Alverestat for use in the treatment of transplant rejection, bronchiolitis obliterans syndrome, and graft-versus-host disease

Abstract

The present invention relates to the treatment of organ rejection, in particular the treatment of lung transplant-associated bronchiolitis obliterans syndrome by administering a neutrophil elastase inhibitor such as alverestat. The present invention also relates to the treatment of graft-versus-host disease.

Description

[Technical field]

[0001] Government Licensing Rights This invention was made with Government support under 1UG3TR002448-01 awarded by the National Institutes of Health. The Government has certain rights in this invention.

[0002] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of priority to U.S. Provisional Patent Application No. 62 / 901,638, filed Sep. 17, 2019, the contents of which are incorporated herein by reference.

[0003] The present invention relates to a novel method for treating or preventing transplant rejection and graft-versus-host disease, comprising administering to a subject in need thereof a neutrophil elastase inhibitor, in particular alvelestat, or a pharma-ceutically acceptable salt and / or solvate thereof. [Background technology]

[0004] Transplantation of organs, bone marrow, and human stem cells has improved human health. However, transplantation is beset by the immune system's ability to recognize and react to non-self tissue. This is a particular risk in allogeneic transplants, where the tissue comes from a genetically similar but not identical donor and there is a human leukocyte antigen (HLA) tissue type mismatch.

[0005] Graft rejection after solid organ transplantation can occur when the recipient's immune system (particularly the recipient's mature αβ T cells) recognizes foreign HLA antigens expressed on the cells of the donor organ. It is determined by the host's allo-responsiveness to mismatched donor antigens. Acute rejection usually occurs within the first few weeks to months after transplantation and is the major risk factor for the development of chronic rejection. Other risk factors for chronic rejection include infection. Chronic rejection usually develops within months to years after transplantation and is the major cause of long-term graft function loss. Clinically, chronic rejection is characterized as a slow process that results in the replacement of allograft parenchyma with fibrous scar tissue.

[0006] Lung transplantation is an important treatment option for patients with advanced lung disease or irreversible pulmonary failure, with approximately 3,500 lung transplants performed worldwide each year. However, acute lung rejection occurs in approximately one-third of all lung transplant recipients within the first year after transplantation and can progress to chronic lung rejection (i.e., chronic pulmonary allograft dysfunction (CLAD)), which remains the major obstacle to long-term survival after lung transplantation. It is the leading cause of graft loss and death in lung transplant recipients surviving more than three months after transplantation.

[0007] Lung transplant-associated bronchiolitis obliterans syndrome (LT-BOS) is the most common form of CLAD, which manifests as a decline in lung function that is often progressive. It is thought to result from inflammation, destruction, and fibrosis of the small airways of the lung allograft, leading to bronchiolitis obliterans (OB). Median survival after diagnosis is 3-5 years [1].

[0008] Despite its high incidence, there is currently no satisfactory treatment for chronic graft rejection, especially LT-BOS. Current options for LT-BOS include immunosuppressive therapy (often in triple combinations), neo-macrolides (e.g., azithromycin), and treatment of concomitant gastroesophageal reflux disease and infection. However, evidence supporting currently available treatments is limited, therapeutic responses are generally inadequate, and there is a high risk of serious adverse events. That is, immunosuppressive therapy significantly impairs immune reconstitution and increases the risk of infection. As a last resort, lung retransplantation may be considered, but outcomes are unsatisfactory and donor organs are scarce. As a result, the ISHLT / ATS / ERSBOS Task Force concluded in 2014 that no currently available treatments have been proven to provide meaningful benefit in the prevention or treatment of LT-BOS [2].

[0009] An additional complication of graft rejection is the immune response mounted against the recipient of the allograft by mature donor αβ T cells, which can lead to graft-versus-host disease (GVHD). GVHD is usually seen in the setting of allogeneic hematopoietic stem cell transplantation, but can also occur when immunocompromised patients receive blood transfusions. Acute GVHD is characterized by damage to the skin, liver, and gastrointestinal tract, while chronic GVHD has more diverse symptoms and may resemble autoimmune syndromes. The standard treatment is immunosuppressive therapy, which, as mentioned above, is associated with a high risk of adverse events and an increased risk of infection

[10] .

[0010] Therefore, there is a need for new therapies for the treatment and prevention of chronic graft rejection and GVHD, particularly LT-BOS. Summary of the Invention

[0011] Surprisingly, inhibitors of neutrophil elastase (NE), such as alberestat, are useful for the treatment and prevention of GVHD and graft rejection, particularly LT-BOS. This is unexpected, since the main drivers of GVHD and graft rejection are generally believed to be T and B lymphocytes, not neutrophils. NE inhibitors have not previously been demonstrated to be effective against GVHD or graft rejection. In particular, it has not previously been recognized that NE inhibitors may be useful in the treatment or prevention of graft rejection, particularly LT-BOS.

[0012] Thus, the present invention provides a method for treating or preventing transplant rejection, comprising administering to a subject in need thereof an effective amount of a neutrophil elastase inhibitor, in particular alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof.

[0013] The present invention further provides a method for treating or preventing lung transplant-associated bronchiolitis obliterans syndrome (LT-BOS), comprising administering to a subject in need thereof an effective amount of a neutrophil elastase inhibitor, particularly alberestat, or a pharma-ceutically acceptable salt and / or solvate thereof.

[0014] The present invention further provides a method for treating or preventing graft-versus-host disease (GVHD), comprising administering to a subject in need thereof an effective amount of a neutrophil elastase inhibitor, particularly alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof.

[0015] The present invention also provides a method for treating or preventing bronchiolitis obliterans syndrome (BOS) associated with GVHD, e.g., BOS associated with hematopoietic stem cell transplantation, comprising administering to a subject in need thereof an effective amount of a neutrophil elastase inhibitor, particularly alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof. [Brief description of the drawings]

[0016] [Figure 1] 1A-1F are a series of line graphs showing improved survival with alberestat. BALB / c mice were subjected to 8.5 Gy TBI followed by transplantation with either T cell-depleted bone marrow alone (TCDBM), TCDBM+2×106 T cells (TCDBM+T2e6), or TCDBM+T2e6+3 levels of alberestat administered either in premixed diet pellets (1A, 1C, 1E) or as a powder added to wet food (1B, 1D, 1F) at one of three levels (20 mg / kg, 50 mg / kg, or 200 mg / kg). Evaluations included survival (1A, 1B), body weight (1C, 1D), and GVHD scores (1E, 1F). Each experiment (n=5) was performed in duplicate and the results are summarized in the figures (n=10 / group). [Diagram 2] 2A-C are a series of line graphs showing the effect of different doses of T cells on survival rate (2A), body weight (2B), and GVHD score (FIG. 2C). BALB / c mice were subjected to 8.5 Gy total body irradiation (TBI) and then transplanted with either T cell-depleted bone marrow alone (TCDBM), TCDBM + one of three different doses of T cells (1×106 (TCDBM+T1e6), 1.5×106 (TCDBM+T1.5e6), 2×106 (TCDBM+T2e6)), or TCDBM + 2×106 T cells + 20 mg / kg alverestat in premixed diet pellets (TCDBM+T2e6+20 mg / kg-diet) from B10.D2 donors (n=5 / group). Mice transplanted with TCDBM+T2e6+20mg / kg had better survival than mice transplanted with TCDBM+T2e6 alone (p<0.001) and had similar survival rates to mice transplanted with lower doses of T cells. [Diagram 3]A series of histological findings of GVHD in mice transplanted with T cell-depleted bone marrow + 2x106 T cells. Histological examination of skin from mice transplanted with TCDBM+T2e6 shows severe cutaneous GVHD with prominent hyalinized / fibrotic dermis, lipoatrophy, hair follicle loss, and occasional epithelial apoptosis (A), while histological examination of small intestinal mucosa from mice transplanted with TCDBM+T2e6 shows severe intestinal GVHD with prominent reactive / regenerative epithelium with increased mitotic activity and apoptosis (B). In contrast, histological examination of skin from mice transplanted with TCDBM alone (no T cells) showed loose fibrous connective tissue in the dermis, ample subcutaneous adipose tissue, normal epithelium and hair follicles, and no signs of GVHD (C); similarly, histological examination of intestinal mucosa from mice transplanted with TCDBM alone showed adequate cellularity, a healthy appearance of the epithelium, and no signs of GVHD (D). [Figure 4] FIG. 1 is a plot showing histological scoring of GI GVHD. Mice treated with drug (20 mg / kg) had significantly less GVHD as assessed in a blinded manner by an experienced pathologist. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0017] The following description is based on the understanding that the present disclosure should be considered as an example of the subject matter described in the claims, and is not intended to limit the scope of the appended claims to the specific embodiments illustrated. The present disclosure refers to various embodiments and techniques. However, it should be understood that many variations and modifications can be made while remaining within the spirit and scope of the present disclosure. The headings used throughout this disclosure are provided for convenience and should not be construed as limiting the scope of the claims in any way. An embodiment described under any heading can be combined with an embodiment described under any other heading.

[0018] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art. Throughout this specification and the claims that follow, the following terms are defined by the following meanings unless expressly stated otherwise:

[0019] Unless the context requires otherwise, throughout this specification and claims, the term "comprise" and variations thereof, such as "comprises" and "comprising," are to be construed in their open and inclusive sense, i.e., "including but not limited to."

