least five participants in the dibotentan 5 mg monotherapy arm at the second interim analysis (week 12 of treatment), the arm will be discontinued for the remainder of the trial.

[0171] In Part B, an additional 528 eligible participants are planned to be recruited. Of these, 352 will be randomized to the same four treatment arms derived from Part A, each containing 88 participants. The remaining eligible participants will be randomized to two additional treatment arms, each containing 88 participants. - Dibotentan 0.25mg + Dapagliflozin 10mg once daily. - Dibotentan 1.5mg + Dapagliflozin 10mg once daily. - Dibotentan 5mg + Dapagliflozin 10mg once daily. - Dibotentan 5mg once daily. - Dapagliflozin 10 mg once daily. - Placebo, once a day.

[0172] Participants randomized in Part A cannot be randomized to Part B.

[0173] Participants will be stratified at randomization by diabetes mellitus (DKD vs. non-DM CKD) and baseline eGFR (<45 mL / min / 1.73m2 vs. greater than 45 mL / min / 1.73m2) to ensure approximate balance between treatment groups within each subgroup. The number of randomized participants in each stratification will be monitored to ensure that the non-DM CKD subgroup accounts for at least approximately 30% and at most approximately 33% of the total number of randomized participants.

[0174] For each participant, the overall duration of participation will be approximately 17–19 weeks. In each trial part, the screening period may be up to 4 weeks in the pre-randomization period. The first dose will be administered after randomization at the baseline visit on day 1. In addition to the baseline visit, participants will visit the clinic five times during the following 12 weeks of treatment. Approximately two weeks after the last dose, participants will visit the clinic again for follow-up evaluation.

[0175] Objectives and evaluation items The primary endpoint will measure the effects of divotentan and dapagliflozin combination and alone compared to placebo on UACR. Changes in UACR will be measured in logarithmically transformed UACR (UACR(mg / g) = urinary albumin(mg / dL) / urinary creatinine(g / dL)) from baseline to week 12. Secondary endpoints and objectives are summarized in Table 17 below.

[0176] [Table 18]

[0177] [Table 19]

Claims

1. Dibotentan, N-(3-methoxy-5-methylpyrazine-2-yl)-2-[4-(1,3,4-oxadiazole-2-yl)phenyl]pyridine-3-sulfonamide, for use in the treatment of chronic kidney disease in human patients. 【Chemistry 1】 or a pharmaceutically acceptable salt thereof, wherein dibotentan or a pharmaceutically acceptable salt thereof is dapagliflozin, (1S)-1,5-anhydrous-1-{4-chloro-3-[(4-ethoxyphenyl)methyl]phenyl}-D-glucitol, 【Chemistry 2】 Dibotentan, or a pharmaceutically acceptable salt thereof, administered in combination with a pharmaceutically acceptable salt thereof.

2. The use according to claim 1, wherein dibotentan, or a pharmaceutically acceptable salt thereof, is administered once daily in combination with dapagliflozin, or a pharmaceutically acceptable salt thereof.

3. The use according to claim 1 or 2, wherein dibotentan, or a pharmaceutically acceptable salt thereof, is administered once daily in a dose of approximately 5 mg in combination with dapagliflozin, or a pharmaceutically acceptable salt thereof, and dapagliflozin is administered in a dose of 10 mg.

4. The use according to claim 1 or 2, wherein dibotentan, or a pharmaceutically acceptable salt thereof, is administered once daily in a dose of about 1.5 mg in combination with dapagliflozin, or a pharmaceutically acceptable salt thereof, and dapagliflozin is administered in a dose of 10 mg.

5. The use according to claim 1 or 2, wherein dibotentan, or a pharmaceutically acceptable salt thereof, is administered once daily in a dose of about 0.25 mg in combination with dapagliflozin, or a pharmaceutically acceptable salt thereof, and dapagliflozin is administered in a dose of 10 mg.

6. The use according to any one of claims 1 to 5, wherein the human patient is a patient with chronic kidney disease classified as a stage 1 to 4 patient having an eGFR of 20 to 60 ml / min / 1.73 m2.

7. The use according to claim 6, wherein the human patient is a patient with chronic kidney disease classified as a stage 3-4 patient.

8. The use according to claim 6, wherein the human patient is a patient with chronic kidney disease classified as a stage 4 patient.

9. The use according to claim 6, wherein the human patient is a patient with chronic kidney disease classified as a stage 3a or 3b patient.

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