Treatment of angioedema

Abstract

The present invention relates to the treatment of angioedema, specifically bradykinin-mediated non-hereditary angioedema (BK-AEnH). In particular, the present invention provides on-demand treatment of bradykinin-mediated non-hereditary angioedema (BK-AEnH) by orally administering a plasma kallikrein inhibitor to a patient in need of treatment on demand. Periodic (or continuous) treatment of BK-AEnH is also provided.

Description

[Technical field]

[0001] The present invention relates to the treatment of angioedema, specifically non-hereditary bradykinin-mediated angioedema (BK-AEnH) in which there is no or no known genetic component. In particular, the present invention provides on-demand treatment of non-hereditary bradykinin-mediated angioedema (BK-AEnH) by oral administration of a plasma kallikrein inhibitor on-demand to a patient in need of treatment. Periodic (or continuous) treatment of BK-AEnH is also provided. [Background technology]

[0002] Inhibitors of plasma kallikrein have numerous therapeutic applications, particularly in the treatment of bradykinin-mediated non-hereditary angioedema (BK-AEnH).

[0003] Plasma kallikrein is a trypsin-like serine protease that can liberate kinins from kininogens (see KD Bhoola et al., "Kallikrein-Kinin Cascade", "Encyclopedia of Respiratory Medicine", p.483-493; JW Bryant et al, "Human plasma kallikrein-kinin system:physiological and biochemical parameters", Cardiovascular and haematological agents in medicinal chemistry, 7, p234-250, 2009; KD Bhoola et al, Pharmacological Rev., 1992, 44, 1; and DJ Campbell, "Towards understanding the kallikrein-kinin system:insights from the measurement of kinin peptides", Brazilian Journal of Medical and Biological Research 2000, 33, p665-677). Plasma kallikrein is an essential member of the intrinsic blood coagulation cascade, although its role in this cascade does not involve the release or enzymatic cleavage of bradykinin. Plasma prekallikrein is encoded by a single gene and can be synthesized in the liver as well as other tissues. Plasma kallikrein is secreted by hepatocytes as inactive plasma prekallikrein, which circulates in plasma as a heterodimeric complex bound to high molecular weight kininogen (HK), but is activated to yield active plasma kallikrein.This contact activation system (or contact system) can be activated by negatively charged surfaces that activate factor XII (FXII) to factor XIIa (FXIIa), by certain proteases that may not require a negatively charged surface, such as plasmin (Hofman et al Clin Rev Allergy Immunol 2016), or by misfolded proteins (Maas et al J Clinical Invest 2008). FXIIa mediates the conversion of plasma prekallikrein to plasma kallikrein and the subsequent cleavage of high molecular weight kininogen (HK) to generate bradykinin, a potent inflammatory hormone. Kinins are potent mediators of inflammation that act through G protein-coupled receptors, and kinin antagonists (such as bradykinin antagonists) have already been investigated as potential therapeutic agents for the treatment of numerous disorders (F. Marceau and D. Regoli, Nature Rev., Drug Discovery, 2004, 3, 845-852).

[0004] Plasma kallikrein is believed to play a role in many inflammatory disorders. When activated, the bradykinin-mediated pathway described above can result in patients exhibiting signs and symptoms of angioedema, resulting in intermittent swelling of the face, palms, pharynx, gastrointestinal tract, and genitals. The blisters that form during acute episodes contain high levels of plasma kallikrein, which cleaves high molecular weight kininogen (HK), liberating bradykinin and resulting in increased vascular permeability.

[0005] One such example of angioedema is hereditary angioedema (HAE). "Hereditary angioedema" can be defined as any disorder characterized by recurrent episodes of bradykinin-mediated angioedema (e.g., severe swelling) caused by an inherited genetic dysfunction / defect / mutation. Currently, there are three known categories of HAE: (i) HAE type 1, (ii) HAE type 2, and (iii) normal C1 inhibitor HAE (normal C1-Inh HAE). However, as research continues into characterizing the pathogenesis of HAE, it is likely that additional types of HAE will be defined in the future.

[0006] Without wishing to be bound by theory, HAE type 1 is believed to be caused by a mutation in the SERPING1 gene that leads to reduced levels of C1 inhibitor in the blood. Without wishing to be bound by theory, HAE type 2 is believed to be caused by a mutation in the SERPING1 gene that leads to a dysfunction of C1 inhibitor in the blood. Without wishing to be bound by theory, the cause of normal C1-Inh HAE is less clearly understood and it may be the case that the underlying genetic dysfunction / defect / mutation remains unknown. What is known is that the cause of normal C1-Inh HAE is not related to reduced levels or dysfunction of C1 inhibitor (in contrast to HAE types 1 and 2). Normal C1-Inh HAE can be diagnosed by reviewing the family history and noting that angioedema is inherited (hence, it is hereditary angioedema). Normal C1-Inh HAE can also be diagnosed by determining that there is a defect in a gene other than the one associated with C1 inhibitor. For example, it has been reported that dysfunction / defects / mutations in plasminogen can cause normal C1-Inh HAE (see, e.g., Veronez et al., Front Med (Lausanne). 2019 Feb 21, 6:28. doi:10.3389 / fmed.2019.00028, or Recke et al., Clin Transl Allergy. 2019 Feb 14, 9:9. doi: 10.1186 / s13601-019-0247-x). It has also been reported that dysfunction / defects / mutations in factor XII can cause normal C1-Inh HAE (see, for example, Mansi et al. 2014 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine, 2015, 277, 585-593, or Maat et al. J Thromb Haemost. 2019 Jan, 17(1):183-194. doi: 10.1111 / jth.14325).

[0007] However, angioedema is not necessarily hereditary. Indeed, another type of angioedema is bradykinin-mediated non-hereditary angioedema (BK-AEnH), which is not caused by a hereditary genetic dysfunction / defect / mutation. In many cases, the underlying cause of BK-AEnH is unknown and / or undefined. However, the signs and symptoms of BK-AEnH are similar to those of HAE, which is thought to be due to the shared bradykinin-mediated pathway between HAE and BK-AEnH, without being bound by theory. Specifically, BK-AEnH is characterized by recurrent acute attacks in which fluid accumulates outside of blood vessels, blocking the normal flow of blood and lymph, causing rapid swelling of tissues such as the hands, feet, limbs, face, intestinal tract, airways, or genitals. BK-AEnH attacks are acute and usually progress through three main clinically distinct phases: an early prodromal phase (which can typically last up to 12 hours), followed by a swelling phase, and then a resorption phase. The majority of attacks show prodromal symptoms. Two-thirds of prodromal symptoms appear within 6 hours of the attack, and no prodromal symptoms occur earlier than 24 hours of the attack (Magerl et al., Clinical and Experimental Dermatology (2014) 39, pp298-303). For example, the following prodromal symptoms may begin to be observed: mild swelling (especially in the face and neck), a typical type of abdominal pain, and a typical reddening of the skin called "erythema marginata". The attack is fully developed when it reaches maximum swelling and maximum expression of pain (e.g. abdominal attacks), discomfort (e.g. peripheral attacks), or threat to life (e.g. laryngeal attacks). Once the attack has peaked, the period until normalization subsequently depends on the time it takes for the swelling to subside and for the fluid that has infiltrated the tissues to be reabsorbed.

[0008] Specific types of BK-AEnH include non-hereditary angioedema with normal C1 inhibitor (AE-nC1 Inh), which may be environmental, hormonal, or drug induced, acquired angioedema, anaphylaxis-related angioedema, angiotensin-converting enzyme (ACE) inhibitor-induced angioedema, dipeptidyl peptidase-4 inhibitor-induced angioedema, and tPA-induced angioedema (tissue plasminogen activator-induced angioedema). However, it is unclear why these factors and conditions cause angioedema in only a relatively small percentage of individuals.

[0009] Environmental factors that can induce AE-nC1 Inh include air pollution (Kedarisetty et al., Otolaryngol HeadNeckSurg. 2019Apr30:194599819846446. doi:10.1177 / 0194599819846446) and silver nanoparticles, such as those used as antimicrobial components in medical, biomedical, and consumer products (Long et al., Nanotoxicology. 2016; 10(4):501-11. doi:10.3109 / 17435390.2015.1088589).

[0010] Various publications suggest a link between bradykinin and contact system pathways and BK-AEnH, and potential therapeutic efficacy. See, for example, Bas et al. (N Engl J Med 2015, Leibfried and Kovary. J Pharm Pract 2017), van den Elzen et al. (Clinic Rev Allerg Immunol 2018); Han et al. (JCI 2002).

[0011] tPA-induced angioedema has been discussed in various publications as a potentially life-threatening complication following thrombolytic therapy in acute stroke victims (e.g., Simaeo et al., Blood. 2017Apr 20;129(16):2280-2290. doi:10.1182 / blood-2016-09-740670;Froehlich et al., Stroke. 2019 Jun 11:STROKEAHA.119.025260. doi:10.1161 / STROKEAHA.119.025260;Rathbun, Oxf Med Case Reports. 2019 Jan 24; 2019(1):omy112. doi:10.1093 / omcr / omy112;Lekoubou et al., Neurol Res. 2014 Jul; 36(7):687-94. doi:10.1179 / 1743132813Y.0000000302; see Hill et al., Neurology. 2003 May 13;60(9):1525-7.).

[0012] Stone et al. (Immunol Allergy Clin North Am. 2017 Aug; 37(3):483-495.) report that certain medications may cause angioedema.

[0013] Scott et al. (Curr Diabetes Rev. 2018; 14(4):327-333. doi:10.2174 / 1573399813666170214113856) report a case of angioedema induced by a dipeptidyl peptidase-4 inhibitor.

[0014] Hermanrud et al. (BMJ Case Rep. 2017 Jan 10;2017. pii:bcr2016217802) reported recurrent angioedema associated with pharmacological inhibition of dipeptidyl peptidase IV and also discussed acquired angioedema associated with angiotensin-converting enzyme inhibitors (ACEI-AAE). Kim et al. (Basic Clin Pharmacol Toxicol. 2019 Jan;124(1):115-122. doi:10.1111 / bcpt.13097) reported angioedema associated with angiotensin II receptor blockers (ARBs). Reichman et al. (Pharmacoepidemiol Drug Saf. 2017 Oct;26(10):1190-1196. doi:10.1002 / pds.4260) also reported a risk of angioedema in patients taking ACE inhibitors, ARB inhibitors, and beta-blockers. Diestro et al. (J Stroke Cerebrovasc Dis. 2019 May;28(5):e44-e45. doi:10.1016 / j.jstrokecerebrovasdis.2019.01.030) also reported a possible association between certain angioedema and ARBs.

[0015] Giard et al. (Dermatology. 2012;225(1):62-9. doi:10.1159 / 000340029) report that bradykinin-mediated angioedema can be caused by estrogen contraception.

[0016] There is a lack of approved treatments for certain types of BK-AEnH (see, e.g., Craig et al., Int Arch Allergy Immunol. 2014;165(2):119-27. doi:10.1159 / 000368404; Mager et al., Immunol Allergy Clin North Am. 2017 Aug;37(3):571-584). AE-nC1 Inh may be treatable off-label with agents approved for HAE (see, e.g., Eur J Dermatol. 2017 Apr 1;27(2):155-159. doi:10.1684 / ejd.2016.2948). Specific approved agents for treating HAE are described below.

[0017] Cinryze® and Haegarda® contain C1 esterase inhibitors and are indicated for preventing acute HAE attacks (i.e., prophylactic treatments). Treatment with Cinryze® requires preparation of a solution from a powder and subsequent injections every 3 or 4 days. Similarly, treatment with Haegarda® requires preparation of a solution from a powder and subsequent injections twice a week. Patients are not always able to perform these procedures themselves, and when they cannot, patients must visit a clinic for treatment. Thus, both of these preventative treatments are plagued by high patient burden. Furthermore, the FDA packet insert for Haegarda® states, "Do not use to treat acute HAE attacks," so patients may require additional therapy if they develop an HAE attack.

[0018] Berinert® and Ruconest® contain C1 esterase inhibitors and are indicated for the treatment of acute HAE attacks. Both of these treatments involve the preparation of an injectable solution followed by injection. This process can be burdensome for patients, especially if they are suffering from an acute HAE attack. Self-administration of the dosage is also not always possible, and when this is not possible, administration of the medication can be significantly delayed, thus increasing the severity of the patient's acute HAE attack.

[0019] Tranexamic acid has also been reported to be administered off-label for the treatment of nonhistamine angioedema (see, e.g., 2014 British Society for Immunology, Clinical and Experimental Immunology, 178:112-117).

[0020] Synthetic plasma kallikrein inhibitors and low molecular weight plasma kallikrein inhibitors are described, for example, in Garrett et al. ("Peptide aldehyde...", J. Peptide Res. 52, p62-71 (1998)), T. Griesbacher et al. ("Involvement of tissue kallikrein but not plasma kallikrein in the development of symptoms mediated by endogenous kinins in acute pancreatitis in rats", British Journal of Pharmacology, 137, p692-700 (2002)), Evans ("Selective dipeptide inhibitors of kallikrein", WO03 / 076458), Szelke et al. ("Kininogenase inhibitors", WO92 / 04371), and DMEvans et al. (Immunolpharmacology, 32, p115-116(1996)), Szelke et al. ("Kininogen inhibitors", WO95 / 07921), Antonsson et al. ("New peptide derivatives", WO94 / 29335), J.Corte et al. ("Six membered heterocycles useful as serine protease inhibitors", WO2005 / 123680), J.Stuerzbecher et al. (Brazilian J.Med.Biol.Res, 27, p1929-34(1994)), Kettner et al. (US5,187,157), N.Teno et al. (Chem.Pharm.Bull., 41, p1079-1090(1993)), WBYoung et al. ("Small molecule inhibitors of plasma kallikrein", Bioorg.Med.Chem.Letts., 16, p2034-2036(2006)), Okada et al. WO08 / 049595), Zhang et al. (``Discovery of highly potent small molecule kallikrein inhibitors'', Medicinal Chemistry 2, p545-553(2006)), Sinha et al. (``Inhibitors of plasma kallikrein'', WO08 / 016883), Shigenaga et al. ("Biochemical characterization of a novel high-affinity and specific kallikrein inhibitor", British Journal of Pharmacology (2011), 162(7), p1639-1649). Steinmetzer et al. ("Serine protease inhibitors", WO2012 / 004678) also describe cyclized peptide analogs that are inhibitors of human plasmin and plasma kallikrein. [Prior art documents] [Patent documents]

[0021] [Patent Document 1] International Publication No. 2003 / 076458 [Patent Document 2] WO 92 / 04371 [Patent Document 3] WO 95 / 07921 [Patent Document 4] WO 94 / 29335 [Patent Document 5] WO 2005 / 123680 [Patent Document 6] U.S. Patent No. 5,187,157 Specification [Patent Document 7] WO 2008 / 049595 [Patent Document 8] WO 2008 / 016883 [Patent Document 9] WO 2011 / 118672 [Patent Document 10] WO 2012 / 004678 [Non-Patent Document]

[0022] [Non-Patent Document 1] K. D. Bhoola et al., ″Kallikrein-Kinin Cascade″, ″Encyclopedia of Respiratory Medicine″, p.483-493 [Non-Patent Document 2] J. W. Bryant et al, ″Human plasma kallikrein-kinin system:physiological and biochemical parameters″, Cardiovascular and haematological agents in medicinal chemistry, 7, p234-250, 2009 [Non-Patent Document 3] K. D. Bhoola et al, Pharmacological Rev., 1992, 44, 1 [Non-Patent Document 4] DJ Campbell, “Towards understanding the kallikrein-kinin system:insights from the measurement of kinin peptides”, Brazilian Journal of Medical and Biological Research 2000, 33, p665-677

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[0023] To date, the only selective plasma kallikrein inhibitors approved for medical use in the treatment of HAE are Kalbitor® (active substance ecallantide) and Takhzyro® (active substance lanadelumab). Both treatments are formulated as injectable solutions. Ecallantide is a large protein plasma kallikrein inhibitor that presents a risk of anaphylactic reactions. In fact, the EU marketing authorization application for Kalbitor® was recently withdrawn because the benefits of Kalbitor® were said not to outweigh its risks. Lanadelumab is a recombinant fully human IgG1 kappa light chain monoclonal antibody. Reported side effects of treatment with lanadelumab include hypersensitivity, pain at the injection site, erythema at the injection site, and scarring at the injection site. The approved EMA label for Takhzyro® (active ingredient lanadelumab) states that it is "not intended for the treatment of acute HAE attacks" and that "in the case of breakthrough HAE attacks, individualized treatment with an approved rescue medication should be initiated." Moreover, as injections, both of these treatments are associated with high patient burden.

[0024] Verotralstat (BCX7353) is being investigated as a once-daily oral treatment to prevent HAE attacks. Hwang et al. (Immunotherapy (2019) 11(17), 1439-1444) state that higher doses are associated with more gastrointestinal adverse effects, indicating increased toxicity at higher levels.