[0020] Where the plural is used for compounds, salts and the like, this is taken to mean a single compound, salt, etc.

[0021] As used herein, the term "or" is generally used in its sense including "and / or" unless the context in which it is used clearly dictates otherwise.

[0022] Also herein, the recitations of numerical ranges by endpoints include all numbers subsumed within that range (e.g., 1 to 5 includes 1, 1.5, 2, 2.75, 2.75, 3, 3.80, 4, 5, etc.).

[0023] As used herein, the term "about" means the stated value ±10% of the stated value.

[0024] As used herein, "treatment" or "treating" is an approach to obtain a beneficial or desired result. For purposes of the present invention, beneficial or desired results include, but are not limited to, alleviation of symptoms and / or a decrease in the extent of symptoms associated with a disease or condition. "Treatment" or "treating" includes one or more of the following: a) inhibiting a disease or condition (e.g., decreasing one or more symptoms caused by a disease or condition and / or decreasing the extent of the disease or condition), b) delaying or preventing the onset of one or more symptoms associated with a disease or condition (e.g., stabilizing the disease or condition, slowing the deterioration or progression of the disease or condition), and c) palliating the disease or condition, e.g., regressing clinical symptoms, ameliorating the condition, slowing the progression of the disease, improving quality of life, and / or prolonging survival.

[0025] As used herein, "prevention" or "preventing" refers to a regimen that protects against the onset of a disease or disorder such that clinical symptoms of the disease do not develop. Thus, "prevention" refers to administering a treatment (e.g., administering a therapeutic agent) to a subject before symptoms of the disease are detectable in the subject. The subject may be an individual at risk of developing a disease or disorder, such as an individual with one or more risk factors known to be associated with the development or onset of a disease or disorder. Thus, the term "preventing" in the present invention includes administering to subjects who are scheduled to receive a transplant or who have recently received a transplant without yet developing the associated disease.

[0026] As used herein, the term "therapeutically effective amount" or "effective amount" refers to an amount effective to induce a desired biological or medical response, including an amount of a compound that is sufficient to achieve such treatment for a disease when administered to a subject for treating the disease. The effective amount will vary depending on the particular compound and the characteristics of the subject being treated, such as age, weight, etc. The effective amount can include a variety of amounts. As is understood in the art, an effective amount can be in the form of one or more doses, i.e., a single administration or multiple administrations may be required to achieve a desired therapeutic endpoint. An effective amount may be considered in the context of administering one or more therapeutic agents, and a single agent may be considered to be administered in an effective amount when a desired or beneficial result may be or is achieved in combination with one or more other agents. The appropriate dose of any co-administered compound may be optionally reduced due to the combined effects (e.g., additive or synergistic effects) of the compounds.

[0027] 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, such as ethanol or water. The term "hydrate" is used when said solvent is water, and for the avoidance of doubt, the term "hydrate" is subsumed within the term "solvate".

[0028] The term "pharmaceutically acceptable salt" refers to a physiologically or toxicologically acceptable salt, and includes, where appropriate, pharmaceutically acceptable base addition salts and pharmaceutically acceptable acid addition salts.For example, when a compound contains a basic group such as an amino group, the pharmaceutically acceptable acid addition salts that can be formed include hydrochloride, hydrobromide, sulfate, phosphate, acetate, citrate, lactate, tartrate, mesylate, succinate, oxalate, phosphate, esylate, tosylate, benzenesulfonate, naphthalenedisulfonate, maleate, adipate, fumarate, hippurate, camphorate, xinafoate, p-acetamidobenzoate, dihydroxybenzoate, hydroxynaphthoate, succinate, ascorbate, oleate, hydrogen sulfate, etc. Hemisalts of acids and bases can also be formed, such as hemisulfate and hemicalcium salts. For a review of suitable salts, see “Handbook of Pharmaceutical Salts: Properties, Selection and Use” by Stahl and Wermuth (Wiley-VCH, 2011).

[0029] "Pharmaceutically acceptable" or "physiologically acceptable" refers to compounds, salts, compositions, dosage forms, etc. that are suitable for pharmaceutical use.

[0030] The term "subject" preferably refers to a human, typically a human who has received or is about to receive a transplant.

[0031] All documents referenced herein are individually incorporated in their entirety for all purposes.

[0032] Alberestad A preferred neutrophil elastase inhibitor for use in the present invention is alberestat.

[0033] Alberestat is a potent, orally bioavailable neutrophil elastase inhibitor described in WO2005 / 026123A1 (Example 94, page 85) and [3] (incorporated herein in their entirety). Alberestat has the chemical name N-{[5-(methanesulfonyl)pyridin-2-yl]methyl}-6-methyl-5-(1-methyl-1H-pyrazol-5-yl)-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide and the following chemical structure: [ka] has.

[0034] Alberestat is also known as AZD9668 and MPH996.

[0035] Alberestat can be used in the present invention in any pharmaceutically acceptable form, for example, any free base form, salt form, and / or solvate form. Alberestat or its pharmaceutically acceptable salt and / or solvate can be present in any pharmaceutically acceptable physical form, preferably in solid form.

[0036] Certain salts of arvelestat are described in WO2010 / 09464A1, which is incorporated herein by reference in its entirety. The salts of arvelestat described include the tosylate, p-xylene-2-sulfonate, chloride, mesylate, esylate, 1,5-naphthalenedisulfonate, and sulfate salts.

[0037] In the methods of the present invention, it is preferred that arvelestat free base or arvelestat tosylate is used, with arvelestat tosylate being more preferred.

[0038] Alverestat may also be used in any of the methods of the present invention in the form of a pharma- ceutically acceptable prodrug.

[0039] Neutrophil elastase inhibitors Neutrophil elastase (NE) is an enzyme that attacks lung tissue, causing progressive damage. Compounds that inhibit NE are reviewed in

[13] and include WO2017207430, WO2017102674, WO2016050835, WO2016050835, WO2016016368, WO2016016366, WO2016016365, WO2016016364, WO2016016363, WO2015124563, WO2016020070, WO2015091281, WO2014135414, WO2014122160, WO2015096873, WO2015096872, WO20140 29832, WO2014029831, WO2014029830, WO2014009425, WO2013084199, WO2013037809, WO2011103774, WO2011110858, WO2011110859, WO20111108 52, WO2011039528, WO2010034996, WO2009061271, WO2009058076, WO2009060206, WO2007137080, WO2007137080, WO2007140117, WO2008036379, WO2008036379, WO9962538, WO9962538, WO9962514, WO9739028, WO9616080, WO9533763, WO9533762, WO9527055, WO9311760, WO9220357, WO92156 05, WO9215605, WO03058237, WO03031574, WO03031574, WO2008030158, WO2007129963, WO2007129962, WO2006098684, WO2005026124, WO2005026 123, WO2005021509, WO2005021512, WO2004043924, WO2009060158, WO2009037413, WO2009013444, WO2007129060, WO2007107706, WO2007107706 , WO2006136857, WO2006082412, WO2006082412, WO9623812, WO9521855, WO9401455, WO9324519, WO9321214, WO9321210, WO9321213, WO9321209,Neutrophil inhibitors are known from various publications, including WO9321212, WO2006070012, WO2005082863, WO2005082863, WO2005082864, WO9912933, WO9912933, WO9912931, WO9736903, WO2004020412, WO2008104752, WO2008097676, WO200809767, WO2008085608 (each of which is incorporated by reference). Each of the neutrophil inhibitors described in these publications can be used in the methods of the present invention, and are referred to herein for use in the methods of the present invention as if individually disclosed.

[0040] In addition to the preferred neutrophil elastase inhibitor, alberestat, other exemplary neutrophil elastase inhibitors that can be used in the present invention include sivelestat, ONO-5046-Na, depelestat, prolastin, KRP-109, DX-890, preelafin, MNEI, BAY 85-8501, POL6014, α1-AT, sirtinol, ONO-6818 (2-(5-amino-6-oxo-2-phenyl-1,6-dihydropyrimidin-1-yl)-N-[(1R,2R)-1-(5-tert-butyl-1,3,4-oxadiazol-2-yl)-1-hydroxy-3-methylbutan-2-yl]acetamide), elastatinal, SSR 69071 (2-[[6-methoxy-4-(1-methylethyl)-1,1-dioxo-3-oxo-1,2-benzisothiazol-2(3H)-yl]methoxy]-9-[2-(1-piperidinyl)ethoxy]-4H-pyrido[1,2-a]pyrimidin-4-one), and M0398 (N-(methoxysuccinyl)-L-alanyl-L-alanyl-L-prolyl-L-valine chloromethyl ketone), and pharma- ceutically acceptable salts and / or solvates thereof.

[0041] The term neutrophil elastase inhibitor includes all pharma- ceutically acceptable forms of the compound, including all pharma- ceutically acceptable salts, solvates, isomers, and prodrug forms.

[0042] In certain embodiments, the neutrophil elastase inhibitor is a small molecule compound, ie, has a molecular weight of less than about 900 daltons.

[0043] The neutrophil elastase inhibitor is preferably an inhibitor of human neutrophil elastase.

[0044] While many embodiments of the present invention relate to alverestat, it is understood that for each and every embodiment described herein that refers to "alverestat," the invention also provides a corresponding embodiment that includes the use of a "neutrophil elastase inhibitor."