[0025] Other plasma kallikrein inhibitors known in the art are generally small molecules some of which contain highly polar, ionizable functional groups such as guanidine or amidine. Recently, plasma kallikrein inhibitors that do not feature guanidine or amidine functional groups have been reported. For example, see Brandl et al. ("N-((6-amino-pyridin-3-yl)methyl)-heteroaryl-carboxamides as inhibitors of plasma kallikrein", WO2012 / 017020), Evans et al. ("Benzylamine derivatives as inhibitors of plasma kallikrein", WO2013 / 005045), Allan et al. ("Benzylamine derivatives", WO2014 / 108679), Davie et al. ("Heterocyclic derivates", WO2014 / 188211), and Davie et al. ("N-((het)arylmethyl)-heteroaryl-carboxamides compounds as plasma kallikrein inhibitors", WO2016 / 083820).

[0026] The applicant has developed a novel series of compounds that are inhibitors of plasma kallikrein, as disclosed in WO2016 / 083820 (PCT / GB2015 / 053615). These compounds show good selectivity for plasma kallikrein. One such compound is N-[(3-fluoro-4-methoxypyridin-2-yl)methyl]-3-(methoxymethyl)-1-({4-[(2-oxopyridin-1-yl)methyl]phenyl}methyl)pyrazole-4-carboxamide. The name N-[(3-fluoro-4-methoxypyridin-2-yl)methyl]-3-(methoxymethyl)-1-({4-[(2-oxopyridin-1-yl)methyl]phenyl}methyl)pyrazole-4-carboxamide refers to the structure depicted in Formula A below.

[0027] [ka]

[0028] Thus, there is a need for a dedicated treatment for bradykinin-mediated non-hereditary angioedema (BK-AEnH). In particular, there is a need for a treatment for BK-AEnH that is less burdensome to the patient in order to maximize patient compliance. In particular, there is a need for a treatment for BK-AEnH that can be administered orally. There is also a need for oral treatment of acute BK-AEnH attacks on demand, for example, when symptoms of an acute BK-AEnH attack are recognized. There is also a need for prophylactic treatment of BK-AEnH to reduce the likelihood of an acute BK-AEnH attack. There is also a need for a treatment for acute BK-AEnH attacks that can be used by patients on demand and does not require regular (or ongoing) dosing, for example, does not require twice-weekly injections. [Means for solving the problem]

[0029] As mentioned above, there is a lack of approved treatments for certain types of BK-AEnH. HAE medications are often used off-label to treat some types of BK-AEnH. All approved treatments for HAE are injectable. Aside from the obvious underuse of off-label medications, treating BK-AEnH with HAE medications also means that patients are subject to the shortcomings of current HAE treatments.

[0030] HAE attacks are expected to resolve faster and last shorter after early treatment (Maurer M et al., PLoS ONE 2013;8(2):e53773. doi:10.1371 / journal. pone. 0053773), and the same is expected for BK-AEnH attacks. Therefore, early intervention when BK-AEnH attacks are expected or ongoing is essential for the desirable management of this disease. Injection HAE treatments suffer from delayed administration of medication, as patients may need to prepare the formulation or go to the hospital for treatment. It is therefore important that BK-AEnH treatments are not compromised by delays in administration caused by high burden on patients. In fact, Maurer M et al. explain that more than 60% of patients receive HAE injections later than 1 hour from the onset of the attack. Without wishing to be bound by theory, HAE injection treatments suffer from delayed dosing due to inconvenience (self-administration is not always possible), pain (both during and after injection), and preference (all too often patients simply want a less severe attack, not a cure.) The present invention aims to provide a treatment, particularly for BK-AEnH, that avoids some of the problems associated with currently approved treatments for HAE.

[0031] The present invention provides an improved treatment for BK-AEnH compared to any currently administered therapeutic agent for BK-AEnH. The present invention provides an oral treatment for BK-AEnH that is particularly useful as an on-demand treatment for acute BK-AEnH attacks and / or to reduce the likelihood of acute BK-AEnH attacks. Specifically, as described herein, the treatment according to the present invention (i) has a rapid onset of action, (ii) is potent, (iii) has a good safety profile, and (iv) has an extended pharmacodynamic effect.

[0032] Thus, in accordance with the present invention, there is provided a method for treating bradykinin-mediated non-hereditary angioedema (BK-AEnH) on demand, comprising orally administering to a patient in need of treatment a compound of formula A (or a pharma- ceutically acceptable salt and / or solvate thereof) on demand.

[0033] Provided is a compound of formula A (or a pharma- ceutically acceptable salt and / or solvate thereof) for use in the treatment of bradykinin-mediated non-hereditary angioedema (BK-AEnH) comprising orally administering the compound of formula A (or a pharma- ceutically acceptable salt and / or solvate thereof) on demand to a patient in need of treatment.

[0034] In any of the treatments of the invention described herein, the bradykinin-mediated non-hereditary angioedema (BK-AEnH) is not caused by a hereditary genetic malfunction / defect / mutation, i.e., it is not hereditary angioedema (HAE). In some embodiments, the underlying cause of BK-AEnH may be unknown and / or undefined. The specific BK-AEnH that can be treated according to the invention is selected from non-hereditary angioedema with normal C1 inhibitor (AE-nC1 Inh), which may be environmental, hormonal or drug-induced, acquired angioedema, anaphylaxis-related angioedema, angioedema induced by angiotensin-converting enzyme (ACE or ace) inhibitor, dipeptidyl peptidase-4 inhibitor-induced angioedema, and tPA-induced angioedema (tissue plasminogen activator-induced angioedema).

[0035] In embodiments where BK-AEnH is AE-nC1 Inh and is environmentally induced, AE-nC1 Inh may be environmentally induced by air pollution and / or silver nanoparticles such as those used as antimicrobial ingredients in healthcare, biomedical and consumer products.

[0036] In embodiments where the BK-AEnH is dipeptidyl peptidase-4 inhibitor-induced angioedema, the BK-AEnH may be induced by the use of a dipeptidyl peptidase-4 inhibitor as an antidiabetic drug. In some embodiments, the BK-AEnH may be dipeptidyl peptidase-4 inhibitor-induced by sitagliptin, metformin, saxagliptin, linagliptin, empagliflozin, alogliptin, or pioglitazone.

[0037] In embodiments where the BK-AEnH is ace inhibitor induced angioedema, the BK-AEnH can be ace inhibitor induced by benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, or trandolapril.

[0038] In embodiments where the BK-AEnH is tPA-induced angioedema, the BK-AEnH may be induced by thrombolytic therapy using tissue plasminogen activator. In these embodiments, the patient may receive thrombolytic therapy using tissue plasminogen activator to treat acute stroke, such as ischemic stroke.

[0039] In embodiments where the BK-AEnH is non-hereditary angioedema with normal C1 inhibitor (AE-nC1 Inh) and is drug-induced (i.e., drug-induced AE-nC1Inh), the BK-AEnH can be drug-induced by at least one of a nonsteroidal anti-inflammatory agent, a β-lactam antibiotic, and a non-β-lactam antibiotic. In some embodiments, the nonsteroidal anti-inflammatory agent can be at least one of aspirin, celecoxib, diclofenac, diflunisal, etodolac, ibuprofen, indomethacin, ketoprofen, ketorolac, nabumetone, naproxen, oxaprozin, piroxicam, salsalate, sulindac, and tolmetin.

[0040] In some embodiments, when BK-AEnH is non-hereditary angioedema with normal C1 inhibitor (AE-nC1 Inh) and drug-induced (i.e., drug-induced AE-nC1 Inh), BK-AEnH can be induced by angiotensin II receptor blockers (ARBs). In some embodiments, BK-AEnH can be induced by azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, or valsartan.

[0041] In some embodiments where the BK-AEnH is drug-inducible AE-nC1 Inh, the BK-AEnH can be drug-inducible by a beta-blocker.

[0042] In some embodiments where BK-AEnH is non-hereditary angioedema with normal C1 inhibitor (AE-nC1 Inh) and is hormonally induced, AE-nC1 Inh can be hormonally induced by hormonal contraceptives. In some embodiments, AE-nC1 Inh can be hormonally induced by estrogen. In some embodiments, the patient is female and is taking estrogen as a contraceptive. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0043] In any of the treatments of the invention described herein, the term "compound of formula A" is an abbreviation for "compound of formula A (or a pharma- ceutically acceptable salt and / or solvate thereof)". The term "solvate" is used herein to describe a molecular complex comprising a compound of the invention and one or more pharma- ceutically acceptable solvent molecules, e.g., ethanol or water. The term "hydrate" is used when the solvent is water, and for the avoidance of doubt, the term "hydrate" is encompassed within the term "solvate".

[0044] In any of the treatments of the invention described herein, "pharmaceutically acceptable salts" means physiologically or toxicologically tolerable salts and includes, where appropriate, pharmaceutically acceptable base addition salts and pharmaceutically acceptable acid addition salts. For example, (i) when the compound of the invention contains one or more acidic groups, e.g., a carboxy group, pharma- ceutically acceptable base addition salts which may be formed include sodium, potassium, calcium, magnesium and ammonium salts, or salts with organic amines such as diethylamine, N-methylglucamine, diethanolamine or amino acids (e.g., lysine), and (ii) when the compound of the invention contains a basic group, such as an amino group, pharma-ceutically acceptable acid addition salts which may be formed include hydrochloride, hydrobromide, sulfate, phosphate, acetate, citrate, lactate, tartrate, mesylate, succinate, oxalate, phosphate, esylate, tosylate, benzenesulfonate, naphthalene disulfate, maleate, adipate, fumarate, hippurate, camphorate, xinafoate, p-acetamidobenzoate, dihydroxybenzoate, hydroxynaphthoate, succinate, ascorbate, oleate, bisulfonate, and the like.

[0045] Hemisalts of acids and bases can also be formed, such as hemisulfate and hemicalcium salts.

[0046] For a review of suitable salts, see "Handbook of Pharmaceutical Salts: Properties, Selection and Use", Stahl and Wermuth (Wiley-VCH, Weinheim, Germany, 2002).

[0047] Those skilled in the art will understand that "on-demand" treatment in the context of bradykinin-mediated non-hereditary angioedema (BK-AEnH) refers to administering the compound of formula A in response to the need for therapy related to one particular acute BK-AEnH attack. As described herein, this one particular BK-AEnH attack can be ongoing (e.g., treatment is initiated once symptoms of an acute BK-AEnH attack are recognized) or likely to occur (e.g., when the patient expects that an acute BK-AEnH attack is likely to be induced or triggered). Multiple doses of the compound of formula A can be administered as part of the on-demand treatment, but these multiple doses are administered in the context of the same single acute BK-AEnH attack. In other words, "on-demand" does not require administering the compound of formula A continuously at regular intervals (e.g., once a week, twice a week, etc.) regardless of the case of an acute BK-AEnH attack. In the treatment of the present invention, the compound of formula A is taken when the patient needs an immediate therapeutic effect. Particular "on-demand" treatments of the invention include (i) on-demand treatment of an acute BK-AEnH attack, where a compound of formula A is administered when symptoms of an acute BK-AEnH attack are recognized, and (ii) on-demand prophylactic reduction of the likelihood of a BK-AEnH attack, for example, when it is expected that an acute BK-AEnH attack may be induced (or caused), as described in more detail below.

[0048] In any of the treatments of the invention described herein, the patient is preferably a human. BK-AEnH can affect patients of all ages. Thus, the human patient can be a child (0-18 years old) or an adult (18 years old or older). In any of the treatments described herein, the patient can have a predisposition to angioedema. Specifically, the patient can be 12 years old or older. The patient can also be 2 years old or older.

[0049] As shown in the examples, the compound of formula A is a potent inhibitor of plasma kallikrein. As already explained, inhibiting plasma kallikrein inhibits the cleavage of high molecular weight kininogen, which contributes to BK-AEnH attacks. In addition, as shown in Example 4, the compound of formula A can also reduce the generation of factor XIIa (FXIIa) following the cleavage of plasma prekallikrein and activation of the contact system. These advantageous additional effects support the highly effective treatment of the present invention, and are demonstrated in particular when the concentration of the compound of formula A is at least 500 ng / mL of plasma. After administration of a dose of at least about 60 mg (more specifically at least about 70 or about 80 mg) of the compound of formula A, a plasma concentration of at least 500 ng / mL can be observed.

[0050] Thus, in any of the treatments of the invention disclosed herein, in addition to inhibiting plasma kallikrein, particularly following a dose of at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg), the treatment can also, following administration, reduce the cleavage of plasma prekallikrein to produce plasma kallikrein and / or reduce the production of factor XIIa (FXIIa). Thus, in some embodiments, the treatment can block cleavage of plasma prekallikrein to produce plasma kallikrein and / or block cleavage of FXII to produce FXIIa, particularly following a dosage of at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg) of a compound of formula A.

[0051] Compounds of formula A are meant to include compounds that differ only in the presence of one or more isotopically enriched atoms. For example, compounds in which hydrogen is replaced by deuterium or tritium, or carbon is replaced by 13 C or 14 Compounds in which C is substituted are included within the scope of the invention.

[0052] The terms "acute attack of BK-AEnH" and "acute BK-AEnH attack" are used interchangeably herein. The term "bradykinin-mediated non-hereditary angioedema" means bradykinin-mediated angioedema that is not caused by an inherited gene malfunction, defect, or mutation.

[0053] Treatment of acute BK-AEnH attacks on demand According to one aspect of the present invention, there is provided a method for treating an acute attack of bradykinin-mediated non-hereditary angioedema (BK-AEnH) on demand, comprising orally administering to a patient in need of treatment a compound of formula A, wherein the compound of formula A is orally administered on demand upon recognition of symptoms of an acute BK-AEnH attack.

[0054] Accordingly, one aspect of the present invention provides a compound of formula A for use in treating an acute attack of bradykinin-mediated non-hereditary angioedema (BK-AEnH) on demand, comprising orally administering a compound of formula A to a patient in need of treatment, wherein the compound of formula A is orally administered on demand upon recognition of symptoms of an acute BK-AEnH attack.

[0055] Each BK-AEnH attack may vary in severity and in terms of the area affected. Patients suffering from BK-AEnH, medical professionals with knowledge of BK-AEnH, and caregivers of BK-AEnH patients (and indeed those skilled in the art may be) can be astute in identifying the symptoms of an acute BK-AEnH attack. These symptoms include, but are not limited to, tissue swelling, such as in the hands, feet, extremities, face, intestinal tract, and / or airways, fatigue, headache, muscle pain, skin tingling, abdominal pain, nausea, vomiting, diarrhea, difficulty swallowing, hoarseness, shortness of breath, and / or mood swings. Thus, in some embodiments, administration of a compound of formula A can be performed upon recognition of at least one of the above symptoms.

[0056] Those skilled in the art will also understand that "administered upon recognition of symptoms of an acute BK-AEnH attack" means administration as soon as possible after recognition of symptoms of an acute BK-AEnH attack. For example, a patient is expected to have a compound of formula A (possibly in the form of a pharma- ceutically acceptable composition) readily and readily available at all times to ensure that treatment can be administered once symptoms of an acute BK-AEnH attack are recognized. In other words, treatment is on demand. For example, in some embodiments, a compound of formula A can be administered within 1 hour of recognition of symptoms of an acute BK-AEnH attack, preferably within 30 minutes, 20 minutes, 10 minutes, or 5 minutes of recognition of symptoms of an acute BK-AEnH attack.

[0057] In the case where the symptoms of acute BK-AEnH attack are recognized in the prodromal phase, one embodiment of the present invention is that the compound of formula A can be administered in the prodromal phase of acute BK-AEnH attack.In these circumstances, the symptoms recognized can be mild swelling, especially mild swelling affecting the face and neck.In addition, or in the alternative, the symptoms can be abdominal pain, especially abdominal pain is considered to be characteristic of BK-AEnH attack.In addition, or in the alternative, the symptoms can be redness of the skin, such as erythema marginata.

[0058] Treatment according to the invention can prevent acute BK-AEnH attacks from increasing in severity. In some circumstances, treatment can shorten the duration of attacks, and sometimes even stop attacks altogether. For example, treatment can stop the progression of peripheral BK-AEnH attacks or abdominal BK-AEnH attacks. In some embodiments, treatment according to the invention can inhibit subsequent swelling development, sometimes completely, and especially when treatment is initiated during the prodromal phase. In particular, in some embodiments, treatment can prevent acute BK-AEnH attacks from progressing to the swelling stage, when treatment is initiated during the prodromal phase.

[0059] The compound of formula A can be sufficient to treat acute BK-AEnH attacks alone, i.e., without administering any active pharmaceutical ingredient other than the compound of formula A to the patient. Thus, in some embodiments of the present invention, no active pharmaceutical ingredient other than the compound of formula A is administered to the patient to treat acute BK-AEnH attacks. In particular, in some embodiments, the treatment of the present invention does not require the administration of any active pharmaceutical ingredient for treating BK-AEnH attacks (e.g., rescue drugs such as pdC1INH, rhC1INH, or icatibant) other than the compound of formula A. More specifically, in some embodiments, no active pharmaceutical ingredient suitable for treating BK-AEnH attacks (e.g., rescue drugs such as pdC1INH, rhC1INH, or icatibant) other than the compound of formula A is administered to the patient.