[0045] treatment The present invention generally provides a method for treating or preventing graft rejection, acute graft rejection, chronic graft rejection, CLAD, LT-BOS, GVHD, etc. in a subject in need thereof, comprising administering to the subject an effective amount of a neutrophil elastase inhibitor, particularly alberestat, or a pharmacologic acceptable salt and / or solvate thereof.

[0046] Thus, the present invention provides a method for treating or preventing transplant rejection in a subject in need thereof, said method comprising administering to said subject an effective amount of alvelestat or a pharma- ceutically acceptable salt and / or solvate thereof.

[0047] Graft rejection may also be called organ transplant rejection.

[0048] The methods described herein are useful for treating or preventing acute transplant rejection. In certain embodiments, the methods are for treating acute transplant rejection. In other embodiments, the methods are for preventing acute transplant rejection.

[0049] The methods described herein are useful for treating or preventing chronic transplant rejection. In certain embodiments, the methods are for treating chronic transplant rejection. In other embodiments, the methods are for preventing chronic transplant rejection.

[0050] The graft may include any solid organ, particularly a frequently transplanted solid organ, and thus may include one or more organs selected from the group consisting of the kidney, the heart, the liver, the lung, and the pancreas.

[0051] Chronic rejection of cardiac (i.e., heart) allografts is manifested by cardiac allograft vasculopathy (CAV). CAV is usually characterized by occlusion of coronary vessels. The 5-year incidence of CAV is 30-40%. Thus, the present invention provides a method for treating or preventing CAV in a subject in need thereof, comprising administering to said subject an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof.

[0052] Chronic rejection of kidney allografts is manifested by cardiac allograft nephropathy (CAN). CAN is the leading cause of renal function decline, accounting for nearly 40% of graft loss after 10 years. Thus, the present invention provides a method for treating or preventing CAN in a subject in need thereof, comprising administering to said subject an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof.

[0053] In a preferred embodiment, the transplant comprises a lung. The transplant may be a single lung transplant or a double lung transplant. The transplant may be a heart-lung transplant. Accordingly, the present invention provides a method for treating or preventing lung transplant rejection in a subject in need thereof, comprising administering to the subject an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof. The lung transplant rejection may be acute lung transplant rejection or chronic lung transplant rejection.

[0054] Chronic rejection of lung allografts is manifested by chronic pulmonary allograft dysfunction (CLAD).Accordingly, the present invention provides a method for treating or preventing CLAD in a subject in need thereof, comprising administering to the subject an effective amount of alberestat or a pharma-ceutically acceptable salt and / or solvate thereof.

[0055] The most common phenotype of CLAD is lung transplant-associated bronchiolitis obliterans syndrome (LT-BOS). Bronchiolitis obliterans is also called obliterative bronchiolitis. Common features include obstructive pulmonary dysfunction and air trapping / mosaic attenuation in exhalation CT. Thus, the present invention provides a method for treating or preventing LT-BOS in a subject in need thereof, comprising administering to the subject an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof.

[0056] The methods of preventing LT-BOS according to the present invention are particularly useful in subjects at risk for LT-BOS, who may have one or more risk factors selected from the group consisting of primary graft failure, gastroesophageal reflux disease, infection, airway ischemia, acute rejection, lymphocytic bronchiolitis, infection and colonization with microorganisms (e.g., Pseudomonas aeruginosa and Aspergillus fumigatus), donor and recipient genetics, particulate matter, and the presence of HLA antibodies or antibodies against self-antigens (such as K-α1 tubulin and collagen V).

[0057] The present invention provides a method for treating or preventing GVHD in a subject in need thereof, comprising administering to the subject an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof. GVHD appears after tissue transplantation. In some embodiments, the graft is selected from the group consisting of skin, hematopoietic stem cells, blood, and bone marrow. In a preferred embodiment, the graft is hematopoietic stem cells.

[0058] The GVHD may be acute graft-versus-host disease (aGVHD). The disease may be chronic graft-versus-host disease (cGVHD). Acute GVHD is usually characterized by damage to the skin, liver, and gastrointestinal tract, while chronic GVHD usually has more diverse symptoms and may resemble autoimmune syndromes, such as eosinophilic fasciitis, scleroderma-like skin disease, and lesions of the salivary and lacrimal glands.

[0059] A further embodiment provides a method of inhibiting the development of symptoms of GVHD, including aGVHD and cGVHD, comprising administering to a recipient of an allogeneic hematopoietic stem cell transplant a pharma- ceutical effective amount of alverestat, or a pharma- ceutical acceptable salt and / or solvate thereof.

[0060] In the methods relating to GVHD, the GVHD can be characterized by damage to one or more selected from the group consisting of eyes, joints, fascia, reproductive organs, lungs, liver, skin, or digestive tract (e.g., mouth, esophagus).

[0061] In particular, in the methods relating to GVHD, said GVHD may be characterized by damage to one or more selected from the group consisting of the lungs, liver, skin, or gastrointestinal tract.

[0062] Chronic GVHD can be classified according to various criteria. The 2005 and 2014 National Institutes of Health Consensus Development Projects on Criteria for Clinical Trials in Chronic GVHD standardized the terminology for the chronic GVHD classification system

[16] .

[0063] One classification system is the NIH severity score, which is classified into mild, moderate, or severe based on the number of organs involved and the severity. Thus, in the method of the present invention related to the treatment of cGVHD, the subject may suffer from cGVHD that is mild, moderate, or severe according to the NIH severity score. In particular, the cGVHD may be moderate or severe, usually severe. Further, a method for improving the cGVHD severity score in a subject suffering from cGVHD is provided herein, comprising administering alberestat or a pharmacologic acceptable salt and / or solvate thereof.

[0064] Another classification system based on patient-reported outcomes is the Lee cGVHD Symptom Scale

[17] . Thus, provided herein is a method for improving the Lee cGVHD Symptom Scale in a cGVHD patient, comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof. In particular, provided herein is a method for improving the Lee cGVHD Symptom Scale pulmonary score in a subject suffering from cGVHD affecting the lungs, comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof.

[0065] The present invention also provides a method for treating or preventing bronchiolitis obliterans syndrome (BOS) associated with GVHD, comprising administering an effective amount of alberestat or its pharmaceutically acceptable salt and / or solvate to a subject in need thereof. In a preferred embodiment, the subject has undergone hematopoietic stem cell transplantation. Also provided is alberestat or its pharmaceutically acceptable salt for use in treating or preventing bronchiolitis obliterans syndrome (BOS) associated with GVHD. Also provided is the use of alberestat or its pharmaceutically acceptable salt for the manufacture of a medicament for treating or preventing bronchiolitis obliterans syndrome (BOS) associated with GVHD.

[0066] In the described method, the NE inhibitor, particularly arvelestat or its pharmaceutically acceptable salt and / or solvate, may be administered to the subject before transplantation. For example, administration of arvelestat may begin 14 days, 7 days, 3 days, 2 days, or 1 day before transplantation.

[0067] In the described method, the NE inhibitor, particularly arvelestat or its pharmaceutically acceptable salt and / or solvate, may be administered to the subject after transplantation.For example, administration of arvelestat may be started on the day of transplantation, or 1 day, 2 days, 3 days, 7 days, or 14 days after transplantation.

[0068] Methods of the invention relating to BOS, particularly LT-BOS, may also include improving one or more respiratory function parameters in a subject.

[0069] In particular, the methods of the present invention may improve a subject's FEV1. Forced expiratory volume (FEV1) is the volume of air exhaled based on a maximum forced effort measured over a set period of time, e.g., 1 second (FEV1).

[0070] In particular, the methods of the present invention may improve a subject's FEV1% predicted, which is the ratio, expressed as a percentage, of the subject's FEV1 to the predicted FEV1 of a normal individual similarly matched for race or ethnicity, sex, age, height, and weight.

[0071] Thus, there is also provided a method for improving FEV1% predicted in a subject suffering from LT-BOS by administering an effective amount of a NE inhibitor, particularly alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof.

[0072] In certain embodiments, treatment with an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof increases predicted FEV1% by at least about 1%, 1.5%, 2.0%, 2.5%, 3.0%, 4.0%, 5.0%, 6.0%, 7.0%, 8.0%, 9.0%, 10%, 15%, 20%, 30%, 40%, or 50% compared to baseline predicted FVC% measurements. In further embodiments, treatment with an effective amount of alberestat or a pharma-ceutically acceptable salt and / or solvate thereof prevents deterioration of FEV1%.

[0073] The method of the present invention relating to LT-BOS may also include improving the grade of BOS in a subject. The BOS classification scheme adopted in 1993 provides a staging system based on the severity of post-transplant lung function decline that has been used for clinical decision-making and research purposes. This staging system was most recently revised in 2002 [2]. The 2002 version of the BOS classification scheme: [Table A] is used according to the present invention.

[0074] Thus, in embodiments relating to the treatment of LT-BOS, treatment with an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof improves the grading of BOS by at least one grade. In further embodiments relating to the treatment of LT-BOS, treatment with an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof prevents a worsening of the grading of BOS.

[0075] The diagnosis of BOS can be made by a skilled clinician. Imaging tests such as high-resolution chest CT scans and pulmonary function tests can help detect BOS. Chest x-rays can also be used. Surgical lung biopsies can also be performed to diagnose BOS. Lung biopsies may show involvement of small airways with fibrotic obstruction of the lumen. Bronchoalveolar lavage (BAL) may show neutrophilic and / or lymphocytic inflammation.

[0076] The present invention also provides a method for treating or preventing BOS associated with connective tissue disease, systemic lupus erythematosus, rheumatoid arthritis, infection, exposure to toxic gases, or Stevens-Johnson syndrome, comprising administering to a subject in need thereof an effective amount of a neutrophil elastase inhibitor, particularly alberestat, or a pharma-ceutically acceptable salt and / or solvate thereof.

[0077] In some embodiments, a patient to be treated with the methods of the invention may have a baseline FEV1 of 30% or more, e.g., 35% or more, or 40% or more, of predicted FEV1. The patient's baseline FEV1 may be 20-90%, e.g., 30-80%, 35-75%, or 40-50% of predicted FEV1.

[0078] Without wishing to be bound by theory, it is believed that alberestat is beneficial in the methods of the present invention due to its ability to inhibit neutrophil elastase. Thus, the present invention also provides a method for inhibiting neutrophil elastase in a subject suffering from or at risk of any disease described herein, including graft rejection or GVHD, particularly LT-BOS, comprising administering to the subject an effective amount of a neutrophil elastase inhibitor. Also provided are each of the above methods for treating or preventing any disease described herein, including graft rejection or GVHD, particularly LT-BOS, by inhibiting neutrophil elastase, comprising administering to the subject an effective amount of a neutrophil elastase inhibitor, particularly alberestat or a pharma- ceutically acceptable salt and / or solvate thereof.

[0079] The present invention also relates to a method for improving pulmonary function in a subject referred to in the present disclosure, particularly a subject suffering from GVHD affecting the lungs, such as chronic GVHD, comprising administering to said subject an effective amount of a NE inhibitor, particularly alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof.

[0080] The present invention also relates to a method for preventing deterioration of pulmonary function in a subject referred to in the present disclosure, particularly a subject suffering from GVHD affecting the lungs, such as chronic GVHD, comprising administering to said subject an effective amount of a NE inhibitor, particularly alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof.

[0081] The present invention also relates to a method for stabilizing lung function in a subject referred to in the present disclosure, particularly a subject suffering from GVHD affecting the lungs, such as chronic GVHD, comprising administering to the subject an effective amount of a NE inhibitor, particularly alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof.

[0082] The present invention also relates to a method for preventing disease progression or worsening in a subject referred to in this disclosure, particularly a subject suffering from GVHD, such as cGVHD.The present invention also relates to a method for stabilizing disease in a subject referred to in this disclosure, particularly a subject suffering from GVHD, such as cGVHD.

[0083] The present invention also relates to a method for preventing disease progression in a subject referred to in this disclosure, particularly a subject suffering from GVHD, such as cGVHD.The present invention also relates to a method for stabilizing disease in a subject referred to in this disclosure, particularly a subject suffering from GVHD, such as cGVHD.

[0084] Also provided is alberestat or a pharmaceutically acceptable salt and / or solvate thereof for use in the treatment or prevention of transplant rejection, such as chronic or acute transplant rejection.Alberestat or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of lung transplant-associated bronchiolitis obliterans syndrome.Alberestat or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of GVHD is also provided.

[0085] Also provided is the use of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof for the manufacture of a medicament for treating or preventing transplant rejection, such as chronic or acute transplant rejection. Also provided is the use of alberestat or a pharma- ceutically acceptable salt thereof for the manufacture of a medicament for treating or preventing lung transplant-associated bronchiolitis obliterans syndrome. Also provided is the use of alberestat or a pharma- ceutically acceptable salt thereof for the manufacture of a medicament for treating or preventing GVHD.

[0086] Administration For the above therapeutic indications, the dose of neutrophil inhibitor, particularly alberestat or its pharmacologic acceptable salts and / or solvates, to be administered will depend on the disease to be treated, the severity of the disease, the mode of administration, the age, weight, and sex of the patient. Such factors can be determined by the attending physician. Generally, however, satisfactory results are obtained when the compound is administered to humans at a daily dose of 0.1 mg / kg to 100 mg / kg (measured as active ingredient).

[0087] The daily dose is preferably 0.5 to 1000 mg / day, for example 50 to 800 mg / day, particularly 50 to 600 mg / day, more particularly 120 mg to 550 mg, and even more particularly 200 to 500 mg. For example, the daily dose is about 240, 270, 300, 330, 360, 390, 420, 450, or 480 mg / day. The dose may be administered as a single dose or as a divided dose, for example, by dividing the total daily dose into two or more small doses that are administered on the same day. Administration may be daily, or multiple times a day (for example, twice a day), or multiple times a week, or monthly, or multiple times a month.

[0088] In certain embodiments, arvelestat or its pharmaceutically acceptable salt and / or solvate is administered twice a day (BID administration).In further embodiments, arvelestat or its pharmaceutically acceptable salt and / or solvate is administered twice a day, each dose being equivalent to up to 240mg of arvelestat free base, for example, 60mg twice a day, 90mg twice a day, 120mg twice a day, 150mg twice a day, 180mg twice a day, 210mg twice a day, or 240mg twice a day.In particular, 120mg is administered twice a day, or 240mg is administered twice a day.

[0089] The compound can be administered to an individual according to an effective dosing regimen for a desired period of time or duration, such as at least one week, at least about one month, at least about two months, at least about three months, at least about six months, at least about twelve months, at least about twenty-four months, or more, etc. For example, the compound may be administered on a daily or intermittent schedule for the life of the subject.

[0090] The above doses of alberestat or its pharma- ceutically acceptable salts and / or solvates may be administered according to a dose titration regime in all methods of the invention. This allows for safe titration up to a standard daily dose of alberestat, for example 240 mg twice daily. For example, a dose titration regime up to a standard daily dose of alberestat, for example 240 mg twice daily, according to the invention, includes administering alberestat or its pharma- ceutically acceptable salts and / or solvates at a dose of 60 mg twice daily in a first period, followed by 120 mg twice daily in a second period, followed by 180 mg twice daily in a third period, followed by 240 mg twice daily. The first, second, and third periods may each last 10 to 20 days, for example about 2 weeks each. In particular, arvelestat or a pharma- ceutically acceptable salt and / or solvate thereof is administered at 60 mg twice daily for two weeks, followed by 120 mg twice daily for two weeks, followed by 180 mg twice daily for two weeks, then 240 mg twice daily. The doses are referred to as arvelestat free base equivalents.

[0091] composition The neutrophil inhibitor, in particular alberestat or a pharma- ceutically acceptable salt and / or solvate thereof, is administered to the subject in the form of a pharmaceutical composition.

[0092] Thus, the present invention provides a method for the treatment or prevention of any of the diseases described herein, comprising administering to a subject in need thereof a pharmaceutical composition comprising an effective amount of a neutrophil inhibitor, in particular alberestat, or a pharma- ceutically acceptable salt and / or solvate thereof, and one or more pharma- ceutically acceptable excipients.

[0093] Pharmaceutical compositions can be prepared using one or more pharma- ceutically acceptable excipients, which can be selected in accordance with conventional practice.

[0094] "Pharmaceutically acceptable excipients" include, but are not limited to, adjuvants, carriers, fillers, glidants, sweeteners, diluents, preservatives, dyes / colorants, flavorings, surfactants, wetting agents, dispersing agents, suspending agents, stabilizers, isotonic agents, solvents, or emulsifiers approved by the U.S. Food and Drug Administration as acceptable for use in humans. All compositions are described in Shesky et al., Handbook of Pharmaceutical Excipients, 8 th edition, 2017. Excipients may include ascorbic acid and other antioxidants, chelating agents such as EDTA, carbohydrates such as dextrin, hydroxyalkylcellulose, hydroxyalkylmethylcellulose, stearic acid, and the like.

[0095] Pharmaceutical compositions include those suitable for various routes of administration, including oral administration. The compositions may be provided in unit dosage form and may be prepared by any method well known in the art of pharmacy. Such methods include mixing the active ingredient (e.g., a compound of the present disclosure or a pharma- ceutically acceptable salt thereof) with one or more pharma- ceutically acceptable excipients. The compositions may be prepared by uniformly and intimately mixing the active ingredient with liquid excipients or finely divided solid excipients, or both, and then shaping the product as necessary. Techniques and formulations are described in Remington: The Science and Practice of Pharmacy, 22nd This is generally described in the IEEE International Conference on Computer Vision and Information Technology (ICCI) 2012.

[0096] Preferred pharmaceutical compositions are solid dosage forms, including solid oral dosage forms such as tablets. Tablets may contain excipients including glidants, fillers, binders, and the like.

[0097] In carrying out the methods described herein, the pharmaceutical composition can be administered in any form and route that makes the compound bioavailable.Thus, the pharmaceutical composition can be administered by various routes, including oral and parenteral routes, more particularly by inhalation, subcutaneous, intramuscular, intravenous, transdermal, intranasal, rectal, intravaginal, intraocular, topical, sublingual and buccal, intraperitoneal, intravenous, intraarterial, transdermal, sublingual, intramuscular, rectal, transbuccal, intranasal, intraadipose, intrathecal, as well as via local delivery, for example, by catheter or stent.The pharmaceutical composition is preferably administered orally.