[0060] Alternatively, in some embodiments, the treatment of the present invention can be used in combination with other active pharmaceutical ingredients suitable for treating BK-AEnH. For example, in some embodiments, the on-demand acute therapy described herein can be used as a "top-up" to another treatment suitable for treating BK-AEnH. In some embodiments, the patient may be receiving another prophylactic treatment suitable for treating BK-AEnH, and it may be considered to use the on-demand therapy described herein to treat acute BK-AEnH attacks that were not prevented by the other prophylactic treatment suitable for treating BK-AEnH.

[0061] For example, as mentioned above, some HAE treatments are used off-label to treat BK-AEnH. Thus, in some embodiments, a method is provided for treating BK-AEnH in a patient already taking a C1 inhibitor (Cinryze®, Haegarda®, Berinert®, etc.) for prophylaxis, comprising orally administering a compound of formula A to the patient on demand upon recognizing symptoms of an acute BK-AEnH attack. In another embodiment, a method is provided for treating BK-AEnH in a patient already taking lanadelumab for prophylaxis, comprising orally administering a compound of formula A to the patient on demand upon recognizing symptoms of an acute BK-AEnH attack. In another embodiment, a method is provided for treating BK-AEnH in a patient already taking berotralstat for prophylaxis, comprising orally administering a compound of formula A to the patient on demand upon recognizing symptoms of an acute BK-AEnH attack.

[0062] In any of the above treatments, the symptoms can be recognized by the patient.In any of the above treatments, the symptoms can be recognized by a health care professional, such as a health care professional with knowledge of BK-AEnH.In any of the above treatments, the symptoms can be recognized by a caregiver of the patient.

[0063] Treatment according to the invention can reduce the proportion of BK-AEnH attacks that progress by 1 level or more on a 5-point Likert scale (5LS). Treatment according to the invention can reduce the proportion of BK-AEnH attacks that progress by 1 level or more on the 5LS within 12 hours of administering the compound. Treatment according to the invention can improve the resolution time of BK-AEnH attacks on the 5LS to "none". The 5LS is a scale known in the art that can be used to report the severity of BK-AEnH attacks (see, for example, Allergy Asthma Proc. 2018 Jan 1;39(1):74-80. doi:10.2500 / aap. 2018. 39. 4095), and can be used, for example, to report attacks as "none", "mild", "moderate", "severe", or "very severe".

[0064] Treatment according to the invention can reduce the proportion of BK-AEnH attacks rated as "worse" or "much worse" on the 7-point transition question (7TQ). Treatment according to the invention can increase the proportion of BK-AEnH attacks rated as "better" or "much better". The 7TQ is a measure known in the art that can be used to score the progression of BK-AEnH attacks and report attacks as "much better", "good", "slightly better", "no change", "slightly worse", "worse", or "much worse".

[0065] In some embodiments of any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient may be administered a single dose of a compound of formula A to treat the acute BK-AEnH attack. In some other embodiments of any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient may be administered multiple doses of a compound of formula A to treat the acute BK-AEnH attack. For example, the on-demand treatment may include administering two doses of a compound of formula A within 24 hours starting from when the first dose is taken. Alternatively, the on-demand treatment may include administering three doses of a compound of formula A within 24 hours starting from when the first dose is taken. Alternatively, the on-demand treatment may include administering four doses of a compound of formula A within 24 hours starting from when the first dose is taken. When multiple doses are taken, the doses may be evenly spaced such that each dose is approximately equally spaced apart. For example, the next dose is taken 8 hours, 16 hours, and 24 hours after the first dose.

[0066] In some embodiments of any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient may receive a daily dose in two doses per day. These two doses may be administered simultaneously, separately, or sequentially. In some embodiments, the two doses may be administered at any time within the same day, with the interval between the two doses being specific to the patient and the severity of the acute BK-AEnH attack. In some embodiments, the second dose may be administered within about 2 hours of the first dose (more specifically, about 1 to 2 hours after the first dose). In some embodiments, the second dose may be administered about 1 and about 4 hours after the first dose (more specifically, about 1 to 3 hours, about 2 to 3 hours, or 3 to about 4 hours after the first dose). In some embodiments, the second dose may be administered about 4 to about 12 hours after the first dose (more specifically, about 4 to about 8 hours, or about 6 hours after the first dose). In some embodiments, the second dose can be administered about 2 to about 6 hours after the first dose (more specifically, about 3 to about 6 hours after the first dose). In some embodiments, the second dose can be administered about 8 hours after the first dose (more specifically, about 4 to about 8 hours after the first dose). In some embodiments, the second dose can be administered about 12 hours after the first dose (more specifically, about 8 to about 12 hours after the first dose). In some embodiments, the second dose can be administered about 16 hours after the first dose (more specifically, about 12 to about 16 hours after the first dose). In some embodiments, the second dose can be administered about 20 hours after the first dose (more specifically, about 16 to about 20 hours after the first dose). In some embodiments, the second dose can be administered about 24 hours after the first dose (more specifically, about 20 to about 24 hours after the first dose). In these embodiments, each of the two doses can be 600 mg of the compound of formula A.

[0067] In any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient can be administered the daily dose in two doses per day, with the second dose being administered at least about 6 hours after the first dose. The patient can be administered the daily dose in two doses per day, with the second dose being administered at least about 5 to about 7 hours after the first dose. More specifically, the patient can be administered the daily dose in two doses per day, with the second dose being administered at about 6 hours after the first dose. In these embodiments, each of the two doses can be 600 mg of the compound of formula A. Each of these 600 mg doses can be two tablets containing 300 mg of the compound of formula A.

[0068] In some embodiments of any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient may receive a daily dose in three doses per day. These three doses may be administered simultaneously, separately, or sequentially. In some embodiments, the three doses may be administered at any time within the same day, with the interval between the three doses being specific to the patient and the severity of the acute BK-AEnH attack. In some embodiments, the second and third doses may both be administered within about four hours of the first dose. More specifically, the second dose may be administered about 1-3 hours after the first dose, and the third dose may be administered about 3-4 hours after the first dose. The second dose can be administered about 4 to 12 hours after the first dose (more specifically, about 4 to about 8 hours, or about 6 hours after the first dose), and the third dose can be administered about 4 to 12 hours after the second dose (more specifically, about 4 to about 8 hours, or about 6 hours after the second dose). Even more specifically, the second dose can be administered about 2 hours after the first dose, and the third dose can be administered about 4 hours after the first dose. In some embodiments, both the second and third doses can be administered within about 8 hours of the first dose. More specifically, the second dose can be administered about 3 to 5 hours after the first dose, and the third dose can be administered about 7 to about 8 hours after the first dose. Even more specifically, the second dose can be administered about 4 hours after the first dose, and the third dose can be administered about 8 hours after the first dose. In some embodiments, the second and third doses can both be administered within about 16 hours after the first dose. More specifically, the second dose can be administered about 7 to 9 hours after the first dose, and the third dose can be administered about 15 to about 16 hours after the first dose. Even more specifically, the second dose can be administered about 8 hours after the first dose, and the third dose can be administered about 16 hours after the first dose. In these embodiments, each of the three doses can be 600 mg of the compound of formula A.

[0069] In any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient may be administered the daily dose in three doses per day, with the second and third doses being administered at least about 6 hours after the preceding dose. The patient may be administered the daily dose in three doses per day, with the second dose being administered about 5 to about 7 hours after the first dose, and the third dose being administered about 11 to about 13 hours after the first dose. More specifically, the daily dose may be administered in three doses per day, with the second dose being administered about 6 hours after the first dose, and the third dose being administered about 12 hours after the first dose. In these embodiments, each of the three doses may be 600 mg of the compound of formula A. Each of these 600 mg doses may be two tablets containing 300 mg of the compound of formula A.

[0070] For example, if BK-AEnH seizures persist after administration of the first dose, multiple doses can be administered. As used in this context, "sustained" can mean, for example, that the first dose does not prevent the severity of acute BK-AEnH seizures from increasing, or that the first dose does not completely stop BK-AEnH seizures, or that the first dose does not reduce the severity of BK-AEnH seizures. Thus, the on-demand treatment of BK-AEnH seizures of the present invention can include administering a first dose, and then administering a second dose if BK-AEnH seizures persist after administration of the first dose. The on-demand treatment of BK-AEnH seizures of the present invention can also include administering a first dose, and then administering a second dose if BK-AEnH seizures persist after administration of the first dose, and then administering a third dose if BK-AEnH seizures persist after administration of the second dose. In each case, each subsequent dose can be administered simultaneously, separately, or sequentially. In each case, each subsequent dose can be administered at least about 6 hours (e.g., about 6 hours) after the preceding dose. In each case, each dose can contain 600 mg of the compound, and can be administered, for example, as two tablets containing 300 mg.

[0071] Specifically, the on-demand treatment of acute BK-AEnH seizures of the present invention may include administering a first dose containing 600 mg of the compound (e.g., as two tablets containing 300 mg of the compound), and then administering a second dose containing 600 mg of the compound (e.g., as two tablets containing 300 mg of the compound) if the BK-AEnH seizures continue after administering the first dose. The second dose can be administered at least about 6 hours (e.g., at about 6 hours) after the first dose. If the BK-AEnH seizures continue after the second dose, the on-demand treatment of acute BK-AEnH seizures of the present invention may include administering a third dose containing 600 mg of the compound (e.g., as two tablets containing 300 mg of the compound). The third dose can be administered at least about 6 hours (e.g., at about 6 hours) after the second dose.

[0072] Even if the severity of the BK-AEnH seizures appears to be reduced (or completely stopped) after administration of the first dose, multiple doses can be administered to prevent the severity of the BK-AEnH seizures from worsening again. For example, multiple doses can be used to ease the patient's anxiety for the patient's peace of mind. Thus, the on-demand treatment of BK-AEnH seizures of the present invention can include administering a first dose, and then administering a second dose to prevent the severity of the BK-AEnH seizures from increasing again, even if the severity of the BK-AEnH seizures appears to be reduced (or completely stopped) after administration of the first dose. Even if the severity of the BK-AEnH seizures appears to be reduced (or completely stopped) after administration of the first and / or second doses, the on-demand treatment of BK-AEnH seizures of the present invention can also administer a third dose to prevent the severity of the BK-AEnH seizures from increasing again. In each case, each subsequent dose can be administered simultaneously, separately, or sequentially. In each case, each subsequent dose can be administered at least about 6 hours (e.g., at about 6 hours) after the preceding dose. In each case, each dose can contain 600 mg of the compound, and can be administered, for example, as two tablets containing 300 mg of the compound.

[0073] Specifically, an on-demand treatment of acute BK-AEnH seizures of the present invention may include administering a first dose containing 600 mg of the compound (e.g., as two tablets containing 300 mg of the compound) and then administering a second dose containing 600 mg of the compound (e.g., as two tablets containing 300 mg of the compound) to prevent the BK-AEnH seizures from increasing in severity again, even if the severity of the BK-AEnH seizures appears to decrease (or stop altogether) after administration of the first dose. The second dose may be administered at least about 6 hours (e.g., at about 6 hours) after the first dose. Even if the severity of the BK-AEnH seizures appears to decrease (or stop altogether) following administration of the first and / or second dose, on-demand treatment of acute BK-AEnH seizures of the present invention can include administering a third dose containing 600 mg of the compound (e.g., as two tablets containing 300 mg of the compound) to prevent the BK-AEnH seizures from increasing in severity again. The third dose can be administered at least about 6 hours (e.g., at about 6 hours) after the second dose.

[0074] On-demand treatment of an acute BK-AEnH attack according to the invention may include administering no more than three doses in a 24 hour period (e.g., three doses containing 600 mg of the compound, optionally as six tablets each containing 300 mg of the compound).

[0075] On-Demand Prophylactic Treatment of Acute BK-AEnH Attacks According to one aspect of the invention, there is provided a method for on-demand treatment of bradykinin-mediated non-hereditary angioedema (BK-AEnH), comprising orally administering to a patient in need of treatment a compound of formula A, wherein the compound of formula A is orally administered on-demand to prophylactically reduce the likelihood of an acute BK-AEnH attack.

[0076] Accordingly, one aspect of the present invention provides a compound of formula A for use in the treatment of bradykinin-mediated non-hereditary angioedema (BK-AEnH) comprising orally administering the compound of formula A to a patient in need of treatment, where the compound of formula A is administered orally on demand to prophylactically reduce the likelihood of an acute BK-AEnH attack.

[0077] In some embodiments, administration of a compound of formula A can prevent acute BK-AEnH attacks.

[0078] As mentioned above, the treatment according to the present invention does not require the administration of the compound of formula A on a regular basis to provide preventive treatment. Indeed, in some embodiments, the compound of formula A can be administered on demand. For example, when an acute BK-AEnH attack is expected to be induced (or caused), i.e., when the patient is expected to suffer from an acute BK-AEnH attack, the compound of formula A can be administered on demand to reduce the possibility of an acute BK-AEnH attack (e.g., to prevent an acute BK-AEnH attack). In some embodiments, a medical professional, such as a medical professional with knowledge of BK-AEnH, can predict that an acute BK-AEnH attack will be induced (or caused). In some embodiments, a patient's caregiver can predict that an acute BK-AEnH attack will be induced (or caused). For example, acute BK-AEnH attacks can be triggered (or caused) by various stimuli, such as physical trauma (e.g., medical, dental, or surgical procedures) and / or stress (e.g., high stress situations, such as mental stress, which may be related to examinations or mental stress related to medical, dental, or surgical procedures). For example, acute BK-AEnH attacks can be triggered (or caused) by an increase in the patient's stress / anxiety level, when the patient may be expecting to have a BK-AEnH attack. Furthermore, the frequency of acute BK-AEnH attack episodes can change over time in the same patient. Patients often suffer from periods of higher than normal frequency of acute BK-AEnH attacks. Thus, acute BK-AEnH attacks can be expected during periods when the patient is suffering from more frequent acute BK-AEnH attack episodes compared to normal.

[0079] Furthermore, if the patient is exposed to high air pollution, the patient may be expected to suffer from an acute BK-AEnH attack (particularly environmentally induced AE-nC1 Inh). If the patient is exposed to silver nanoparticles, the patient may also be expected to suffer from an acute BK-AEnH attack (particularly environmentally induced AE-nC1 Inh). If the patient is also administered one or more dipeptidyl peptidase-4 inhibitors, the patient may also be expected to suffer from an acute BK-AEnH attack (particularly dipeptidyl peptidase-4 inhibitor-induced angioedema). If the patient is also administered one or more ace inhibitors, the patient may also be expected to suffer from an acute BK-AEnH attack (particularly ace inhibitor-induced angioedema). If the patient is also administered tissue plasminogen activator, the patient may also be expected to suffer from an acute BK-AEnH attack (particularly tPA-induced BK-AEnH). If the patient is receiving a nonsteroidal anti-inflammatory drug, a beta-lactam antibiotic, a non-beta-lactam antibiotic, an angiotensin II receptor blocker, or a beta-blocker, the patient may also be expected to suffer from an acute BK-AEnH attack (particularly drug-induced AE-nC1Inh). If the patient is also receiving a hormonal contraceptive such as an estrogen, the patient may also be expected to suffer from an acute BK-AEnH attack (particularly hormone-induced AE-nC1Inh).

[0080] Those familiar with BK-AEnH will be aware that acute BK-AEnH attacks may be induced (or caused) at least as described above. Patients, medical professionals with knowledge of BK-AEnH, and patient caregivers may also be astute in predicting such triggers. Thus, in accordance with the present invention, a therapeutic agent may be administered on demand when the patient is expected to be exposed to one or more of these stimuli or circumstances. On-demand prophylactic treatment may be administered before, during, or after the patient is exposed to any of the above stimuli or circumstances. A treatment is prophylactic insofar as it is administered before signs and symptoms of an acute BK-AEnH attack are recognized. In some embodiments, on-demand prophylactic treatment may be administered before the patient is exposed to any of the above stimuli or circumstances. In some embodiments, on-demand prophylactic treatment may be administered during the patient's exposure to any of the above stimuli or circumstances. In some embodiments, on-demand prophylactic treatment may be administered after the patient is exposed to any of the above stimuli or circumstances.

[0081] As described above, the compound of formula A can be administered to the patient as part of the on-demand preventive treatment of acute BK-AEnH attacks. As described above, this treatment reduces the possibility of acute BK-AEnH attacks. However, in some circumstances, the patient may still suffer from acute BK-AEnH attacks. Thus, an embodiment of the present invention can be administered to the patient as part of the on-demand preventive treatment of acute BK-AEnH attacks, as described above, and further includes taking an on-demand dose of the compound of formula A when the patient recognizes the symptoms of acute BK-AEnH attacks to treat acute BK-AEnH attacks when they occur. These on-demand treatments of acute BK-AEnH attacks are discussed above.

[0082] Thus, in some embodiments, there is provided a method of treating bradykinin-mediated non-hereditary angioedema (BK-AEnH) on demand comprising orally administering to a patient in need thereof a compound of formula A, wherein the on-demand oral administration of the compound of formula A prophylactically reduces the likelihood of an acute BK-AEnH attack, and further comprising orally administering the compound of formula A on demand upon recognition of symptoms of an acute BK-AEnH attack.

[0083] In some embodiments of any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient can be administered a single dose of the compound of formula A to treat the acute BK-AEnH attack. In some other embodiments of any of the on-demand treatments of acute BK-AEnH attacks of the present invention, the patient can be administered multiple doses of the compound of formula A to treat the acute BK-AEnH attack. For example, the on-demand treatment can include administering two doses of the compound of formula A within 24 hours starting from when the first dose is taken. Alternatively, the on-demand treatment can include administering three doses of the compound of formula A within 24 hours starting from when the first dose is taken. Alternatively, the on-demand treatment can include administering four doses of the compound of formula A within 24 hours starting from when the first dose is taken. When multiple doses are taken, the doses can be evenly spaced such that the time between each dose is approximately equal, for example, subsequent doses are taken 8 hours, 16 hours, and 24 hours after the first dose.

[0084] In some embodiments of any of the on-demand prophylactic treatments of acute BK-AEnH attacks described herein, the patient may be administered two doses per day. These two doses may be administered simultaneously, separately, or sequentially. In some embodiments, the two doses may be administered at any time throughout the day, with the interval between the two doses being patient specific. In some embodiments, the second dose may be administered within about 2 hours of the first dose (more specifically, about 1 to 2 hours after the first dose). In some embodiments, the second dose may be administered about 1 to about 4 hours after the first dose (more specifically, about 1 to 3 hours, about 2 to 3 hours, or about 3 to about 4 hours after the first dose). In some embodiments, the second dose may be administered about 4 to about 12 hours after the first dose (more specifically, about 4 to about 8 hours, or about 6 hours after the first dose). In some embodiments, the second dose can be administered about 2 hours to about 6 hours after the first dose (more specifically, about 3 hours to about 6 hours after the first dose). In some embodiments, the second dose can be administered within about 8 hours after the first dose (more specifically, about 4 hours to about 8 hours after the first dose). In some embodiments, the second dose can be administered within about 12 hours after the first dose (more specifically, about 8 hours to about 12 hours after the first dose). In some embodiments, the second dose can be administered within about 16 hours after the first dose (more specifically, about 12 hours to about 16 hours after the first dose). In some embodiments, the second dose can be administered within about 20 hours after the first dose (more specifically, about 16 hours to about 20 hours after the first dose). In some embodiments, the second dose can be administered within about 24 hours of the first dose (more specifically, about 20 to about 24 hours after the first dose). In these embodiments, each of the two doses can be 600 mg of the compound of formula A.

[0085] In any of the on-demand prophylactic treatments of acute BK-AEnH attacks described herein, the patient can be administered the daily dose in two doses per day, with the second dose being administered at least about 6 hours after the first dose. The patient can be administered the daily dose in two doses per day, with the second dose being administered about 5 to about 7 hours after the first dose. More specifically, the patient can be administered the daily dose in two doses per day, with the second dose being administered about 6 hours after the first dose. In these embodiments, each of the two doses can be 600 mg of the compound of formula A. Each of these 600 mg doses can be two tablets containing 300 mg of the compound of formula A.

[0086] In some embodiments of any of the on-demand prophylactic treatments of acute BK-AEnH attacks described herein, the patient may receive a daily dose in three doses per day. These three doses may be administered simultaneously, separately, or sequentially. In some embodiments, the three doses may be administered at any time of the day, with the interval between the three doses being specific to the patient. In some embodiments, the second and third doses may both be administered within about four hours of the first dose. More specifically, the second dose may be administered about 1 to 3 hours after the first dose, and the third dose may be administered about 3 to about 4 hours after the first dose. The second dose may be administered about 4 and about 12 hours after the first dose (more specifically, about 4 to about 8 hours, or about 6 hours after the first dose), and the third dose may be administered about 4 to about 12 hours after the second dose (more specifically, about 4 to about 8 hours, or about 6 hours after the second dose). Even more specifically, the second dose can be administered about 2 hours after the first dose, and the third dose can be administered about 4 hours after the first dose. In some embodiments, both the second and third doses can be administered within about 8 hours of the first dose. More specifically, the second dose can be administered about 3 to 5 hours after the first dose, and the third dose can be administered about 7 to about 8 hours after the first dose. Even more specifically, the second dose can be administered about 4 hours after the first dose, and the third dose can be administered about 8 hours after the first dose. In some embodiments, both the second and third doses can be administered within about 16 hours of the first dose. More specifically, the second dose can be administered about 7 to 9 hours after the first dose, and the third dose can be administered about 15 to about 16 hours after the first dose. Even more specifically, the second dose can be administered about 8 hours after the first dose, and the third dose can be administered about 16 hours after the first dose. In these embodiments, each of the three doses can be 600 mg of the compound of formula A.

[0087] In any of the on-demand prophylactic treatments of acute BK-AEnH attacks described herein, the patient may be administered the daily dose in three doses per day, with the second and third doses administered at least about 6 hours after the preceding dose. The patient may be administered the daily dose in three doses per day, with the second dose administered about 5 hours to about 7 hours after the first dose, and the third dose administered about 11 to about 13 hours after the first dose. More specifically, the patient may be administered the daily dose in three doses per day, with the second dose administered about 6 hours after the first dose, and the third dose administered about 12 hours after the first dose. In these embodiments, each of the three doses may be 600 mg of the compound of formula A. Each of these 600 mg doses may be two tablets containing 300 mg of the compound of formula A.

[0088] For example, multiple doses can be administered if there is a continuing need to prophylactically reduce the likelihood of an acute BK-AEnH attack (e.g., as described above, if the patient continues to anticipate that a BK-AEnH attack will be induced). Thus, the on-demand treatment of BK-AEnH attacks of the present invention can include administering a first dose, and administering a second dose if there is a continuing need to prophylactically reduce the likelihood of an acute BK-AEnH attack after administering the first dose. The on-demand treatment of BK-AEnH attacks of the present invention can also include administering a first dose, then administering a second dose if there is a continuing need to prophylactically reduce the likelihood of an acute BK-AEnH attack after administering the first dose, and then administering a third dose if there is a continuing need to prophylactically reduce the likelihood of an acute BK-AEnH attack after administering the second dose. In each case, each subsequent dose can be administered simultaneously, separately, or sequentially. In each case, each subsequent dose can be administered at least about 6 hours (e.g., at about 6 hours) after the preceding dose. In each case, each dose can contain 600 mg of the compound, for example, administered as two tablets containing 300 mg of the compound.

[0089] Specifically, the on-demand prophylactic treatment of acute BK-AEnH attacks described herein may include administering a first dose containing 600 mg of the compound (e.g., as two tablets each containing 300 mg of the compound), and then administering a second dose containing 600 mg of the compound (e.g., as two tablets each containing 300 mg of the compound) if there is a need to prophylactically reduce the likelihood of an acute BK-AEnH attack after administering the first dose. The second dose can be administered at least about 6 hours (e.g., at about 6 hours) after the first dose. If there is an ongoing need to prophylactically reduce the likelihood of an acute BK-AEnH attack after the second dose, the on-demand treatment of acute BK-AEnH attacks of the present invention may include administering a third dose containing 600 mg of the compound (e.g., as two tablets each containing 300 mg of the compound). The third dose can be administered at least about 6 hours (e.g., at about 6 hours) after the second dose.

[0090] On-demand prophylactic treatment of acute BK-AEnH attacks as described herein may include administering no more than three doses in a 24-hour period (e.g., three doses containing 600 mg of the compound, optionally as six tablets each containing 300 mg of the compound).

[0091] Continuous and regular preventive measures for BK-AEnH According to one aspect of the present invention, there is provided a method for treating bradykinin-mediated non-hereditary angioedema (BK-AEnH), comprising orally administering to a patient in need of treatment a compound of formula A, wherein the compound of formula A is administered orally to prophylactically reduce the likelihood of an acute BK-AEnH attack, and the compound of formula A is administered periodically to the patient.

[0092] Accordingly, one aspect of the present invention provides a compound of formula A for use in the treatment of bradykinin-mediated non-hereditary angioedema (BK-AEnH), comprising orally administering a compound of formula A to a patient in need of treatment, wherein the compound of formula A is orally administered to prophylactically reduce the likelihood of an acute BK-AEnH attack, and the compound of formula A is administered to the patient on a regular basis.

[0093] The term "administered periodically" means that the compound of formula A is administered continuously at regular intervals (e.g., once a week, twice a week, etc.) to provide effective treatment. A medical professional will readily understand what is meant by regular (or continuous) administration.

[0094] In some embodiments, a compound of formula A can be administered to prevent acute BK-AEnH attacks.

[0095] In some embodiments, the compound of formula A can be administered orally once a day. In other embodiments, the compound of formula A can be administered twice a day. In other embodiments, the compound of formula A can be administered three times a day. In other embodiments, the compound of formula A can be administered every other day.

[0096] As described above, the compound of formula A can be administered to the patient as part of the continuous and regular preventive treatment of BK-AEnH. As described above, this treatment reduces the possibility of acute BK-AEnH attacks. However, in some circumstances, the patient may still suffer from acute BK-AEnH attacks. Thus, an embodiment of the present invention, as described above, can be administered to the patient as part of the continuous and regular preventive treatment of BK-AEnH, and further includes taking an on-demand dose of the compound of formula A upon recognizing symptoms of acute BK-AEnH attacks to treat acute BK-AEnH attacks as they occur. These on-demand treatments of acute BK-AEnH attacks are discussed above.

[0097] Thus, in some embodiments, there is provided a method for treating bradykinin-mediated non-hereditary angioedema (BK-AEnH), the method comprising orally administering a compound of formula A to a patient in need thereof, whereby oral administration of the compound of formula A prophylactically reduces the likelihood of an acute BK-AEnH attack, periodically administering the compound of formula A to the patient, and further comprising orally administering the compound of formula A on demand upon recognition of symptoms of an acute BK-AEnH attack.

[0098] dosage In any of the treatments of the invention described herein, the compound of formula A is administered orally in a therapeutically effective amount.

[0099] In some embodiments, the compound of formula A can be administered in a daily dosage of about 5 mg to about 2000 mg per day. By "daily dosage" is meant the total amount administered in one day. More specifically, the compound of formula A can be administered at a daily dose of about 100 mg to about 1500 mg, about 300 mg to about 1800 mg, about 100 mg to about 1400 mg, about 200 mg to about 1200 mg, about 300 mg to about 1200 mg, about 600 mg to about 1200 mg, about 450 mg to about 900 mg, about 500 mg to about 1000 mg, about 450 mg to about 600 mg, about 500 mg to about 700 mg (more specifically 600 mg), about 800 mg to about 1000 mg, about 900 mg to about 1400 mg (more specifically 1200 mg), or about 900 mg to about 1200 mg. In a specific embodiment, the daily dose is 300 mg. In another specific embodiment, the daily dose is 600 mg. In another particular embodiment, the daily dosage is 900 mg. In another particular embodiment, the daily dosage is 1200 mg. In another particular embodiment, the daily dosage is 1800 mg.

[0100] The daily dose can be administered as one single dose or divided into multiple doses for administration periodically throughout the day.Each dose can then be administered as a single dosage form or divided into multiple dosage forms.For example, a daily dose of 1200 mg can be administered as two separate dosage forms of 600 mg, and each of these subdoses can be administered as two separate dosage forms of 300 mg.When multiple doses and multiple dosage forms are used, they can be administered simultaneously, separately or sequentially.

[0101] In some embodiments, each single unit dosage form comprising the compound of formula A contains about 5 mg to about 1000 mg, about 50 mg to about 800 mg, about 100 mg to about 700 mg, about 200 mg to about 700 mg, about 300 mg to about 700 mg, or about 500 mg to about 700 mg of the compound of formula A. In some embodiments, each single unit dosage form comprising the compound of formula A contains about 5 mg, about 10 mg, about 20 mg, about 40, about 80 mg, about 160 mg, about 300 mg, about 400 mg, about 450 mg, about 500 mg, or about 600 mg.

[0102] Each dose administered to a patient may contain 600 mg of the compound, which may be subdivided into two tablets containing 300 mg of the compound.

[0103] Alternatively, each dose may contain 300 mg of the compound, which may be one tablet containing 300 mg of the compound.

[0104] In a particular embodiment, the patient is administered a daily dose of 600 mg administered as a single dose.

[0105] In another particular embodiment, the patient is administered a daily dose of 1200 mg, which is administered as two doses, in particular where the second dose is administered 2-6 hours after the first dose, preferably about 3-6 hours after the first dose.

[0106] In another particular embodiment, a patient is administered a daily dose of 1800 mg, which is administered as three doses, in which, inter alia, the second dose is administered 2-8 hours after the first dose (e.g., about 2 hours, 4 hours, about 6 hours, or about 8 hours) and the third dose is administered about 4 hours to 16 hours after the first dose (e.g., about 4 hours, about 6 hours, about 8 hours, about 12 hours, or about 16 hours).

[0107] The treatment of the present invention involves oral administration. In any of the treatments of the present invention, the compound of formula A can be administered as an oral dosage form comprising the compound of formula A and a pharma- ceutically acceptable excipient. The oral dosage form can be in the form of a tablet or capsule. In one embodiment, the oral dosage form is a tablet. In another embodiment, the oral dosage form is a capsule.

[0108] The treatment of the present invention can include not administering more than three doses in a 24-hour period.Specifically, if each dose contains 600 mg of compound, it means that the treatment of the present invention can include not administering more than 1800 mg of compound in a 24-hour period.If each dose containing 600 mg of compound is divided into two doses (e.g. tablets) containing 300 mg of compound, the treatment of the present invention can include administering six or less doses each containing 300 mg of compound in a 24-hour period, and each dose can be a tablet.

[0109] The dosage form can be a tablet containing microcrystalline cellulose as a diluent, croscarmellose sodium as a disintegrant, polyvinylpyrrolidone as a binder, and optionally magnesium stearate as a lubricant. In a preferred tablet, the compound of formula A comprises (i) at least about 40% by weight of the tablet (more specifically, about 40% to about 60% by weight) relative to the total weight of the tablet, (ii) about 25% to about 60% by weight of the diluent (more specifically, about 25% to about 40% by weight) relative to the total weight of the tablet, (iii) about 1% to about 15% by weight of the disintegrant (more specifically, about 2% to about 6% by weight) relative to the total weight of the tablet, (iv) about 1% to about 20% by weight of the binder (more specifically, about 2% to about 5% by weight) relative to the total weight of the tablet, and, if present, (v) about 0.1 to about 5% by weight of the lubricant (more specifically, about 0.1% to about 1.5% by weight) relative to the total weight of the tablet. The dosage form can be a tablet containing 300 mg of the compound.

[0110] The tablet may further comprise extragranular excipients including microcrystalline cellulose as an extragranular diluent, croscarmellose sodium as an extragranular disintegrant, polyvinylpyrrolidone as an extragranular binder, and / or magnesium stearate as an extragranular lubricant.

[0111] The dosage forms (e.g., tablets) described herein can be film coated, and the film coating can include one or more of hypromellose, lactose monohydrate, titanium dioxide, and triacetin.

[0112] Further details of the treatment of the present invention As shown herein, the compound of formula A acts rapidly. Specifically, the compound of formula A is a potent inhibitor of plasma kallikrein activity and is highly effective in blocking the positive feedback loop of the contact activation system between plasma kallikrein, prekallikrein, factor XII (FXII), and factor XIIa (FXIIa). The pharmacokinetic and pharmacodynamic data provided herein demonstrate that these effects are exhibited immediately after oral administration of the compound of formula A. Thus, the treatment of the present invention is fast-acting and therefore particularly suitable for treating BK-AEnH on demand.

[0113] As noted above, the treatment of the present invention is particularly advantageous when the concentration of the compound of formula A is at least 500 ng / mL in the plasma. After administration of a dose of at least about 60 mg (more specifically, at least about 70 mg or about 80 mg) of the compound of formula A, a plasma concentration of at least 500 ng / mL can be observed.

[0114] Treatment according to the invention provides rapid protection from HK (high molecular weight kininogen) cleavage, which is particularly suitable for prophylactically reducing the likelihood of acute BK-AEnH attacks and / or shortening (or even halting) the severity of ongoing acute BK-AEnH attacks. As described herein, treatment according to the invention also provides prolonged pharmacodynamic effects. The pharmacodynamic effects of the compound of formula A related to the treatment of BK-AEnH include providing protection from HK cleavage, which may cause acute BK-AEnH attacks, as described above. For example, the compound of formula A can provide protection from HK cleavage by at least (i) inhibiting plasma kallikrein, (ii) reducing plasma prekallikrein cleavage, and / or (iii) reducing the generation of factor XIIa from factor XII.