[0098] For oral use, tablets, troches, lozenges, aqueous or oily suspensions, powdered or granular dispersions, emulsions, hard or soft capsules, syrups or elixirs can be prepared. The compositions described herein suitable for oral administration may be presented as discrete units (unit dosage forms), including, but not limited to, capsules, cachets, or tablets, each containing a predetermined amount of the active ingredient. The pharmaceutical composition is preferably a tablet.

[0099] Aqueous compositions may be prepared in sterile form and, if intended for delivery by other than oral administration, will generally be isotonic.

[0100] The amount of active ingredient that can be combined with the inactive ingredients to produce a dosage form can vary depending on the intended subject of treatment and the particular mode of administration.

[0101] Combination therapy In the present invention, the method may further comprise administering to the subject one or more additional therapeutic agents, which may be administered before, simultaneously with, or after the administration of the neutrophil inhibitor.

[0102] Additional therapeutic agents include immunosuppressants, anti-infective agents, anti-inflammatory agents, and analgesics.

[0103] In certain embodiments, the one or more therapeutic agents are immunosuppressants, for example, one, two, or preferably three immunosuppressants may be administered.

[0104] Examples of the immunosuppressant include corticosteroids (e.g., methylprednisolone, prednisone, prednisolone, budesonide, dexamethasone), Janus kinase inhibitors (e.g., tofacitinib), calcineurin inhibitors (e.g., cyclosporine, tacrolimus), mTOR inhibitors (e.g., sirolimus, everolimus, temsirolimus), biologics (e.g., abatacept, adalimumab, anakinra, certo The therapeutic agent may be selected from the group consisting of: rituximab, etanercept, golimumab, infliximab, ixekizumab, natalizumab, rituximab, secukinumab, tocilizumab, ustekinumab, vedolizumab), monoclonal antibodies (e.g., basiliximab, daclizumab), tyrosine kinase inhibitors (e.g., imatinib), thalidomide, pentostatin, azathioprine, mycophenolate, and methotrexate.

[0105] In certain embodiments, the method further comprises administering to the subject an immunosuppressant, for example, a triple combination of tacrolimus, mycophenolate, and a corticosteroid.

[0106] The one or more therapeutic agents may be anti-infective agents, including antibiotics, anti-fungals, anti-parasitic agents, anti-malarials, anti-protozoal agents, anti-tuberculous agents, and anti-viral agents.

[0107] The one or more therapeutic agents may be prednisone, methylprednisone, budesonide, beclomethasone dipropionate, cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil, tyromisole, imuthiol, antithymocyte globulin, azathioprine, azodiacarbonide, bisindolylmaleimide VIII, brequinar, chlorambucil, CTLA4-Ig, cyclophosphamide, deoxyspergualin, dexamethasone, leflunomide, mercaptopurine, 6-mercaptopurine, methotrexate, methylprednisolone, mizoribine, mizoribine monophosphate, muromonab CD3, mizorabine, mizorabine monophosphate ... Cophenolate mofetil, OKT3, rho(D) immunoglobulin, vitamin D analogs, MC1288, daclizumab, infliximab, rituximab, tocilizumab, alemtuzumab, methotrexate, antithymocyte globulin, denileukin diftitox, Campath-1H, keratinocyte growth factor, abatacept, remestemcel-L, suberoylanilide hydroxamic acid, pentostatin, thalidomide, imatinib mesylate, cyclophosphamide, fludarabine, OKT3, melphalan, thiopeta, lymphocyte immunoglobulin, and antithymocyte globulin.

[0108] It will also be understood that each of the above agents, administered individually or combined in a combination therapy or regimen, may be administered at an initial dose and then tapered over time by a medical professional to arrive at a lower effective dose. For example, in the combinations and regimens herein, systemic glucocorticoids (corticosteroids), such as prednisone and methylprednisone, may be administered to a human patient at a dose of about 1-2 mg / kg / day. Initial daily doses of mTOR agents include 2-40 mg of sirolimus administered once daily and 0.25-1 mg of everolimus administered twice daily. Initial daily doses of calcineurin agents include tacrolimus at about 0.025-0.2 mg / kg / day and cyclosporine at about 2.5-9 mg / kg / day. Mycophenolate mofetil (CellCept®) may be administered at an initial daily dose of about 250-3,000 mg / day. Each of these agents may be administered in combination with a pharma- tically effective amount of a Syk inhibitor as described herein following hematopoietic cell transplantation. In different embodiments herein, agents useful for treating GVHD may be administered locally to a human in need of such treatment, such as in the form of a topical ointment or cream or in an eye drop formulation.

[0109] The present invention also provides a method of treating GVHD further comprising the step of administering phototherapy (also known as extracorporeal photochemotherapy).

[0110] [Example] The embodiments provided herein can be more fully understood by referring to the following examples. These examples are intended to illustrate the methods provided herein, but are not intended to be limiting. It will be apparent to those skilled in the art that various changes and modifications can be made. Such modifications are also intended to fall within the scope of the appended claims.

[0111] The alberestat used in the following examples can be synthesised according to WO2005 / 026123A1 (Example 94, page 85). EXAMPLES

[0112] Alverestat is a potent and specific inhibitor of neutrophil elastase (NE) As further discussed in [3], the following results were obtained:

[0113] Alberestat has a high binding affinity (K D = 9.5 nM), which potently inhibits NE activity. p I C 50 (I C 50 ) value and K i The values ​​are 7.9 (12 nM) and 9.4 nM, respectively.

[0114] Alberestat is at least 600-fold more selective for human NE than another serine protease, cathepsin G, and at least 1900-fold more selective for human NE than other serine proteases (proteinase-3, chymotrypsin, pancreatic elastase, and trypsin).

[0115] Alverestat exhibits good crossover efficacy to NE from other species, including mouse.

[0116] In whole blood assays, cell-associated assays, and burst release assays p I C 50 (I C 50 ) values ​​were 7.36 (44 nM), 7.32 (48 nM), and 7.30 (50 nM), respectively.

[0117] The results of the presented study demonstrate that arvelestat is a specific, potent, and rapidly reversible inhibitor of human NE. The potent inhibitory activity of arvelestat against NE in biochemical assays was confirmed in whole blood and cell-based systems. EXAMPLES

[0118] Alverestat shows protective effect against GVHD This preclinical study was conducted to evaluate the efficacy of alberestat in preventing GVHD. We demonstrated that alberestat has similar efficacy against NE in mice and humans ( p I C 50 Given the comparative variability in efficacy and safety in mice (6.5 vs 7.9)[3], preclinical studies in mice are reasonable.

[0119] The mouse model of GVHD used in this study is described in [4]. BALB / c recipients were lethally irradiated (8.5 Gy total body irradiation) and then transplanted with T cell-depleted bone marrow + / - purified T cells from B10.D2 donors. Negative controls received T cell-depleted bone marrow (TCDBM) alone (no T cells, no GVHD), whereas positive controls received TCDBM + 2 × 10 6 T cells (100% lethal GVHD). In the treatment groups, mice were administered alverestat at 20, 50, and 200 mg / kg per day on days 1–45 via a premixed characteristic diet or as a powder added to wet food. These doses were based on theoretical considerations and previous studies in rodents (e.g., [5]). This schedule was chosen to ensure adequate drug levels from pre-irradiation (day 0) through the time of death due to GVHD. Survival (primary endpoint), body weight, and GVHD scores (clinical and histological) ([4], [6]) were monitored. To ensure scientific rigor, experiments were performed in duplicate.

[0120] These experiments were performed using a 2×10 6We confirm that the addition of T cells to TCDBM (TCDBM+T2e6) results in lethal GVHD at 5 days compared to 100% survival in mice transplanted with TCDBM alone, and show that the addition of alberestat, either in premixed diet pellets (Figure 1A) or as a powder mixed with wet food (Figure 1B), significantly improves survival compared to TCDBM+T2e6 (log rank p=0.001 TCDBM+T2e6 vs. TCDBM+T2e6+20mg / kg diet; log rank p=0.01 TCDBM+T2e6 vs. TCDBM+T2e6+20mg / kg wet food). Experiments (n=5 per group) were performed in duplicate and a total of 20 mice (n=10 diet, n=10 wet food) were evaluated for each dose. All control animals died by day 5, making it difficult to estimate the effects on body weight or GVHD scores, but no dose-response was observed in survival or improvement in body weight or GVHD scores among the three dose levels tested (Fig. 1C–F).

[0121] 2×10 6 Death in positive control mice transferred with 2 × 10 T cells was more rapid than reported in some models (e.g., C57BL / 6 → BALB / c) ([4], [7], [8]), but similar to that reported in other models (e.g., C3H / Hej / C3Heb / Fej → (C3FeB6)F1) (9). Nevertheless, to confirm that the deaths seen in Figure 1 were driven by a T cell-mediated process, we used 2 × 10 6 Mice were transplanted with T cells at a lower dose (1 × 10 6 T cells and 1.5 x 10 6 We performed another experiment comparing the dose of T cells from 1 × 10 to 1 × 10 6 There was no mortality at day 45 with 2 × 10 T cells, and mortality was earlier with higher T cell doses (linear trend test with Cox proportional hazards model p<0.0001) (mice were followed for a longer period than in Figure 1 due to a desire to observe mice transferred with lower doses of T cells). Again, 2 × 10 6Mice receiving 20 mg / kg alverestat in premixed food pellets were treated with 2 × 10 T cells, 6 1 × 10 T cells alone, which significantly improved survival 6 T cells and 1.5 x 10 6 This experiment is the fifth replicate in which alverestat 20 mg / kg (either added to the premixed diet or to the wet food) produced a survival advantage. The most severe case (2 × 10 6 Because a significant survival advantage had already been observed with alberestat and lower doses of T cells (Figures 1A-B and 2A), further experiments with alberestat and lower doses of T cells were not performed.

[0122] Necropsies of the mice were performed after death or sacrifice at the end of the experiment, which confirmed the findings that mice transplanted with TCDBM+T2e6 developed GVHD (Figure 3A-B), whereas mice transplanted with TCDBM alone showed no signs of GVHD (Figure 3C-D).

[0123] To more fully characterize the effect of T cells and alberestat on organ toxicity, the above experiment was repeated with mice (n=5 / group) implanted with either T2e6 or T2e6+20 mg / kg diet, sacrificed on day 4, and histologically analyzed. Tissues were reviewed by a blinded pathologist specialized in GVHD and scored based on architecture (crypt regeneration, surface erosion, ulceration, lamina propria inflammation, atrophy, crypt branching, endocrine cell excess, and Paneth cell excess) and epithelial cytology (vacuolation, attenuation, apoptosis, luminal shedding, lymphocytic infiltration, neutrophilic infiltration). Each feature was graded on a scale of 0-4 (0: normal, 0.5: focal and rare, 1: focal and mild, 2: diffuse and mild, 3: diffuse and moderate, 4: diffuse and severe) and results were summarized by organ. In mice treated with alverestat, no toxicity was observed in the skin or liver on day 4, whereas intestinal abnormalities (Figure 4) were observed, particularly reappearance of crypts, columnar attenuation, and apoptosis, with a trend toward increased pathology in the T2e6 group (p=0.08).

[0124] In summary, these results demonstrate a significant difference in survival with alverestat in a mouse model of GVHD and support the use of alverestat in the prevention of GVHD.

[0125] Consideration The above results indicate that alverestat is effective in treating and preventing GVHD. This result is highly unexpected, since it is understood that the primary inducers of GVHD (if not exclusively) are T and B lymphocytes, not neutrophils. Extensive studies have demonstrated that alverestat inhibits the proliferation and proliferation of mature CD4 + and / or CD8 + It is well established that T cells initiate GVHD and that GVHD is dependent on recipient antigen-presenting cells that mount an alloimmune T cell response against foreign histocompatibility antigens. Notably, it has been demonstrated that removal of αβ T cells from the donor cell inoculum prevents GVHD in rodents, humans, and dogs

[10] .

[0126] Given the importance of T lymphocytes in the pathogenesis of tissue damage observed during GVHD, it is surprising that alverestat, a drug that specifically targets neutrophils, has the effects observed above on GVHD, namely, increasing survival in GVHD models and reducing gastrointestinal GVHD pathology. Although neutrophils have previously been implicated in the pathology of GVHD, prior to these experiments it was not known that inhibiting neutrophil elastase was a viable therapeutic strategy.

[0127] Based on these results, the inventors recognized that alverestat (and more generally neutrophil elastase inhibitors) would be effective in treating or preventing diseases associated with common mechanisms and pathologies to GVHD.

[0128] Like GVHD, organ rejection is primarily mediated by the recipient's CD4 + and CD8 + Recipient recognition of donor organ tissue antigens is mediated by allorecognition of donor MHC-derived peptides by T cells. The foreign antigens are presented to the recipient's immune system, but donor antigen-presenting cells (APCs) released from the organ migrate to the recipient's draining lymph nodes, where recipient dendritic cells process and present the alloantigens, priming T cells that become activated and migrate back to the organ, resulting in damage to the organ. Alternatively, recipient APCs capture and self-present donor antigens

[11] . In both GVHD and chronic organ rejection, alloreactive T cells are primed and generated, driving the pathological process. The role of allogeneic T cells as a common pathway has been confirmed by the fact that both GVHD and graft rejection can be transferred via T cells in adoptive transfer experiments in animal models. This is further substantiated by clinical observations that the pathology of BOS observed in chronic lung rejection is similar to that observed in GVHD in bone marrow and stem cell transplants

[12] .

[0129] It has been previously reported that elevated levels of elastase-derived peptides have been detected in bronchoalveolar lavage fluid from patients with LT-BOS.

[14] However, no causative role for elastase has been proposed, and neutrophil elastase inhibition has not previously been considered to provide a therapeutic strategy for the treatment or prevention of organ rejection, including LT-BOS. The therapeutic effect of inhibiting NE would reflect the much earlier observation, in 1999, that neutrophils may be involved in LT-BOS.

[15]

[0130] In view of the significant results observed in GVHD, the inventors rationalized that neutrophil elastase inhibitors such as alverestat would also be effective in treating or preventing organ rejection.

[0131] Taken together, these findings support the potential for NE inhibition using alberestat to have beneficial effects in the treatment or prevention of organ rejection, particularly BOS associated with organ rejection. This is an important step forward, as there are currently no established treatments for these diseases.

[0132] Based on the scientific rationale and data presented above, alverestat will be investigated in clinical trials designed to evaluate its safety and efficacy in the treatment and prevention of BOS in patients after lung transplantation. EXAMPLES

[0133] Preventing the development of BOS in patients after lung transplantation Lung transplant recipients will be administered alberestat as part of a multicenter, randomized, standard of care controlled trial to demonstrate the efficacy and safety of alberestat in improving survival and preventing BOS when administered prophylactically in addition to standard immunosuppressive regimens.

[0134] In this study, patients will receive alverestat at a maximum dose of 240 mg twice daily starting immediately after lung transplantation. Treatment will continue for two years and may be extended for up to five years.

[0135] Selection criteria: Patients who have had a lung transplant (either single or double lungs), Patients who are able to consent and register within 30 days of receiving a lung transplant.

[0136] Exclusion criteria: History of heart-lung transplant, lung retransplant, or another solid organ transplant Clinically significant stenosis unresponsive to dilatation and / or stent placement ·Active lung infection Failure of anastomotic sites

[0137] Primary endpoint: Difference in FEV1 (percentage predicted) between the alberestat group and the standard of care group at weeks 12 and 24 Differences in BOS stage / BOS-free survival between the alverestat and standard care groups at 12 and 24 weeks

[0138] Secondary endpoints (effective compared to standard of care): Respiratory function measured by mean FEV1% predicted at 1 and 2 years after randomization -BOS stage in the alberestat and standard treatment groups at 1 and 2 years All-cause and transplant-related mortality up to 2 years Onset of RAS Symptoms Safety and tolerability Relapse-free survival (defined as reported by SAEs) corresponds to the time from the date of randomization to either death or the occurrence of serious bacterial and viral infections originating from the lungs.

[0139] Alberestat is expected to demonstrate efficacy in one or more of the primary endpoints listed above. EXAMPLES

[0140] Treatment of BOS in patients after lung transplantation Alberestat will be administered to lung transplant recipients as part of a multicenter, randomized, standard of care controlled trial to demonstrate the efficacy and safety of alberestat in improving BOS when administered in addition to the recipient's standard immunosuppressive regimen.

[0141] During the study, patients who developed BOS after lung transplantation were given alverestat at doses of up to 240 mg twice daily.

[0142] Selection criteria: Lung transplant (either single or double lung), Diagnosis of BOC >Stage 1 Other causes of lung disease have been ruled out

[0143] Exclusion criteria: ·Restrictive allograft syndrome -Patients who require a change in immunosuppressive regimen ·Active lung infection

[0144] Primary endpoint: Difference in FEV1 (percentage predicted) between the alberestat group and the standard of care group at weeks 12, 24, 48, and 106 -BOS stage at 12 and 24 weeks in the alberestat group and standard treatment group

[0145] Secondary endpoints (effective compared to standard of care): Respiratory function measured by mean FEV1% predicted at 1 and 2 years after randomization -BOS stage in the alverestat and standard treatment groups at 2 years All-cause and transplant-related mortality up to 2 years Onset of RAS Symptoms Safety and tolerability Relapse-free survival (defined as reported by SAEs) corresponds to the time from the date of randomization to either death or the occurrence of serious bacterial and viral infections originating from the lungs.

[0146] Alberestat is expected to demonstrate efficacy in one or more of the primary endpoints listed above. EXAMPLES

[0147] Phase 1 study of alverestat in patients with bronchiolitis obliterans syndrome (BOS) after hematopoietic cell transplantation (HCT) A phase 1 trial of alverestat in patients with BOS after HCT was conducted.

[0148] method: Patients aged 18 years or older with post-HCT BOS and chronic graft-versus-host disease (GVHD) were recruited on a National Cancer Institute protocol (NCT02669251). Patients had stable systemic immunosuppression and FEV1% predicted ≥ 30% on pulmonary function tests (PFTs).

[0149] This phase 1 study consisted of two parts: an 8-week intrapatient dose-escalation period followed by a continuation period allowing treatment for up to 6 months. Alberestat was administered orally starting at 60 mg twice daily (a dose previously used in patients with chronic lung disease) and increasing every 2 weeks to 120 mg twice daily, 180 mg twice daily, and finally 240 mg twice daily. Patients continued on this dose until completion of the continuation phase or until the occurrence of unacceptable toxicity, discontinuation of treatment for more than 28 days, or progression of GVHD or BOS.