[0115] In some embodiments, treatment according to the invention can provide protection from HK (high molecular weight kininogen) cleavage within 1 hour after administration, particularly when the dose of the compound of formula A is at least about 60 mg (specifically at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg). In some embodiments, treatment according to the invention can provide protection from HK (high molecular weight kininogen) cleavage within 45 minutes after administration, or within 30 minutes after administration. In these embodiments, protection from HK (high molecular weight kininogen) cleavage is confirmed by comparing HK levels in untreated plasma to HK levels in treated plasma, i.e., plasma from subjects who received a dose of the compound of formula A, and then activating the plasma with dextran sulfate to activate the contact system to induce HK cleavage. If the level of HK in treated plasma exceeds the level of HK in untreated plasma, HK is protected from HK cleavage in activated plasma.

[0116] In some embodiments of the invention, the treatment can inhibit at least 80% of plasma kallikrein activity within 30 minutes after administration, particularly when the dose of a compound of Formula A is at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg). In some embodiments of the invention, the treatment can inhibit at least 90% of plasma kallikrein activity within 30 minutes after administration, particularly when the dose of a compound of Formula A is at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg). In some embodiments of the invention, the treatment can inhibit at least 95% of plasma kallikrein activity within 30 minutes after dosing, particularly when the dose of a compound of Formula A (or a pharma- ceutically acceptable salt and / or solvate thereof) is at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg). In embodiments where inhibition of plasma kallikrein activity is referred to, inhibition of plasma kallikrein activity is determined by time-dependent hydrolysis with a fluorogenic substrate (e.g., (HD-Pro-Phe-Arg-AFC; Peptide Protection Research) by procedures known in the art. In these embodiments, inhibition of plasma kallikrein activity is identified in plasma obtained from subjects who have received a dose of a compound of Formula A, which is subsequently activated with dextran sulfate to emulate the BK-AEnH situation.

[0117] In some embodiments of the invention, a therapeutically effective concentration of the compound of formula A may be achieved within 20 minutes after administration.

[0118] In some embodiments of the present invention, the T max The time period can be 30 minutes to 3 hours after administration, preferably 30 minutes to 2 hours after administration.

[0119] In some embodiments of the invention, the treatment can inhibit at least 90% of plasma kallikrein activity over a period of at least 45 minutes to 2 hours after administration, particularly when the dose of the compound of formula A is 100 mg to 200 mg (preferably 160 mg). In some embodiments, the treatment can inhibit at least 90% of plasma kallikrein activity over a period of at least 20 minutes to 4 hours after administration, particularly when the dose of the compound of formula A is 100 mg to 200 mg (preferably 160 mg). In some embodiments, the treatment can inhibit at least 90% of plasma kallikrein activity over a period of at least 30 minutes to 10 hours after administration, particularly when the dose of the compound of formula A is 300 mg to 800 mg (preferably 600 mg). In some embodiments, the treatment can inhibit at least 95% of plasma kallikrein activity over a period of at least 20 minutes to 6 hours after administration, particularly when the dose of the compound of formula A is 300 mg to 800 mg (preferably 600 mg). In some embodiments, the treatment can inhibit at least 99% of plasma kallikrein activity over a period of at least 20 minutes to 6 hours after administration, particularly when the dose of the compound of formula A is between 300 mg and 800 mg, preferably 600 mg. Again, in these embodiments, inhibition of plasma kallikrein activity is observed in plasma obtained from subjects who have received a dose of the compound of formula A which has subsequently been activated with dextran sulfate to emulate the BK-AEnH situation.

[0120] In some embodiments, the pharmacodynamic effect of the compound of formula A in relation to the treatment of BK-AEnH may be maintained for at least 12 hours after administration, particularly when the dose of the compound of formula A is between 300 mg and 800 mg (preferably 600 mg). In some embodiments, the treatment may inhibit at least 50% of plasma kallikrein activity for at least 10 hours after administration, particularly when the dose of the compound of formula A is between 100 mg and 200 mg (preferably 160 mg). In these embodiments, the pharmacodynamic effect refers to at least (i) inhibition of plasma kallikrein, (ii) protection from / reduction of HK cleavage in blood, (iii) protection from (or reduction of) factor XIIa generation by factor XII cleavage, and / or (iv) protection from (or reduction of) plasma kallikrein generation by plasma prekallikrein cleavage. Thus, the treatment according to the invention is a suitable candidate to be an advantageously effective treatment of acute BK-AEnH attacks, since it is fast-acting and potent (e.g., inhibitory) for a sufficiently long period of time.

[0121] As noted above, in any of the treatments of the present invention, the compounds of formula A are capable of inhibiting plasma kallikrein.

[0122] In any of the treatments of the invention, a compound of formula A can inhibit cleavage of factor XII to produce factor XIIa, particularly following administration of at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg) of a compound of formula A. In any of the treatments of the invention, the compound of formula A can inhibit the cleavage of plasma prekallikrein to plasma kallikrein, particularly following administration of at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg) of a compound of formula A. In any of the treatments of the invention, particularly following administration of at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg) of a compound of formula A, the compound of formula A can provide inhibition (e.g., blockage) of contact system activation for up to 6 hours following administration. In some embodiments, when a dose of at least about 60 mg (more specifically, at least about 70 mg or about 80 mg, e.g., about 80 mg to about 900 mg, about 100 mg to about 800 mg, about 200 mg to about 700 mg, about 300 mg to about 600 mg, or about 400 mg to about 600 mg, specifically 600 mg) is administered, contact system activation can be inhibited (e.g., blocked) for at least 6 hours, e.g., 6 hours to 12 hours or 18 hours, after administration.

[0123] drawing In the drawings, the term "compound" refers to a compound of formula A. [Brief description of the drawings]

[0124] [Figure 1]1 is a powder X-ray diffraction pattern of the compound of formula A produced in Example 1. [Figure 2A] 1 is an assay result showing the plasma kallikrein inhibitory activity of the compound of Formula A and C1 inhibitor C1-INH in dextran sulfate (DXS)-activated diluted plasma. [Figure 2B] 1 is an assay result showing the plasma kallikrein inhibitory activity of the compound of Formula A and C1 inhibitor (C1-INH) in DXS-activated undiluted plasma. [Figure 3A] 1 is the results of an assay comparing the plasma kallikrein inhibitory activity of the compound of Formula A and C1-INH in DXS-activated diluted plasma. [Figure 3B] 1 is an assay result comparing the inhibitory activity of the compound of formula A and C1-INH after addition to preactivated undiluted human plasma. Data are presented as the mean total fluorescence (fluorescence units) over time ± SEM of n=3 experiments. [Figure 4A] 1 is an assay (bioanalytical) result showing plasma concentrations of the compound of formula A from 0 to 24 hours post-dose in fasted subjects from eight single ascending dose cohorts. [Figure 4B] FIG. 4B is a table of Cmax values ​​determined from the assay (bioanalytical) results shown in FIG. 4A. [Figure 5A] Assay results showing plasma kallikrein activity in DXS-activated undiluted plasma from cohorts 6 to 8 (160 mg, 300 mg, and 600 mg). [Figure 5B] 13 is an assay result showing the mean plasma kallikrein activity and mean plasma concentration of the compound of Formula A in undiluted plasma in subjects from Cohort 8 (600 mg dose). [Figure 6A] 1 is an assay result showing mean fluorescence kinetic measurements indicating the lag time in catalytic activity upon contact system activation in DXS-activated undiluted plasma from subjects receiving a 600 mg dose of the compound of Formula A. [Figure 6B] FIG. 6B is an enlarged view of FIG. 6A from 0 to 5 minutes after catalyst activation. [Figure 7]Assay results showing mean percent HK protection at selected time points following dosing in DXS-activated undiluted plasma for cohorts 6-8 (160 mg, 300 mg, and 600 mg), and representative WES gel images of immunoblot data. [Figure 8] 13 is a representative WES gel image of assay results and immunoblot data showing the effect of compound of Formula A on DXS-activated HK cleavage at selected time points following dosing of Cohort 8 (600 mg). [Figure 9] 1 is a representative WES gel image of assay results and immunoblot data showing the effect of compound of Formula A on DXS-activated plasma prekallikrein (PPK) cleavage at selected time points following dosing of Cohort 8 (600 mg). [Figure 10] Representative WES gel images of assay results and immunoblot data showing the effect of compound of formula A on DXS-activated production of FXIIa at selected time points after administration of cohort 8 (600 mg). [Figure 11] Assay (bioanalytical) results showing the effect of plasma concentrations of compound of formula A at various stages after administration in cohort 8 (600 mg) at the time points selected for HK, FXIIa, and PPK analysis. [Figure 12] Assay results showing no significant food effect on the plasma kallikrein inhibitory activity of the compound of Formula A in DXS-activated undiluted plasma. [Figure 13A] 13 shows assay results and representative blot images showing the time course of dextran sulfate-activated cleavage of HK in BK-AEnH undiluted whole plasma as determined using Western blotting. [Figure 13B] 13 shows assay results and representative blot images showing the time course of dextran sulfate-activated cleavage of HK in BK-AEnH undiluted whole plasma as determined using Western blotting. [Figure 14A] 1 shows assay results and representative WES system gel images showing dose response of compound of formula A on full length HK levels in dextran sulfate-activated healthy control plasma and HAE plasma. [Figure 14B] 1 shows assay results and representative WES system gel images showing dose response of compound of formula A on full length HK levels in dextran sulfate-activated healthy control plasma and HAE plasma. [Figure 15] Preliminary pharmacokinetic data from an ongoing Phase 2 study. [Figure 16A] Mean plasma concentrations over time for four cohorts in a Phase I multiple dose study. [Figure 16B] Mean plasma concentrations over time (semi-log scale) for four cohorts in a Phase I multiple-dose study.

[0125] The embodiments provided herein may be more fully understood by reference to the following examples, which are illustrative of the treatments provided herein but are in no way limiting. Indeed, the scope of the invention is defined by the claims.

[0126] While examples of certain specific embodiments have been provided herein, it will be apparent to one of ordinary skill in the art that various changes and modifications can be made, which are intended to fall within the scope of the appended claims. EXAMPLES

[0127] General Experimental Details In the examples below, the following abbreviations and definitions are used:

[0128] [Table 1]

[0129] All reactions were carried out under a nitrogen atmosphere unless otherwise stated.

[0130] 1 1 H NMR spectra were recorded on a Bruker (400 MHz) or JEOL (400 MHz) spectrometer at room temperature referenced to deuterated solvents.

[0131] Molecular ions were acquired using LCMS performed using a Chromolith Speedrod RP-18e column, 50 x 4.6 mm, with a linear gradient from 10% to 90% 0.1% HCOH / MeCN to 0.1% HCOH / H2O over 13 min, flow rate of 1.5 mL / min, or an Agilent, X-Select, acidic, 5% to 95% MeCN / water over 4 min. Data was collected using a Thermofinnigan Surveyor MSQ mass spectrometer with electrospray ionization coupled with a Thermofinnigan Surveyor LC system.

[0132] Alternatively, molecular ions were acquired using LCMS performed using an Agilent Poroshell 120 EC-C18 (2.7 μm, 3.0 × 50 mm) column using the following: 0.1% by volume formic acid in water [eluent A]; MeCN [eluent B]; flow rate 0.8 mL / min, equilibration time 1.5 min between samples, gradient. Mass detection was performed on an API 2000 mass spectrometer (electrospray).

[0133] gradient:

[0134] [Table 2]

[0135] Where products were purified by flash chromatography, "silica" refers to silica gel for chromatography, 0.035-0.070 mm (220-440 mesh) (e.g., Merck silica gel 60), and nitrogen pressurized accelerated column elution up to about 69 kPa (10 psi). Reverse-phase preparative HPLC purification was performed using a Waters 2525 binary gradient pump system at a flow rate typically of 20 mL / min using a Waters 2996 photodiode array detector.

[0136] All solvents and commercial reagents were used as received.

[0137] Chemical names were generated using automated software such as Autonom software provided as part of the ISIS Draw package from MDL Information Systems, or Chemaxon software provided as a component of MarvinSketch or as a component of IDBS E-WorkBook.

[0138] X-ray powder diffraction patterns were collected on a Philips X-Pert MPD diffractometer and analyzed using the following experimental conditions (Method A) unless otherwise stated. Tube anode:Cu Generator voltage: 40kV Tube current: 40mA Wavelength α1: 1.5406Å Wavelength α2: 1.5444Å Starting angle [2θ]:4 End angle [2θ]: 40

[0139] Continuous Scan Approximately 2 mg of the sample under analysis was gently pressed onto an XRPD zero background single obliquely cut silica sample holder. The sample was then mounted into the diffractometer for analysis.

[0140] Example 1 - Preparation of Compounds of Formula A A. 1-(4-hydroxymethyl-benzyl)-1H-pyridin-2-one 4-(Chloromethyl)benzyl alcohol (5.0 g, 31.93 mmol) was dissolved in acetone (150 mL). 2-Hydroxypyridine (3.64 g, 38.3 mmol) and potassium carbonate (13.24 g, 95.78 mmol) were added and the reaction mixture was stirred at 50° C. for 3 h, after which the solvent was removed under reduced pressure and the residue was taken up in chloroform (100 mL). The solution was washed with water (30 mL), brine (30 mL), dried (Na2SO4) and evaporated under reduced pressure. The residue was purified by flash chromatography (silica), eluent 3% MeOH / 97% CHCl3 to give a white solid identified as 1-(4-hydroxymethyl-benzyl)-1H-pyridin-2-one (5.30 g, 24.62 mmol, 77% yield).

[0141] [M+Na] + =238.

[0142] B. 1-(4-Chloromethyl-benzyl)-1H-pyridin-2-one 1-(4-Hydroxymethyl-benzyl)-1H-pyridin-2-one (8.45 g, 39.3 mmol), anhydrous DCM (80 mL) and triethylamine (7.66 mL, 55.0 mmol) were cooled in an ice bath. Methanesulfonyl chloride (3.95 mL, 51.0 mmol) was added and stirred in the ice bath for 15 min. The ice bath was removed and stirring was continued at room temperature overnight. The reaction mixture was partitioned between DCM (100 mL) and saturated aqueous NH4Cl (100 mL). The aqueous layer was further extracted with DCM (2 x 50 mL) and the combined organic layers were washed with brine (50 mL), dried over Na2SO4, filtered and concentrated to give 1-(4-chloromethyl-benzyl)-1H-pyridin-2-one as a pale yellow solid (8.65 g, 36.6 mmol, 93% yield).

[0143] [MH] + =234.1.

[0144] C. Methyl 3-(methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylate Potassium carbonate (519 mg, 3.76 mmol) was added to a solution of methyl 3-(methoxymethyl)-1H-pyrazole-4-carboxylate (320 mg, 1.88 mmol, CAS number 318496-66-1 (synthesized according to the method described in WO2012 / 00909)) and 1-(4-(chloromethyl)benzyl)pyridin-2(1H)-one (527 mg, 2.26 mmol) in DMF (5 mL) and heated at 60° C. overnight. The reaction mixture was diluted with EtOAc (50 mL), washed with brine (2×100 mL), dried over magnesium sulfate, filtered and reduced in vacuo. The crude product was purified by flash chromatography (40 g column, 0% to 100% EtOAc / isohexane) to give the two regioisomers. The second isomer from the column was collected to give methyl 3-(methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylate (378 mg, 1.01 mmol, 53.7% yield) as a colorless gum.

[0145] [MH] + =368.2.

[0146] D. 3-(Methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylic acid To 3-(methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylate (3.77 g, 10.26 mmol) in THF (5 mL) and MeOH (5 mL) was added 2M NaOH solution (15.39 mL, 30.8 mmol) and stirred at room temperature overnight. 1M HCl (50 mL) was added and extracted with EtOAc (50 mL). The organic layer was washed with brine (50 mL), dried over magnesium sulfate, filtered and reduced in vacuo to give 3-(methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylic acid (1.22 g, 3.45 mmol, 33.6% yield) as a white powder.

[0147] [MH] + =354.2.

[0148] E. 3-Fluoro-4-methoxy-pyridine-2-carbonitrile In a large microwave vial, copper(I) cyanide (1.304 g, 14.56 mmol) was added to a solution of 2-bromo-3-fluoro-4-methoxypyridine (1 g, 4.85 mmol) in DMF (5 mL). The reaction vial was sealed and heated to 100° C. for 16 h. The reaction mixture was diluted with water (20 mL) and EtOAc (20 mL). The resulting viscous suspension was sonicated, and additional water (40 mL) and EtOAc (2×50 mL) were added and sonicated to break up the precipitated solids. The combined layers were filtered through a pad of Celite, the organic layer was isolated, washed with brine (50 mL), dried over magnesium sulfate, filtered, and the solvent was removed under reduced pressure to give a pale green solid identified as the desired compound 3-fluoro-4-methoxy-pyridine-2-carbonitrile (100 mg, 0.578 mmol, 12% yield).

[0149] F. (3-Fluoro-4-methoxy-pyridin-2-ylmethyl)-carbamic acid tert-butyl ester 3-Fluoro-4-methoxy-pyridine-2-carbonitrile (100 mg, 0.578 mmol) was dissolved in anhydrous methanol (10 mL, 247 mmol) and nickel chloride hexahydrate (14 mg, 0.058 mmol) was added followed by di-tert-butyl dicarbonate (255 mg, 1.157 mmol). The resulting pale green solution was cooled to -5 °C in an ice-salt bath and then sodium borohydride (153 mg, 4.05 mmol) was added in small portions, maintaining the reaction temperature at approximately 0 °C. The deep brown solution was stirred at 0 °C, slowly warmed to room temperature and then stirred at room temperature for 3 h. The reaction mixture was evaporated to dryness at 40 °C to give a black residue which was diluted with DCM (10 mL) and washed with sodium bicarbonate (10 mL). An emulsion formed so the organic phase was separated via a phase separation cartridge and concentrated. The resulting crude liquid was purified by chromatography eluting with EtOAc / iso-hexane to give the title compound (3-fluoro-4-methoxy-pyridin-2-ylmethyl)-carbamic acid tert-butyl ester as a clear yellow oil (108 mg, 62% yield).

[0150] [MH] + =257.

[0151] GC-(3-Fluoro-4-methoxy-pyridin-2-yl)-methylamine hydrochloride (3-Fluoro-4-methoxy-pyridin-2-ylmethyl)-carbamic acid tert-butyl ester (108 mg, 0.358 mmol) was taken up in isopropyl alcohol (1 mL), then HCl (6N solution in isopropyl alcohol) (1 mL, 0.578 mmol) was added at room temperature and stirred for 2 hours at 40° C. The reaction mixture was concentrated under reduced pressure, then triturated with ether, sonicated, and then decanted to give a cream-colored solid identified as C-(3-fluoro-4-methoxy-pyridin-2-yl)-methylamine hydrochloride (75 mg, 55% yield).

[0152] [MH] + =157.

[0153] Example 1a - N-[(3-fluoro-4-methoxypyridin-2-yl)methyl]-3-(methoxymethyl)-1-({4-[(2-oxopyridin-1-yl)methyl]phenyl}methyl)pyrazole-4-carboxamide (compound of formula A) 3-(Methoxymethyl)-1-(4-((2-oxopyridin-1(2H)-yl)methyl)benzyl)-1H-pyrazole-4-carboxylic acid (825 mg, 2.34 mmol) and C-(3-fluoro-4-methoxy-pyridin-2-yl)-methylamine hydrochloride (450 mg, 2.34 mmol) were dissolved in DCM with cooling to 0° C. 1-Ethyl-3-(3-dimethylaminopropyl)carbodiimide hydrochloride (627.0 mg, 3.27 mmol), HOBt (378.8 mg, 2.80 mmol) and triethylamine (1.63 mL, 1182 mmol) were added with stirring and the mixture was allowed to warm to room temperature and stirring was continued for 20 h. Chloroform (50 mL) was added and the mixture was washed with saturated NaHCO3 (aq) and reduced in vacuo. The crude material was purified by chromatography eluting with methanol / DCM. The solvent was removed under vacuum and the resulting solid was triturated with diethyl ether. The resulting solid was collected by filtration to give the compound of formula A.

[0154] [MH] + =492.0.

[0155] NMR (CD3OD)δ: 3.41 (3H, s), 4.03 (3H, s), 4.65 (2H, s), 4.72 (2H, d, J=2.3Hz), 5.24 (2H, s), 5.37 (2H, s), 6.44 (1H, td, J=1.4, 6.8Hz), 6.62 (1H , d, J=9.0Hz), 7.18-7.22(1H, m), 7.31-7.38(4H, m), 7.56-7.60(1H, m), 7.75(1H, dd, J=1.9, 7.1Hz), 8.18(1H, s), 8.27(1H, d, J=5.6Hz)ppm.

[0156] The XRPD diffractogram of compound of formula A obtained from the above procedure is shown in FIG.

[0157] Peak Location Table:

[0158] [Table 3]

[0159] Example 2 - Preparation of a dosage form containing a compound of formula A Mixing and roller compaction Equipment: Freund Vector TFC Lab Micro roller compactor and granulator (The roller compactor and granulator are separate items.) Equipment parameters are as follows:

[0160] [Table 4]

[0161] method Two tablet formulations (Tablets A and B) were prepared according to the following method at a 30 g blend scale to produce tablets with the amounts of ingredients shown below.

[0162] [Table 5]

[0163] For each tablet, a blend was prepared by forcing the intragranular components through a 355 μm sieve at a scale appropriate to the range of the roller compactor in a glass container using a Turbula Blender at 34 rpm. The blend was then passed through a roller compactor using the parameters mentioned above. The ribbons produced were collected in an appropriately sized container. The collected ribbons were then passed through a granulator fitted with a 1 mm sieve and the resulting granules were collected for further downstream processing.

[0164] Tablet compression Equipment: RIVA Mini single station tablet press. Equipment parameters are given below:

[0165] [Table 6]

[0166] Subsequently, the granules were mixed with their extragranular excipients, respectively. The extragranular excipients were prepared by sieving through a 355 μm sieve in a glass vessel using a Turbula Blender at 34 rpm. Target tablet weights were then dispensed and manually compressed into tablets. Tablet A was compressed at a compression force of 7.2-8.8 kN. Tablet B was compressed at a compression force of 6.9-7.7 kN.

[0167] The tablets were found to be robust. Tablets A and B were then submitted for long-term stability testing.

[0168] Tablet production by the above method was scaled to 180 g with a roller compaction time of approximately 60 minutes.

[0169] Example 3 - Comparison of the compound of formula A with C1 inhibitor (C1-INH) Objective: To identify the biochemical and biophysical properties of compound of formula A that contribute to optimal efficacy in regulating the kallikrein-kinin system in plasma. These properties are then compared to C1-INH.

[0170] method: In vitro plasma kallikrein inhibitory activity was determined using standard published methods (e.g., Johansen et al., Int. J. Tiss. Reac. 1986, 8, 185; Shori et al., Biochem. Pharmacol., 1992, 43, 1209; Sturzebecher et al., Biol. Chem. Hoppe-Seyler, 1992, 373, 1025). Human plasma kallikrein (Protogen) was incubated at 25°C with the fluorogenic substrate H-DPro-Phe-Arg-AFC and various concentrations of test compounds. Residual enzyme activity (initial velocity of reaction) was determined by measuring the change in absorbance at 410 nm and the IC of test compounds was calculated. 50 The value was calculated.

[0171] The rate of formation of the enzyme-inhibitor complex (K on ) was determined using purified PKa rapidly mixed with a solution containing a fluorogenic substrate and a range of inhibitor concentrations. The time-dependent probability of inhibition was then used to calculate the rate of formation of the enzyme-inhibitor complex for each inhibitor concentration. K was determined by plotting the percent inhibition versus inhibitor concentration. on The data in Table 1 are in μM. -1 seconds -1 This was provided by

[0172] The catalytic activity of PKa in dextran sulfate-activated (DXS, Sigma; 10 μg / mL) plasma (1:4 diluted or undiluted, VisuCon-F control plasma, Affinity Biologicals Inc) was determined by the time-dependent hydrolysis of a fluorogenic substrate. IC 50 To determine potency, compound of formula A or C1-INH (Sigma catalog no. E0518) was added either before (FIGS. 2A and 2B) or after (FIG. 3A) the addition of DXS to plasma.

[0173] DXS-activated cleavage of HK in undiluted plasma was performed in the absence or presence of 300 nM PKa inhibitor and quantified by SDS-PAGE gel electrophoresis using 7.5% Criterion TGX Precast gels (Biorad). Transfer to Immunobilon-FL PVDF membranes was performed. Image analysis was performed using a LICOR imaging system. For conventional immunoblotting, a mouse monoclonal anti-HK antibody (MAB15692, R&D systems) was used. Data are expressed as % of HK remaining after 20 min incubation with DXS compared to HK levels in non-activated plasma (Table 1).

[0174] The plasma free fraction was determined using a "Rapid Equilibrium Dialysis" system (Thermo Scientific), where test compounds were prepared at 5 μM in undiluted human plasma and dialyzed against phosphate buffer at 37° C. for 5 h. Quantification of compounds distributed into the two chambers of the dialysis device was performed via LCMS / MS. The proportion of compound not bound to plasma proteins was expressed as a % of total.

[0175] The ability of compounds to inhibit the enzyme activity of preactivated plasma was assessed by adding compounds after DXS stimulation. Aliquots of plasma (20 μL) were mixed with 2.5 μL of a solution containing 1,300 mM fluorogenic substrate (H-DPro-Phe-Arg-AFC) and 2.5 μL of a solution of dextran sulfate (DXS; 100 μg / mL), which acts as an activator of the plasma kallikrein-kinin pathway. Enzyme activity was immediately measured by monitoring the accumulation of fluorescence released from the substrate upon substrate cleavage over a period of 16 min. 3.5 min after DXS addition, 5 μL of inhibitor or water control was added to each well. Compounds were tested at concentrations of 300, 1000, and 3000 nM. C1-INH at a concentration of 3000 nM and a vehicle control were also included. Data are presented in Figure 3B.

[0176] result: As shown in FIG. 2, in assays using fluorogenic substrates, the compound of formula A appears to be a highly potent inhibitor of PKa with 17-fold and 20-fold increased potency compared to exogenously added C1-INH in diluted plasma (FIG. 2A) and undiluted plasma (FIG. 2B), respectively.

[0177] Table 1 shows the biochemical profiles of the therapies examined in this example.

[0178] [Table 7]

[0179] FIG. 3A shows a comparison of the effects of two inhibitors (the compound of formula A and C1-INH) on plasma kallikrein activity in DXS-activated plasma (1:4 dilution). Approximately 100 seconds after addition of DXS, both inhibitors were activated at their IC 50 The antibody was added to plasma at a concentration 10 times that of the antibody.

[0180] FIG. 3B shows that addition of a compound of formula A after activation of plasma causes a rapid and dose-dependent inhibition of enzyme activity compared to the slower action of C1-INH.

[0181] Table 2 shows the potency and selectivity of compounds of formula A against the human isolated enzyme using the literature method for the in vitro plasma kallikrein assay described above.

[0182] [Table 8]

[0183] Example 4 - Phase I single ascending dose study in healthy males and food effect of compound OBJECTIVE:To evaluate the pharmacodynamic (PD) effects of compound of formula A when administered orally using ex vivo whole plasma assays of plasma kallikrein catalytic activity and HK cleavage in samples from a phase 1 single-dose ascending study in healthy adult males. Additionally, an objective was to investigate the safety, tolerability and pharmacokinetic (PK) effects of compound of formula A when administered orally.

[0184] method The study was a randomized, double-blind, placebo-controlled, single ascending dose (SAD) and crossover study of the food effect and capsule / tablet formulations.

[0185] Sixty-four healthy male participants (n=6 active, 2 placebo per cohort, 8 SAD cohorts) were administered single ascending doses of the compound of formula A in capsules: 5, 10, 20, 40, 80, 160, 300, or 600 mg.

[0186] Eight participants were administered 100 mg of the compound of formula A in a crossover study of capsule and tablet formulations.

[0187] Twelve participants were administered 600 mg of compound of formula A in a food-effect crossover study.

[0188] Samples for pharmacokinetic (PK) and PD assessments were collected at repeated intervals over 48 hours.

[0189] Plasma samples used for PK evaluation were analyzed using a validated liquid chromatography tandem mass spectrometry (LCMS / MS) method.

[0190] PD measurements were determined in dextran sulfate (DXS) stimulated undiluted plasma using a fluorescent enzyme assay and a capillary-based HK cleavage immunoassay.

[0191] The catalytic activity of PKa in DXS-stimulated (Sigma; 10 μg / mL) plasma samples from the Formula A compound Phase 1 study was determined by the time-dependent hydrolysis of a fluorogenic substrate in all samples from all parts of the study.

[0192] The time for the appearance of detectable amidolytic activity in DXS-stimulated plasma (lag time) was calculated from the catalytic activity assay. The sensitivity for detection of the rate of catalytic activity in plasma based on the use of a Spark (Tecan) fluorometer is an increase in fluorescence reaching 1 ΔF unit / sec.

[0193] DXS-stimulated cleavage of HK in undiluted plasma was quantified by a capillary-based immunoassay on the Wes System (ProteinSimple) using a monoclonal anti-HK antibody and chemiluminescence-based detection. Plasma kallikrein-mediated HK cleavage in undiluted citrated human plasma was induced by contact-based activation with DXS (6.25 μg / mL) at 4°C in selected samples from the SAD phase.

[0194] DXS-stimulated cleavage of plasma prekallikrein and factor XII (FXII) was also quantified by capillary-based immunoassays on the Wes System (ProteinSimple).

[0195] result: FIG. 4A shows the plasma concentration of the compound of formula A from 0 to 24 hours after dosing. As can be seen, when orally administered, the compound of formula A achieved rapid and dose-dependent plasma exposure over the dose range tested, from 5 mg to 600 mg. FIG. 4A shows the concentration curves, and FIG. 4B shows the C-values ​​for each SAD cohort. max The compound of formula A was administered as a capsule formulation and subjects were in the fasted state.

[0196] Figure 5A shows the enzyme assays of activated undiluted plasma performed on samples from cohorts 6, 7, and 8. Doses of 160 mg and above showed a mean inhibition of greater than 90% of plasma kallikrein catalytic activity over 45 min to 2 h for cohort 6 and over 20 min to 4 h for cohort 7. A dose of 600 mg (cohort 8) provided >90% inhibition of plasma kallikrein catalytic activity over 30 min to 6 h and >50% inhibition over 10 h after dosing (Figure 5B).

[0197] Kinetic fluorescence measurements from undiluted plasma enzyme assays can be plotted as assay progress curves (Figures 6A and 6B). These curves highlight that the compound of formula A not only has an inhibitory effect on enzyme activity, but also increases the time (lag time) for catalytic activity to appear upon contact system activation. At early time points after dosing, plasma samples showed no detectable catalytic activity, even after prolonged activation with the potent activator DXS. In this study, subjects were dosed at 600 mg in tablet formulation.

[0198] FIG. 7 shows the mean percent HK protection in DXS-activated neat plasma (SAD cohorts 6 (160 mg), 7 (300 mg), and 8 (600 mg)). As shown, all three doses of the compound of formula A were able to inhibit plasma kallikrein catalytic activity by more than 90% over a period of time. The duration of these PD effects was dose-proportional. The compound of formula A has been shown to protect HK from DXS-activated cleavage in neat plasma for at least 10 hours after a single dose of 600 mg.

[0199] In FIG. 7, a representative WES system gel image was obtained with duplicate neat plasma samples + / - DXS activation from one subject in Cohort 8 who received 600 mg of the compound of Formula A compared to pre-dose (PD).

[0200] In Figure 7, HK cleavage was assessed after DXS activation of undiluted plasma samples at selected time points from cohorts 6 to 8. Data are presented as mean ± SEM, n = 6.

[0201] To assess whether compounds of formula A also reduced plasma kallikrein and factor XIIa production, immunoassays were used to quantitate the levels of contact system proteins in DXS-activated plasma before and up to 12 hours after oral administration of 600 mg capsules. The results of these assays are shown in Figures 8-11 and indicate that compounds of formula A not only reduce HK cleavage, but also reduce PPK cleavage and reduce FXIIa production. These results suggest that compounds of formula A inhibit the contact activation system via interruption of a positive feedback loop mediated by PKa-stimulated activation of FXII.

[0202] Figure 12 shows that no significant food effect was observed in the pharmacodynamic (PD) profile of the 600 mg tablet provided in the fed and fasted states. As can be seen, the PD effect is observed rapidly in the fed and fasted states, with >90% plasma kallikrein inhibition achieved by 30 minutes in both states.

[0203] No serious adverse events were reported in the phase I study. There were no signals of tolerability. No subjects discontinued the study.

[0204] These data indicate that the compounds of formula A have inhibitory effects on the bradykinin and contact activation systems. As described above, these pharmacodynamic effects are relevant to disorders such as BK-AEnH. These data also indicate that the compounds of formula A have a pharmacokinetic profile suitable for oral administration.

[0205] Example 5 - Immunoassay to examine compounds of formula A in protecting high molecular weight kininogen (HK) from PKa-mediated cleavage in HAE and control plasma method: High molecular weight kininogen (HK) cleavage in undiluted citrated human plasma was induced by contact activation with dextran sulfate (DXS, Sigma#31395-10G, 6.25 μg / mL) on wet ice. Pooled normal (CONTROL) human plasma (VisuCon-F frozen normal control plasma) was purchased from Affinity Biologicals Inc. Working stock solutions of 10 mM compound of formula A ("Compound") in DMSO were prepared and diluted with 1XPBS to the respective final concentrations listed. HAE plasma was obtained from HAE subjects (n=6) and C1 inhibitor deficiency was confirmed by Western blotting. Protection of HK from PKa-mediated cleavage in DXS-stimulated undiluted whole plasma was then determined by two methods: conventional Western blotting and semi-automated capillary-based immunoassay.