[0150] The primary objective was to determine the maximum tolerated dose (MTD) based on dose-limiting toxicity. Secondary objectives included measuring pharmacokinetics, markers of neutrophil elastase (NE) activity, and markers of inflammation in blood and sputum. PFTs and chronic GVHD assessments were performed at baseline, at weeks 4 and 8 during the dose escalation period, and at months 3 and 6 during the extension period.

[0151] result: Seven patients were enrolled (3 men and 4 women). At enrollment, the median post-bronchodilator FEV1 was 44% (range 38-74).

[0152] All seven patients were able to tolerate dose escalation of alverestat to a maximum dose of 240 mg twice daily, and the MTD was not reached. The most common adverse events (AEs) potentially related to treatment in the study were all grade 2 and included increased creatinine (3 cases), elevated ALT or AST (3 cases), and upper respiratory tract infection (3 cases). The only grade 3 AEs potentially related to study drug were gastroenteritis and vomiting requiring hospitalization in one patient, and pneumonia in one patient.

[0153] Three patients completed the study after 8 weeks + 6 months of treatment. Four patients required dose interruption, only one of whom required dose reduction due to grade 3 gastroenteritis (resulting in dehydration and elevated creatinine). Four patients discontinued treatment before the end of the study: two patients had dose interruption for >28 days due to adverse events, one patient had a fall in FEV1 after pneumonia, and one patient discontinued treatment at the investigator's discretion.

[0154] The median duration of treatment was 6.4 months. Based on the NIH Chronic GVHD Consensus Criteria, six patients had stable disease and one patient had progressive disease (decline in FEV1 after pneumonia). No patients achieved the 10% improvement in FEV1 required for organ response, but two patients had a 9% improvement in FEV1 and four patients had improvement in Lee Chronic GVHD Symptom Scale pulmonary scores.

[0155] Preliminary pharmacokinetic analysis of seven patients showed linear dose-dependent increases in each exposure metric (steady-state trough and steady-state peak), albeit with some interpatient variability. Bronchoalveolar lavage fluid and expectorant samples are being analyzed for NE activity.

[0156] Conclusion: In this phase 1 study of the oral NE inhibitor alverestat in patients with BOS after HCT, the MTD was not reached and the investigational drug was well tolerated. Six patients had stable disease, while one patient progressed in the setting of pneumonia. Two patients had a clear 9% improvement in FEV1, and four patients had improvement in pulmonary symptoms at some point during treatment, two of which improved during the 6-month treatment evaluation and two at the end of the study treatment period. We demonstrated that NE inhibition was well tolerated and showed signs of stabilizing disease in patients with advanced BOS.

[0157] The ability to improve lung function and / or prevent disease progression and further deterioration of lung function could significantly improve the treatment of GVHD, particularly cGVHD, and related diseases.

[0158] These results further support the use of alberestat in the methods of the invention including or relating to the treatment or prevention of graft rejection, LT-BOS, and GVHD. [Table 1]

[0159] References [1] Verleden SE, Vos R, Vanaudenaerde BM, Verleden GM, J Thorac Dis 2017;9(8):2650-2659 [2] Meyer KC, Raghu G, Verleden GM, Corris PA, Aurora P, Wilson KC, Brozek J, Glanville AR and the ISHLT / ATS / ERS BOS Task Force Committee;Eur Respir J 2014;44:1479-1503 [3] Stevens T,Ekholm K,Granse M,Lindahl M,Kozma V,Jungar C,Ottosson T,Falk-Hakansson H,Churg A,Wright JL,Lal H,Sanfridson A.AZD9668:pharmacological characterization of a novel oral inhibitor of neutrophil elastase.The Journal of pharmacology and experimental therapeutics.2011;339(1):313-20.Epub 2011 / 07 / 28.doi:10.1124 / jpet.111.182139.PubMed PMID:21791628. [4] Chen BJ,Cui X,Liu C,Chao NJ.Prevention of graft-versus-host disease while preserving graft-versus-leukemia effect after selective depletion of host-reactive T cells by photodynamic cell purging process.Blood.2002;99(9):3083-8.Epub 2002 / 04 / 20.PubMed PMID:11964269. [5] Delbosc S,Rouer M,Alsac JM,Louedec L,Philippe M,Meilhac O,Whatling C,Michel JB.Elastase inhibitor AZD9668 treatment prevented progression of experimental abdominal aortic aneurysms.Journal of vascular surgery.2016;63(2):486-92.e1.Epub 2014 / 09 / 02.doi:10.1016 / j.jvs.2014.07.102.PubMed PMID:25175632.

[0160] [6] Zhang P,Wu J,Deoliveira D,Chao NJ,Chen BJ.Allospecific CD4(+)effector memory T cells do not induce graft-versus-host disease in mice.Biology of blood and marrow transplantation:journal of the American Society for Blood and Marrow Transplantation.2012;18(10):1488-99.Epub 2012 / 07 / 20.doi:10.1016 / j.bbmt.2012.07.009.PubMed PMID:22809867;PMCID:PMC3443280. [7] Chen BJ,Deoliveira D,Cui X,Le NT,Son J,Whitesides JF,Chao NJ.Inability of memory T cells to induce graft-versus-host disease is a result of an abortive alloresponse.Blood.2007;109(7):3115-23.Epub 2006 / 12 / 07.doi:10.1182 / blood-2006-04-016410.PubMed PMID:17148592;PMCID:PMC1852216. [8] Chen BJ,Cui X,Sempowski GD,Liu C,Chao NJ.Transfer of allogeneic CD62L- memory T cells without graft-versus-host disease.Blood.2004;103(4):1534-41.Epub 2003 / 10 / 11.doi:10.1182 / blood-2003-08-2987.PubMed PMID:14551132. [9] Cooke KR,Hill GR,Crawford JM,Bungard D,Brinson YS,Delmonte J,Jr.,Ferrara JL.Tumor necrosis factor- alpha production to lipopolysaccharide stimulation by donor cells predicts the severity of experimental acute graft-versus-host disease.The Journal of clinical investigation.1998;102(10):1882-91.Epub 1998 / 11 / 20.doi:10.1172 / jci4285.PubMed PMID:9819375;PMCID:PMC509139.

[10] Schlomchik WD,Nature Reviews Immunology,vol.7,pages 340-352(2007).

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[11] Nath DS,Basha HI,Mohanakumar T,Curr.Opin.Organ Transplant.2010 February;15(1):16-20;doi:10.1097 / MOT.0b013e3283342780

[12] Verleden SE,Mcdonough J,Schoemans H,Knoop C,Verschakelen J,Dubbledam A,Boone M,Van Hoorebeke L,Verbeken E,Weynand B,Van Raemdonck D,Verleden G,Vos R,Vanaudenaerde B,The Journal of Heart and Lung Transplantation,38(4),S407 - S408

[13] Groutas WC,Dou D,Alliston KR,Expert Opin Ther Pat.2011 March ;21(3):339-354

[14] Stone MD,Harvey SB,Nelsestuen GL,Reilly C,Hertz MI,Wendt CH;PLOS ONE,2 January 2014,Volume 9,Issue 1,e84471,pages 1-6

[15] Hirsch J et al,Am J Respir Crit Care Med Vol 160.pp 1640-1646,1999.

[0162]

[16] Lee SJ,Blood(2017)129(1):30-37.