[0206] Western blotting: SDS-PAGE gel electrophoresis was performed using 7.5% Criterion TGX Precast gel (Bio-rad). Transfer to Immobilon-FL PVDF membrane was performed. Image analysis was performed using a LICOR imaging system. For conventional immunoblotting, a mouse monoclonal anti-human HK antibody (MAB15692, R&D systems) was used.

[0207] Capillary-based immunoassay on WES systems (ProteinSimple): Sample preparation: Combine 1 part 5x fluorescent master mix with 4 parts 1:200 plasma sample. Vortex to mix. Heat samples + fluorescent master mix and biotinylated ladder to 95°C for 5 minutes, vortex, and load onto WES plate. A monoclonal anti-human HK antibody was used for this chemiluminescence-based detection method using the Wes System (ProteinSimple).

[0208] Analysis: Peak area measurements obtained with Compass software (cbz files) were collected for full-length HK molecular weights for each sample time point of DXS-induced activation. Peak area was defined as the area calculated for the HK spectral peak profile. To measure compound inhibition of plasma kallikrein, the percentage of full-length HK detected was calculated.

[0209] result: 13A and 13B show the time course of dextran sulfate-activated cleavage of HK in HAE whole undiluted plasma measured using Western blotting and representative blots.

[0210] Figures 14A and 14B show representative WES system gel images showing that the compound of formula A provides dose-dependent protection against HK cleavage in both dextran sulfate stimulated HAE and healthy control plasma as measured by capillary-based immunoassay using the WES system.

[0211] Example 6 - Phase 2 study of the compound of formula A OBJECTIVE: To evaluate the efficacy and safety of the compound of formula A for on-demand treatment of angioedema attacks in adult subjects with hereditary angioedema type I or II.

[0212] method: The Study is a randomized, double-blind, placebo-controlled, phase 2 crossover clinical trial evaluating the efficacy and safety of the compound of Formula A (the Compound), an oral plasma kallikrein inhibitor, for the on-demand treatment of angioedema attacks in adult subjects with hereditary angioedema type I or II (EudraCT Number: 2018-004489-32).

[0213] the purpose: Main purpose: To examine the efficacy of the compound compared to placebo in halting the progression of peripheral or abdominal hereditary angioedema (HAE) attacks.

[0214] Secondary purpose: - To determine the safety and tolerability of the compound. To investigate the pharmacokinetic (PK) profile of the compound when taken during critical periods between HAE attacks. To investigate the pharmacodynamic (PD) profile of the compound in reducing the concentration of residual cleaved high molecular weight kininogen (HK) during the critical inter-attack period between HAE attacks. To investigate the PD profile of the compound in reducing activated plasma enzyme activity during the critical inter-attack period between HAE attacks.

[0215] setting: This is a two-phase, two-part, two-sequence, two-period (2x2) crossover clinical trial. Subjects with HAEI or II will be recruited through HAE treatment centers in Europe and the United States.

[0216] In Part 1, subjects receive a single oral dose of 600 mg of the compound to determine the safety, PK, and PD of the compound during the critical period between HAE attacks.

[0217] Eligible adult subjects aged 18 years or older will undergo screening evaluations for study entry, receive study drug, and undergo 4-hour in-hospital safety and PK / PD evaluations.

[0218] In Part 2, subjects will be randomized to a 1:1 to 2 treatment sequence. This part of the study will be conducted away from the clinic or hospital. In Sequence 1 (Study Arm 1), subjects will receive a single dose of 600 mg of the compound to treat their first eligible HAE attack. After this attack has resolved, subjects will receive a second single dose of placebo to treat their second eligible HAE attack.

[0219] In sequence 2 (study arm 2), subjects receive a single dose of placebo to treat their first qualifying HAE attack, and after that attack has resolved, subjects receive a second single dose of 600 mg of the compound to treat their second qualifying HAE attack.

[0220] A minimum washout period of 48 hours is required between each administration of study medication.

[0221] Laryngeal or facial attacks are not eligible for treatment. HAE attacks must be treated within the first hour of onset and before they become severe on the Global Attack Severity Scale. Subjects must also be able to identify the onset of an HAE attack. Upon onset of a qualifying HAE attack, subjects notify the designated investigator or qualified designee with a description of the HAE attack. The designated investigator or qualified designee confirms eligibility of the HAE attack and consents to study drug being administered. HAE attacks must be documented in a subject diary with the location of the attack, attack symptoms, time of onset, attack severity, and time of last substantial meal before dosing. Subjects take study drug as directed and complete a timed assessment of HAE attack symptoms over a 48-hour period as described in Table 3 below. The designated investigator or qualified designee will contact the subject within 24 hours of the qualifying HAE attack to ensure the subject's safety and well-being. Instruct subjects to contact the dedicated investigator or qualified designee if they have any safety concerns. In case of hypersensitivity, subjects should contact the dedicated investigator or qualified designee or contact the nearest emergency services. A dedicated investigator or qualified designee will be available to take subjects' calls 24 hours / day and 7 days / week.

[0222] Table 3: Number of subject evaluations

[0223] [Table 9]

[0224] * If conventional seizure medication is used, subjects must be assessed every 30 minutes for 4 hours after the first dose of conventional seizure medication, after which subjects must return to their original frequency of assessments based on the time of study drug administration.

[0225] Subjects will return to the clinic after their first HAE attack and before their second HAE attack for a safety check, including adverse event (AE) reporting, vital signs recording, and subject diary review.

[0226] Once the two HAE attacks have been treated in Part 2, subjects will return to the clinic for a final safety check, which will include AE ​​reporting, recording of vital signs, and blood sampling for laboratory safety measurements.

[0227] If HAE attack symptoms are judged by the subject to be sufficiently severe to require treatment according to the subject's usual treatment, or are deemed ineligible for study drug treatment, or are associated with laryngeal or facial symptoms, conventional attack therapy may be administered 4 hours after study drug ingestion or earlier, as needed. Prior to using conventional attack therapy, subjects will notify the designated investigator or qualified designee, who will confirm that conventional therapy is appropriate per the protocol and subject report of symptom severity. Subjects may treat HAE attacks with conventional attack therapy (pdC1INH or rhC1INH intravenous [iv] or icatibant).

[0228] Investigational Products: Compound of formula A - 100 mg film coated tablets. These contain the following excipients: microcrystalline cellulose, croscarmellose sodium, povidone, magnesium stearate, and the aesthetic coating contains hypromellose, lactose monohydrate, titanium dioxide, and triacetin.

[0229] Placebo versus the compound 100 mg film-coated tablets, which contain microcrystalline cellulose, colloidal silicon dioxide, sodium starch glycolate, and sodium stearyl fumarate, and an aesthetic coating containing hypromellose, lactose monohydrate, titanium dioxide, and triacetin.

[0230] Dose modifications of the investigational drug were not permitted in this study.

[0231] Number of subjects: Approximately 60 subjects will be enrolled in the study, with 50 subjects completing the study.

[0232] population: The study population included male and female subjects aged 18 years or older with HAEI or II.

[0233] Selection criteria: 1.Male or female adult subjects, 18 years of age or older. 2. Confirmed diagnosis of HAEI or II at any time in medical history: A documented medical history consistent with HAE (episodes of subcutaneous or mucosal non-pruritic swelling without urticaria) and b. C1-esterase inhibitor (C1-INH) antigen or functional levels < 40% of normal levels. Subjects with antigen or functional C1-INH levels between 40-50% of normal levels may be enrolled if they have C4 levels below the normal range and a family history consistent with HAEI or II. 3. At least three documented attacks of HAE in the past 93 days, supported by medical history. 4. Access to and ability to use conventional seizure treatments for HAE attacks. 5. Adequate organ function as defined below: Hemoglobin within normal range; b. International normalized ratio (INR) < 1.2; c. Activated partial thromboplastin time (aPTT) ≤ upper limit of normal (ULN); d. Creatinine < 1 × ULN; e. Creatinine clearance (CrCl) ≥ 60 mL / min; f. Alanine aminotransferase (ALT) ≦2×ULN; g. Aspartate aminotransferase (AST) ≤ 2 x ULN; h. Total bilirubin ≤ 1.5 x ULN; i. White blood cells ≦1.5×ULN, j. Platelets ≤1.5×ULN. 6. Women of childbearing potential must agree to use highly effective contraception from the screening visit through the end of study follow-up procedures. Highly effective methods of contraception include: a. Progestogen-only hormonal contraceptives associated with the suppression of ovulation: oral / injection / implant. (Estrogen-containing hormonal contraceptives are excluded due to exclusion criterion 3.) b. Intrauterine device (IUD). c. Intrauterine hormone releasing system (IUS). d. Bilateral tubal obstruction. e. Vasectomized partner (if partner is the only sexual partner of the female subject of childbearing potential and the vasectomized partner is undergoing medical evaluation for surgical success). f. Sexual abstinence (this method is not tolerated in Switzerland). NOTE: Sexual abstinence is considered a highly effective method only if it is defined as abstinence from heterosexual intercourse. The reliability of sexual abstinence needs to be evaluated in relation to the duration of the clinical trial and the subjects' preferred and usual lifestyle. 7. Women who are not capable of childbearing, defined as being surgically infertile (following hysterectomy, bilateral oophorectomy, or bilateral tubal ligation) or at least 12 months postmenopausal, do not require contraception during the study. 8. Men with female partners of childbearing potential must agree to abstain or use highly effective contraception as defined in inclusion criterion 6 from the screening visit until the end of the study follow-up procedures. 9.Able to provide signed informed consent and to voluntarily comply with the requirements and procedures of the study.

[0234] Exclusion criteria: 1. Concomitant diagnosis of another form of chronic angioedema, such as acquired C1 inhibitor deficiency, HAE with normal C1-INH (also known as HAE type III), idiopathic angioedema, or angioedema associated with urticaria. 2.Currently using C1INH, androgen, lanadelumab, or tranexamic acid for HAE prophylaxis. 3. Use of angiotensin-converting enzyme (ACE) inhibitors or estrogen-containing medications with systemic absorption (e.g., oral contraceptives or hormone replacement therapy) within 93 days prior to first study treatment. 4. Use of androgens (e.g., stanozolol, danazol, oxandrolone, methyltestosterones, testosterone) or antifibrinolytic agents within 30 days prior to first study treatment. 5. Use of lanadelumab within 10 weeks prior to first study treatment. 6. Use of strong CYP3A4 / CYP2C9 inhibitors and inducers during participation in the clinical trial. NOTE: These medications include, but are not limited to, cobicistat, conivaptan, itraconazole, ketoconazole, posaconazole, voriconazole, ritonavir, boceprevir, telaprevir, troleandomycin, clarithromycin, carbamazepine, enzalutamide, mitotane, phenytoin, phenobarbital, fluconazole, isoniazid, metronidazole, paroxetine, sulfamethoxazole, rifampin, St. John's wort, diltiazem, idelalisib, nefazodone, and nelfinavir. 7. Clinically significant abnormal electrocardiogram (ECG) at Visit 1 and prior medication at Visit 2. This includes, but is not limited to, QTcF >470 ms (for women) or >450 ms (for men), PR >220 ms or occasional premature ventricular and / or atrial beats that are more frequent or occur as couplets or more in groupings. 8. Clinically significant history of angina, myocardial infarction, syncope, clinically significant cardiac arrhythmia, left ventricular hypertrophy, cardiomyopathy, or other cardiovascular abnormality. 9. Any other systemic dysfunction (e.g., gastrointestinal, renal, respiratory, cardiovascular, etc.) or significant disease or disorder that, in the opinion of the Investigator, may jeopardize the subject's safety by participating in the clinical trial. 10. History of substance abuse or dependence that may affect completion of the study, as determined by the investigator. 11. Known lactose allergy or intolerance. 12. Known hypersensitivity to the compound or placebo or to any of the excipients. 13. Participation in an interventional clinical trial within 93 days or 5 half-lives (whichever is longer) of the last dose of an investigational drug prior to first study treatment. 14. Pregnant or lactating subjects.

[0235] evaluation: Part 1: Blood samples for PK and PD measurements will be collected at the following time points: pre-dose (0 h), 15, 30, 45 min, 1, 1.5, 2, 3, and 4 h post-dose. Vital signs (systolic blood pressure [SBP], diastolic blood pressure [DBP], pulse rate [PR], respiratory rate [RR], and temperature) will be measured pre-dose (0 h), 1, and 4 h post-dose. Samples for post-treatment safety laboratory evaluations will be collected at the 4-h PK / PD sample.

[0236] Part 2: After ingestion of study medication, subject assessment of overall HAE attack severity and change in HAE attack severity will be performed for 48 hours as described in Table 3 above.

[0237] Efficacy variables: Time on conventional attack medications will be assessed. Subject diaries will record time on conventional attack medications and efficacy endpoints such as severity of HAE attacks.

[0238] Overall HAE attack severity is assessed on a 5-point Likert scale (5LS) rated as none, mild, moderate, severe and very severe.

[0239] Changes in the severity of HAE attacks are assessed using the 7-point Transition Question (7TQ) rated as much better / good / slightly better / no change / slightly worse / worse / much worse.

[0240] The types of HAE attack symptoms (abdominal pain, skin pain, and skin swelling) are rated on a 100-mm visual analog scale (VAS) anchored at 0 (none) and 100 (very severe), respectively.

[0241] Safety variables: -AEs, including serious adverse events (SAEs). ·Laboratory test results (clinical chemistry, hematology, coagulation, and urinalysis). · Vital signs (SBP, DBP, PR, RR, temperature). Physical examination findings. ·ECG results. Pregnancy testing (female subjects capable of childbearing).

[0242] Efficacy assessment criteria Primary Efficacy Endpoints: · Time spent using conventional seizure medications.

[0243] Secondary Efficacy Endpoints: Proportion of HAE attacks that progress by ≥1 level on the 5LS or require conventional attack treatment within 12 hours of study drug. · Time between treatment and either (1) a progression of 1 or more levels of overall seizure severity on the 5LS, or (2) the use of conventional seizure treatment, whichever occurs first, within 12 hours.

[0244] Exploratory Endpoints: Cumulative overall seizure severity for 5LS following study drug administration expressed as area under the curve (AUC) for compound 600mg versus placebo. Proportion of HAE attacks requiring conventional attack treatment. Proportion of HAE attacks rated as "worse" or "much worse" on the TQ. Proportion of HAE attacks rated as "better" or "much better" on the TQ. Time from study drug administration to complete resolution of HAE attacks (scored as none) on the Global Seizure Severity Scale (5LS). Time to HAE attack rated as worse or much worse on the TQ. Time to HAE attack rated as better or much better by TQ.

[0245] Common statistical methods and types of analysis Analysis population: · Safety Population (SAF): Subjects who received at least one dose of study drug (including any dose of study drug in Part 1).

[0246] Full Analysis Set (for efficacy) (FAS): All randomized subjects who received both doses of study drug in Part 2.

[0247] Per-Protocol Population (for Efficacy) (PPS): Part 2 randomized subjects who received both doses of study compound in Part 2 and had no major protocol deviations.

[0248] PK / PD analysis population: All subjects from whom PK / PD samples were collected in Part 1.

[0249] Number of samples: A sample size of 50 subjects (25 per sequence) is proposed to provide 90% power to test at a 5% alpha level (2-sided) for the primary endpoint of time on conventional seizure medication. This sample size was derived based on the assumption that 40% of subjects would use conventional seizure medication in the control group and 10% would use conventional seizure medication in the experimental group, with minimal correlation within the subject data. The assumption of minimal correlation should be a conservative assumption with respect to sample size. Approximately 60 subjects will be enrolled to ensure that 50 subjects complete the study.

[0250] An oversampling of 20% (10 subjects) is proposed to account for subjects who may not complete both treatment periods due to rare or ineligible HAE attacks, or who discontinue the study early for any reason. Thus, study enrollment is deemed sufficient to address the primary efficacy hypothesis after 50 subjects have completed both treatment periods. Ongoing subjects who have not completed both periods will be asked to return to the investigational site and complete Visit 4 (Early Discontinuation Visit) since further exposure will not be necessary and will be deemed unnecessary. Data from all completing and non-completing subjects will be analyzed in the safety population.

[0251] General considerations: Individual subject data will be displayed in the Subject Data Listing. Appropriate descriptive statistics will be calculated for continuous and categorical data and summarized in tabular form.

[0252] Sample Analysis: AEs will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) dictionary (v21.0 or later) and categorized by preferred term and system organ class (SOC). Lists of treatment-emergent adverse events (TEAEs), serious TEAEs, and TEAEs leading to early discontinuation will be provided by sequence group and further categorized by TEAE severity and relationship to study drug.