[17] Lee SJ et al;Biol Blood Marrow Tra nsplant 2002;8(8):444-52 The inventions described in the original claims of this application are listed below. [Invention 1] A method for treating or preventing transplant rejection, comprising administering to a subject in need thereof an effective amount of alverestat or a pharma- ceutically acceptable salt and / or solvate thereof. [Invention 2] The method according to claim 1, wherein the graft comprises one or more organs selected from the group consisting of kidney, heart, liver, lung, and pancreas. [Invention 3] The method of claim 1, wherein the graft comprises a lung. [Invention 4] The method according to claim 1, wherein the subject is suffering from or at risk of suffering from lung transplant-associated bronchiolitis obliterans syndrome. [Invention 5] The method according to any one of the preceding inventions (eg, Inventions 1 to 4), wherein the graft rejection is chronic graft rejection. [Invention 6] 5. The method according to any one of Inventions 1 to 4, wherein the graft rejection is acute graft rejection. [Invention 7] A method for treating or preventing lung transplant-associated bronchiolitis obliterans syndrome, comprising administering an effective amount of alverestat or a pharma- ceutically acceptable salt and / or solvate thereof to a subject in need thereof. [Invention 8] A method for treating or preventing graft-versus-host disease (GVHD), comprising administering to a subject in need thereof an effective amount of alverestat or a pharma- ceutically acceptable salt and / or solvate thereof. [Invention 9] The method according to claim 8, wherein the GVHD is chronic GVHD (cGVHD). [Invention 10] The method according to claim 8, wherein the GVHD is acute GVHD (aGVHD). [Invention 11] The method according to any one of Inventions 8 to 10, wherein the GVHD occurs after bone marrow transplantation. [Invention 12] The method according to any one of Inventions 8 to 11, wherein the GVHD occurs after hematopoietic stem cell transplantation. [Invention 13] The method according to any one of claims 8 to 12, wherein the GVHD is characterized by damage to one or more selected from the group consisting of eyes, joints, fascia, reproductive organs, lungs, liver, skin, and digestive tract (e.g., mouth, esophagus). [Invention 14] The method according to any one of Inventions 8 to 12, wherein the GVHD is characterized by damage to one or more selected from the group consisting of the lungs, the liver, the skin, and the digestive tract. [Invention 15] The method according to any one of claims 8 to 14, wherein the subject is suffering from moderate or severe cGVHD. [Invention 16] 16. The method according to any one of Inventions 8 to 15, wherein the subject is suffering from or at risk of suffering from bronchiolitis obliterans syndrome. [Invention 17] A method for treating or preventing bronchiolitis obliterans syndrome (BOS) associated with GVHD, comprising administering an effective amount of alverestat or a pharma- ceutically acceptable salt and / or solvate thereof to a subject in need thereof. [Invention 18] The method according to claim 17, wherein the BOS is associated with hematopoietic stem cell transplantation. [Invention 19] 18. The method of claim 17, wherein the BOS is associated with bone marrow transplantation. [Invention 20] The method according to any one of the preceding inventions (e.g., Inventions 1-19), wherein alverestat or a pharma- ceutically acceptable salt and / or solvate thereof is administered prior to transplantation into said subject. [Invention 21] The method according to any one of Inventions 1 to 16, wherein alverestat or a pharma- ceutically acceptable salt and / or solvate thereof is administered after transplantation into said subject. [Invention 22] The method according to any one of the preceding inventions (e.g., Inventions 1 to 21), wherein the treatment or prevention comprises inhibiting neutrophil elastase. [Invention 23] The method according to any one of the preceding inventions (e.g., inventions 1 to 22), wherein the treatment or prevention comprises improving or preventing a deterioration in predicted FEV1% in the subject. [Invention 24] A method according to any one of the preceding inventions (e.g., inventions 1 to 23), wherein the treatment or prevention comprises improving or preventing a worsening of the grade of BOS in the subject. [Invention 25] The method according to any one of the preceding inventions (e.g., inventions 1 to 24), wherein treating cGVHD comprises improving a cGVHD severity score in the subject. [Invention 26] The method according to any one of the preceding inventions (e.g., inventions 1-25), wherein the treatment of cGVHD comprises improving the Lee cGVHD Symptom Scale in a subject, in particular the pulmonary score on the Lee cGVHD Symptom Scale in a subject whose lungs are affected by cGVHD. [Invention 27] A method according to any one of the preceding inventions (e.g., inventions 1 to 26), comprising improving pulmonary function in a subject. [Invention 28] A method according to any one of the preceding inventions (e.g., Inventions 1 to 27), comprising preventing deterioration of pulmonary function in a subject. [Invention 29] A method according to any one of the preceding inventions (e.g., inventions 1 to 28), comprising preventing disease progression or worsening in a subject. [Invention 30] The method according to any one of the preceding inventions (e.g., Inventions 1 to 29), wherein the alberestat is in the form of a free base. [Invention 31] The method according to any one of the prior inventions (e.g., Inventions 1 to 30), wherein the alberestat is in the form of alberestat tosylate. [Invention 32] A method according to any one of the prior inventions (e.g., Inventions 1 to 31), comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice a day. [Invention 33] The method according to any one of the prior inventions (e.g., Inventions 1 to 32), comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of up to 240 mg of alberestat. [Invention 34] The method according to any one of the prior inventions (e.g., Inventions 1 to 33), comprising administering arvelestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of 60 mg, 120 mg, 180 mg, or 240 mg of arvelestat. [Invention 35] The method according to any one of the prior inventions (e.g., Inventions 1 to 34), comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of 240 mg of alberestat. [Invention 36] The method of any one of the prior inventions (e.g., inventions 1-35), comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof at an alberestat dose of 60 mg twice daily for a first period of time, followed by 120 mg twice daily for a second period of time, followed by 180 mg twice daily for a third period of time, and 240 mg twice daily thereafter. [Invention 37] The method according to any one of the prior inventions (e.g., inventions 1-36), comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof at a dose of 60 mg alberestat twice daily for two weeks, followed by 120 mg twice daily for two weeks, followed by 180 mg twice daily for two weeks, followed by 240 mg twice daily thereafter. [Invention 38] The method according to any one of the prior inventions (e.g., Inventions 1 to 37), comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof by oral administration. [Invention 39] The method according to any one of the preceding inventions (eg, inventions 1 to 38), further comprising administering to said subject one or more immunosuppressants.

Claims

1. 1. A pharmaceutical composition for use in a method for the treatment or prevention of transplant rejection in a human subject in need thereof, comprising: The composition comprises an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof, the method comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of 60 mg, 120 mg, 180 mg, or 240 mg of alberestat; The pharmaceutical composition.

2. 2. The pharmaceutical composition of claim 1, wherein the graft comprises one or more organs selected from the group consisting of kidney, heart, liver, lung, and pancreas, and optionally, the graft comprises a lung.

3. The pharmaceutical composition of claim 1 or 2, wherein the subject is suffering from or at risk of suffering from lung transplant-associated bronchiolitis obliterans syndrome.

4. The pharmaceutical composition according to any one of claims 1 to 3, wherein the graft rejection is a chronic graft rejection or an acute graft rejection.

5. 1. A pharmaceutical composition for use in a method for the treatment or prevention of lung transplant-associated bronchiolitis obliterans syndrome in a human subject in need thereof, comprising: The composition comprises an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof, the method comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of 60 mg, 120 mg, 180 mg, or 240 mg of alberestat; The pharmaceutical composition.

6. 1. A pharmaceutical composition for use in a method for the treatment or prevention of graft-versus-host disease (GVHD) in a human subject in need thereof, comprising: The composition comprises an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof, the method comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of 60 mg, 120 mg, 180 mg, or 240 mg of alberestat; The pharmaceutical composition.

7. The pharmaceutical composition according to claim 6, wherein the GVHD is chronic GVHD (cGVHD) or acute GVHD (aGVHD).

8. (i) the GVHD occurs after bone marrow transplantation; and / or (ii) the GVHD occurs after hematopoietic stem cell transplantation; and / or (iii) the GVHD is characterized by damage to one or more selected from the group consisting of eyes, joints, fascia, reproductive organs, lungs, liver, skin, and digestive tract (e.g., mouth, esophagus); optionally, the GVHD is characterized by damage to one or more selected from the group consisting of lungs, liver, skin, and digestive tract; and / or (iv) the subject is afflicted with moderate or severe cGVHD, and / or (v) the subject is suffering from or at risk of suffering from bronchiolitis obliterans syndrome; A pharmaceutical composition according to claim 6 or 7.

9. 1. A pharmaceutical composition for use in a method for the treatment or prevention of bronchiolitis obliterans syndrome (BOS) associated with graft-versus-host disease (GVHD) in a human subject in need thereof, comprising: The composition comprises an effective amount of alberestat or a pharma- ceutically acceptable salt and / or solvate thereof, the method comprising administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of 60 mg, 120 mg, 180 mg, or 240 mg of alberestat; The pharmaceutical composition.

10. The pharmaceutical composition of claim 9 , wherein the BOS is associated with hematopoietic stem cell transplantation or bone marrow transplantation.

11. The pharmaceutical composition according to any one of claims 1 to 10, wherein the alvelestat or a pharma- ceutically acceptable salt and / or solvate thereof is administered prior to transplantation into the subject.

12. The pharmaceutical composition according to any one of claims 1 to 8, wherein the alverestat or a pharma- ceutically acceptable salt and / or solvate thereof is administered after transplantation into the subject.

13. (i) the treatment or prevention comprises inhibiting neutrophil elastase; and / or (ii) the treatment or prevention comprises improving or preventing a worsening of FEV1% predicted in said subject; and / or (iii) the treatment or prevention comprises ameliorating or preventing a worsening of the grade of BOS in said subject; and / or (iv) treating cGVHD comprises improving a cGVHD severity score in the subject; and / or (v) treating cGVHD comprises improving the Lee cGVHD Symptom Scale in a subject, in particular the Lee cGVHD Symptom Scale pulmonary score in a subject in whom the lungs are affected by cGVHD; and / or (vi) the method comprises improving pulmonary function in a subject; and / or (vii) the method comprises preventing a deterioration of pulmonary function in a subject; and / or (viii) the method comprises preventing progression or worsening of the disease in the subject. The pharmaceutical composition according to any one of claims 1 to 12.

14. (i) the arvelestat is in the form of a free base, and / or (ii) the arvelestat is in the form of arvelestat tosylate; The pharmaceutical composition according to any one of claims 1 to 13.

15. (i) the method comprises administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof twice daily at a dose of 240 mg of alberestat; and / or (ii) the method comprises administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof at an alberestat dose of 60 mg twice daily for a first period, followed by 120 mg twice daily for a second period, followed by 180 mg twice daily for a third period, and then 240 mg twice daily thereafter; and / or (iii) the method comprises administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof at a dose of 60 mg alberestat twice daily for 2 weeks, followed by 120 mg twice daily for 2 weeks, followed by 180 mg twice daily for 2 weeks, followed by 240 mg twice daily thereafter; and / or (iv) the method comprises administering alberestat or a pharma- ceutically acceptable salt and / or solvate thereof by oral administration; and / or (v) the method further comprises administering to the subject one or more immunosuppressive agents. The pharmaceutical composition according to any one of claims 1 to 14.

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