[0253] Efficacy Analysis: Primary Endpoint The primary endpoint, time on conventional seizure medication, was analyzed using a generalization of the Gehan test proposed by Feingold and Gillespie (1996) (crossover design with censored data. Statistics in Medicine 1996;15(10):953-967) to reflect repeated measurements for each subject. Subjects were treated as censored if no exacerbation occurred within 12 hours of study drug.

[0254] Secondary endpoints The proportion of HAE attacks that worsen by ≥1 level on the 5LS or require conventional attack treatment within 12 hours of study drug will be analyzed using Prescott's test (1981) (comparison of success rates in crossover studies in the presence of order effects. Applied Statistics 1981;30:9-15) to compare treatment groups.

[0255] Similar methods as used for the primary endpoint will be used for analysis of the time between study drug and an HAE attack worsening by ≥1 level on the 5LS, or the use of conventional attack treatment administered within 12 hours of study drug. In addition to the tests described above, descriptive statistics are provided for the primary, secondary, and exploratory endpoints, which in each case compare the compound to placebo, e.g., Cumulative overall seizure severity at 5LS after study drug expressed as AUC for 600 mg of the compound versus placebo. Proportion of HAE attacks requiring conventional attack treatment. Proportion of HAE attacks rated as "worse" or "much worse" on the TQ. Proportion of HAE attacks rated as "better" or "much better" on the TQ. Time from study drug administration to complete HAE attack resolution (score of none) on the Global Attack Severity Scale (5LS). Time to HAE attack rated as worse or much worse by TQ. Time to HAE attack rated as better or much better by TQ.

[0256] PK analysis: Non-compartmental PK parameters include maximum concentration in plasma (Cmax), time to reach Cmax in plasma (tmax), and area under the curve from time 0 to the last sample (AUC0-t). Compartmental PK modeling describes the PK of a compound and generates the underlying Cmax, tmax, AUC, apparent clearance (CL / F), apparent volume of distribution (Vd / F), and estimated terminal elimination half-life (t1 / 2).

[0257] PK parameters of the compound are determined from the individual concentration and time data using Phoenix WinNonlin. If there is deviation from the theoretical times, the actual times of blood samples are used to calculate the derived PK parameters. Individual concentrations of the compound in plasma and derived PK parameters are listed and summarized for each treatment. Individual geometric mean concentration-time data are plotted on linear and semi-log scales.

[0258] PD analysis: The effects of the compounds on plasma kallikrein (PKa) activity are analyzed using two exploratory measures of PKa enzyme activity in plasma. An assay for measuring the inhibition of exogenously activated plasma kallikrein enzyme activity from plasma samples obtained before and after administration of the compound. An assay to measure the level of protection from plasma kallikrein enzyme activity in the cleavage of high molecular weight kininogen (HK) substrate (contained in whole plasma).

[0259] PD will be summarized for each treatment, with individual and mean data provided as a report addendum in the appendix to the final clinical trial report.

[0260] Preliminary PK data from Part 1 of the study: At the time of filing this application, preliminary PK data from 27 HAE patients had been collated and analyzed and are presented in Table 4 and FIG.

[0261] Table 4

[0262] [Table 10]

[0263] Thus, these preliminary results demonstrate that the compound of formula A exhibits a favorable pharmacokinetic profile for on-demand oral administration in HAE patients. Studies are ongoing at the time of filing.

[0264] Example 7 - Phase 1 multiple dose study in healthy adult subjects Objective: To evaluate the safety, tolerability, pharmacokinetics, and change from baseline in QTc following administration of the compound formulated as 100 mg film-coated tablets to healthy adult subjects.

[0265] Main purpose: -To determine the safety and tolerability of multiple doses of the compound.

[0266] Secondary purpose: To study the multiple dose pharmacokinetics (PK) of the compound. To evaluate the effect of the compound on ECG parameters, including concentration-QTc relationships, following administration of 100 mg film-coated tablets (KalVista Pharmaceuticals) to healthy adult subjects.

[0267] Exploratory purpose: -To investigate the multiple dose pharmacodynamics (PD) of the compound.

[0268] method: This is a phase 1, double-blind, placebo-controlled, multiple-dose, multiple-cohort study to evaluate the safety and tolerability of the compound, as well as the ECG effects of the compound formulated as 100 mg film-coated tablets in healthy adult male and female subjects.

[0269] Four cohorts are planned for evaluation. Cohorts 1, 2, and 3 will each contain 8 subjects. Cohort 4 will contain 18 subjects. Every attempt will be made to include an equal number of male and female subjects in each cohort.

[0270] During the study, an oral dose of 600 mg of the compound as film-coated tablets (six 100 mg tablets) or six matching placebo tablets will be administered orally every 8 hours (Cohort 1), every 4 hours (Cohort 2), or every 2 hours (Cohorts 3 and 4) to healthy adult male and female subjects up to a maximum total dose of 1800 mg. In Cohorts 1, 2, and 3, six subjects will receive the compound as 100 mg film-coated tablets and two subjects will receive placebo for a total of eight subjects per cohort. In Cohort 4, 12 subjects will receive the compound as 100 mg film-coated tablets and six subjects will receive placebo for a total of 18 subjects.

[0271] Progression from Cohort 1 to Cohort 2 and from Cohort 2 to Cohort 3 will occur after review of safety data (laboratory values, vital signs, safety ECGs, and adverse events) obtained during the conduct of Cohort 1 and Cohort 2. Progression to Cohort 4 will occur after review of safety and pharmacokinetic data from Cohort 3. Pharmacokinetic data from Cohort 3 will be reviewed to ensure that the Cmax of the third dose is high enough to support assessment of the QTcvc interval from baseline.

[0272] A Holter monitor will be attached to each subject for continuous ECG recording, one hour prior to the first dose and will remain in place until after the final blood sample is drawn. The Holter electrodes will be checked at appropriate intervals by clinic personnel to ensure they remain attached.

[0273] Blood samples will be collected pre-dose, at intervals after the first dose, and at least 24 hours after the final (third) dose in each cohort (40 hours after the first dose in cohort 1, 32 hours after the first dose in cohort 2, and 28 hours after the first dose in cohorts 3 and 4). Subjects will be restricted to being at the clinical site from at least 10 hours prior to dosing until after the final blood sample collection in each study cohort, returning to the clinic 5-7 days after the final dose for safety evaluations.

[0274] The pharmacokinetics of the compounds are measured by fully validated analytical procedures and the pharmacodynamic effects on plasma kallikrein inhibitor enzyme activity are assessed by exploratory pharmacodynamic evaluations.

[0275] Statistical analysis is performed to assess the relationship between plasma drug concentrations and the change from baseline in ECG effects of the test formulations.

[0276] Therapeutic Administration Cohort 1 Subjects will receive test or placebo treatment every 8 hours over a 16 hour period according to a two-treatment randomization schedule under direct observation (three doses: 6 tablets of 100 mg of the compound or placebo doses as 100 mg film-coated tablets at 0, 8 and 16 hours, for a total dose of 1800 mg of the compound or placebo). Each dose will be administered with 240 mL of room temperature water. Subjects will be instructed to swallow the tablet whole without chewing or chewing. Subjects who chew or chew the tablet will be dropped from the study. An oral check will be performed immediately after administration.

[0277] Cohort 2 Subjects will receive test or placebo treatment every 4 hours over an 8-hour period according to a two-treatment randomization schedule under direct observation (three doses: 6 tablets of 100 mg of the compound or placebo doses as 100 mg film-coated tablets at 0, 4, and 8 hours, for a total dose of 1800 mg of the compound or placebo). Each dose will be administered with 240 mL of room temperature water. Subjects will be instructed to swallow the tablet whole without chewing or chewing. Subjects who chew or chew the tablet will be dropped from the study. An intraoral check will be performed immediately after administration to ensure that the tablet has been completely swallowed without chewing or chewing.

[0278] Cohorts 3 and 4 Subjects will receive test or placebo treatment every 2 hours over a 4-hour period according to a two-treatment randomization schedule under direct observation (3 doses: 6 doses of 100 mg of the compound or placebo as 100 mg film-coated tablets at 0, 2, and 4 hours, for a total dose of 1800 mg of the compound or placebo). Each dose will be administered with 240 mL of room temperature water. Subjects will be instructed to swallow the tablet whole without chewing or chewing. Subjects who chew or chew the tablet will be dropped from the study. An intraoral check will be performed immediately after administration to ensure that the tablet has been completely swallowed without chewing or chewing.

[0279] All subjects will fast (except for water) for at least 8 hours prior to receiving their first dose. After the first dose, subjects will continue to fast until at least 6 hours after the first dose.

[0280] Method of assigning subjects to treatment groups: Cohorts 1, 2, and 3 Subjects will be randomized so that 6 subjects will receive the test product and 2 subjects will receive a placebo. As a safety measure, each cohort will incorporate a sentinel dosing scheme where 1 subject will receive the test product, 1 subject will receive the placebo product, followed by the remainder of the cohort.

[0281] Cohort 4 Subjects are randomized so that 12 subjects receive the test product and 1 subject receive the placebo.

[0282] Randomization schedules will be generated prior to the first dosing cohort using SAS® version 9.4 or later.

[0283] result: No serious adverse events were reported during the study, and no subjects discontinued due to AEs. All reported adverse events were considered "mild" in severity and had an outcome of "recovered / resolved" after study completion.

[0284] No clinically relevant effects on the ECG parameters tested were identified.

[0285] FIG. 16A shows the mean plasma concentrations of the compound of formula A after the first dose for each cohort.

[0286] FIG. 16B shows the mean plasma concentrations (semi-log scale) of the compound of formula A for each cohort.

[0287] These data indicate that the compound of formula A has a pharmacokinetic profile suitable for oral administration when administered in multiple doses, and the results further suggest that the compound of formula A may be safely administered periodically.

Claims

1. A pharmaceutical composition for use in a method for on-demand treatment of bradykinin-mediated non-hereditary angioedema (BK-AEnH), said composition comprising a compound of formula A or a pharma- ceutically acceptable salt and / or solvate thereof, said method comprising orally administering said composition on-demand to a patient in need of treatment for bradykinin-mediated non-hereditary angioedema (BK-AEnH). 【Chemistry 1】

2. The pharmaceutical composition of claim 1, for use in the on-demand treatment of an acute attack of bradykinin-mediated non-hereditary angioedema (BK-AEnH), wherein the pharmaceutical composition is orally administered on-demand upon recognition of symptoms of an acute BK-AEnH attack.

3. 3. The pharmaceutical composition of claim 2, wherein the recognized symptoms of an acute BK-AEnH attack are at least one of tissue swelling, fatigue, headache, muscle pain, skin tingling, abdominal pain, nausea, vomiting, diarrhea, difficulty swallowing, hoarseness, shortness of breath, and / or mood swings.

4. The pharmaceutical composition of claim 2 or 3, which is orally administered on demand within 1 hour after symptoms of an acute BK-AEnH attack are recognized.

5. A pharmaceutical composition described in any one of claims 2 to 4, which is orally administered on demand within 30 minutes, within 20 minutes, within 10 minutes, or within 5 minutes after symptoms of an acute BK-AEnH attack are recognized.

6. A pharmaceutical composition described in any one of claims 2 to 5, which is orally administered on demand during the prodromal phase of an acute BK-AEnH attack.

7. 7. The pharmaceutical composition of claim 6, wherein the recognized symptoms are at least one of mild swelling, abdominal pain, or skin redness.

8. The pharmaceutical composition of claim 7, wherein the recognized symptom is erythema marginatum.

9. The pharmaceutical composition of any one of claims 1 to 8, wherein said treatment shortens the duration of said acute BK-AEnH attack.

10. 7. The method of claim 6, wherein said treatment prevents said acute BK-AEnH attack from progressing to the swelling stage of an acute BK-AEnH attack.

11. The pharmaceutical composition of claim 1, administered orally on demand to prophylactically reduce the likelihood of an acute BK-AEnH attack.

12. The pharmaceutical composition of claim 11, which is administered orally on demand when an acute BK-AEnH attack is anticipated to be induced.

13. The pharmaceutical composition of claim 11 or 12, administered orally on demand to prevent acute BK-AEnH attacks.

14. 14. The pharmaceutical composition of claim 12 or 13, for oral administration on demand when an acute BK-AEnH attack is expected to be precipitated by physical trauma and / or stress.

15. The pharmaceutical composition of claim 14, wherein the acute BK-AEnH attack is expected to be precipitated by the physical trauma of a dental procedure and / or the psychological stress associated with a dental procedure.

16. The pharmaceutical composition of any one of claims 1 to 15, further comprising a pharma- ceutically acceptable excipient and administered in an oral dosage form.

17. 17. The pharmaceutical composition of claim 16, wherein the oral dosage form is a tablet comprising microcrystalline cellulose as a diluent, croscarmellose sodium as a disintegrant, and polyvinylpyrrolidone as a binder.

18. The pharmaceutical composition of claim 16, wherein the oral dosage form is a tablet comprising microcrystalline cellulose as a diluent, croscarmellose sodium as a disintegrant, polyvinylpyrrolidone as a binder, and magnesium stearate as a lubricant.

19. A pharmaceutical composition described in any one of claims 1 to 18, which (i) inhibits plasma kallikrein, (ii) reduces cleavage of plasma prekallikrein, and / or (iii) reduces the production of factor XIIa from factor XII.

20. 20. The pharmaceutical composition of claim 19, wherein the patient is administered a dose of the compound of formula A, or a pharma- ceutically acceptable salt and / or solvate thereof, such that the patient's plasma has a concentration of the compound of formula A, or a pharma- ceutically acceptable salt and / or solvate thereof, of at least 500 ng / mL.

21. 21. The pharmaceutical composition of claim 20, wherein the patient is administered the composition comprising at least 60 mg of the compound of formula A, or a pharma- ceutically acceptable salt and / or solvate thereof.

22. A pharmaceutical composition described in any one of claims 1 to 21, which blocks activation of the contact system for up to 6 hours.

23. The pharmaceutical composition according to any one of claims 1 to 22, wherein the compound of formula A or a pharma- ceutically acceptable salt and / or solvate thereof is administered in a daily dosage of from 5 mg to 2000 mg.

24. 24. The pharmaceutical composition of any one of claims 1 to 23, wherein the compound of formula A is administered in a daily dosage of 100mg to 1500mg, 300mg to 1800mg, 100mg to 1400mg, 200mg to 1200mg, 300mg to 1200mg, 600mg to 1200mg, 450mg to 900mg, 500mg to 1000mg, 450mg to 600mg, 500mg to 700mg, 800mg to 1000mg, 900mg to 1400mg, or 900mg to 1200mg.

25. 25. The pharmaceutical composition of any one of claims 1 to 24, wherein the patient is administered a daily dose in two doses within a 24 hour period starting from when the first dose is taken.

26. 26. The pharmaceutical composition of claim 25, wherein the two doses are administered separately or sequentially.

27. 27. The pharmaceutical composition of claim 25 or 26, wherein the second dose is administered 2 to 6 hours after the first dose.

28. The pharmaceutical composition of claim 25 or 26, wherein the second dose is administered approximately 3 to 6 hours after the first dose.

29. 27. The pharmaceutical composition of claim 25 or 26, wherein the second dose is administered at least about 6 hours after the first dose.

30. The pharmaceutical composition according to any one of claims 1 to 24, administered to the patient in three doses per day.

31. 31. The pharmaceutical composition of claim 30, wherein the three doses are administered separately or sequentially.

32. 32. The pharmaceutical composition of claim 30 or 31, wherein the second and third doses are administered at least about 6 hours after the preceding dose.

33. The pharmaceutical composition of any one of claims 22 to 32, wherein each dosage comprises about 600 mg of the compound of formula A.

34. 34. The pharmaceutical composition of claim 33, wherein each dose is administered as two tablets each containing about 300 mg of the compound of formula A.

35. 35. The pharmaceutical composition of any one of claims 1 to 34, wherein said bradykinin-mediated non-hereditary angioedema (BK-AEnH) is not caused by an inherited genetic malfunction, defect or mutation.

36. 36. The pharmaceutical composition of claim 35, wherein the BK-AEnH is selected from non-hereditary angioedema due to normal C1 inhibitor (AE-nC1 Inh), which may be environmentally, hormonally or drug-induced, acquired angioedema, anaphylaxis-related angioedema, angioedema induced by angiotensin-converting enzyme (ACE) inhibitors, dipeptidyl peptidase-4 inhibitor-induced angioedema, and tPA-induced angioedema (tissue plasminogen activator-induced angioedema).

37. The pharmaceutical composition of claim 35, wherein the AE-nC1 Inh is environmentally induced by air pollution and / or silver nanoparticles.

38. the BK-AEnH is tPA-induced angioedema; the patient is also receiving tissue plasminogen activator; The pharmaceutical composition according to any one of claims 11 to 13, wherein the composition is administered before, during or after administration of tissue plasminogen activator to the patient.

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