Combination of zibotentan and dapagliflozin for the treatment of chronic kidney disease

Abstract

The present disclosure relates to the endothelin receptor antagonist (ERA) zibotentan in combination with the sodium-dependent glucose cotransporter 2 (SGLT-2) inhibitor dapagliflozin for use in the treatment of certain endothelin-related diseases.

Description

[Technical Field]

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

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

[0003] SGLT-2 inhibitors result in a reduction of fluid overload resulting from glucosuria, largely independent of osmotic diuresis, increased urine output, and changes in systemic sodium load. SGLT-2 inhibitors block glucose reabsorption in the kidney, increasing glucose output and lowering blood glucose levels. In addition to this well-characterized mechanism of action, SGLT-2 inhibitors lower blood pressure, reduce vascular stiffness, improve endothelial function, and possess anti-inflammatory and anti-fibrotic properties similar to those of ERAs (Non-Patent Document 6). SGLT-2 inhibitors have proven effective in DKD (Non-Patent Document 7). Dapagliflozin has been investigated for its efficacy in CKD in the DAPA-CKD clinical trial and was recently discontinued early due to underwhelming efficacy. A post-hoc analysis of the SONAR clinical trial, presented at the 2019 National Kidney Week meeting in Washington, DC, demonstrated that ET A In a subset of DKD patients (n=14) taking both the antagonist atrasenetan and an SGLT2 inhibitor, we demonstrated increased reduction in UACR compared to atrasenetan alone and reduced weight gain caused by atrasentan, a surrogate for fluid retention.

[0004] Zibotentan, N-(3-methoxy-5-methylpyrazin-2-yl)-2-[4-(1,3,4-oxadiazol-2-yl)phenyl]pyridine-3-sulfonamide, has the chemical structure of formula I. [ka] Zibotentan, also called ZD4054, is disclosed as an entothelin receptor antagonist in US Pat. No. 5,629,493, along with details for the chemical synthesis of zibotentan. Specific inhibition of endothelin A receptors by zibotentan has been reported by Non-Patent Document 8.

[0005] Dapagliflozin, (1S)-1,5-anhydro-1-{4-chloro-3-[(4-ethoxyphenyl)methyl]phenyl}-D-glucitol, has the chemical structure of Formula II. [ka] Dapagliflozin is a potent, highly selective, and orally active inhibitor of human renal sodium-dependent glucose transporter 2 (SGLT2) (SGLT2i) that is approved (as an adjunct to diet and exercise) to improve glycemic control in adults with type 2 diabetes and to reduce the risk of hospitalization for heart failure in adults with type 2 diabetes and established cardiovascular disease or multiple cardiovascular risk factors. Dapagliflozin is disclosed in U.S. Patent No. 5,629,999, along with details on its chemical synthesis.

[0006] When zibotentan, a specific inhibitor of the endothelin A receptor, is combined with the SGLT-2 inhibitor dapagliflozin, the diuretic effect of dapagliflozin may be mitigated by the fluid retention side effects associated with the entothelin receptor antagonist zibotentan, thereby reducing both risks associated with each individual compound.

[0007] It is shown herein that dapagliflozin attenuates zibotentan-driven hemodilution (hemodilution is defined as a decrease in hematocrit concentration), thus highlighting the potential for the combination of zibotentan and dapagliflozin to demonstrate efficacy in the treatment of certain endothelin-related diseases.

[0008] Endothelin A and B receptors (ET A and E.T. B Endothelin-1, regulated by endothelin-1 receptors (ERRs), is a highly potent systemic vasoconstrictor and a driver of renal disease progression.

[0009] ET A Antagonist blockers improve renal function while also reducing ET. Balso removes circulating endothelin-1, thus inhibiting ET B Blockers are not preferred.

[0010] Endothelin-related diseases are associated with increased vasoconstriction, proliferation, or inflammation due to endothelin, which occurs in many cardiac and renal metabolic diseases. Examples of such endothelin-related diseases include hypertension, coronary artery disease, heart failure, renal and myocardial ischemia, and chronic kidney disease (CKD). In particular, CKD associated with hypertension or diabetes (diabetic kidney disease, DKD) is associated with hypertension. ERAs may be beneficial in the treatment of peripheral arterial occlusive disease, including diabetic arteriopathy, by exerting acute (peripheral vasodilatation) and chronic (improvements in vasodilatation, vascular structure and sympathetic nerve activity, antithrombotic, and anti-inflammatory) effects.

[0011] The mechanism of action of SGLT-2 involves simultaneous inhibition of glucose and sodium uptake in the renal proximal tubule of the nephron, which is thought to result in a reset of the tubuloglomerular feedback loop, presumably causing glomerular hyperfiltration. The efficacy of SGLT-2 inhibitors is thought to be reduced by low plasma glucose levels or a decrease in glomerular filtration rate (GFR), and therefore, SGLT-2 inhibitors have an inherently low risk of developing hypoglycemia. As a result, the properties of SGLT-2 inhibitors may pave the way for treating HF, including HFpEF, even in non-diabetic patients (Non-Patent Document 9).

[0012] A side effect associated with the pharmacological action of SGLT-2 inhibitors is hypovolemia / intravascular volume reduction, potentially leading to dehydration, hypovolemia, orthostatic hypotension, or hypotension. Accordingly, SGLT-2 inhibitors generally induce an increase in hematocrit (Hot), a marker of hemoconcentration, and an increase in blood viscosity, which are presumed causes of vascular damage associated with peripheral vascular disease.

[0013] Serum creatinine is increased and eGFR is decreased by the pharmacological action of SGLT-2 inhibitors. AZibotentan, an ERAG, which effectively blocks the receptor, may be suitable for treating endothelin-related diseases when prescribed in combination with dapagliflozin. When an ERAG is combined with an SGLT-2 inhibitor, the diuretic effect of such an SGLT-2 inhibitor and its potential pharmacological effects in reducing the risk of heart failure may be suitable for alleviating the most prominent side effects commonly associated with ERAGs, such as fluid retention and potentially increased risk of congestive heart failure. Such combination therapy may provide pharmacological effects on the disclosed endothelin-related diseases, while maintaining a favorable side effect profile compared to the maximum tolerated dose of zibotentan alone, even at optimally effective doses of zibotentan, potentially even at increased doses. When zibotentan is used in combination with dapagliflozin, for example, increased doses of zibotentan, which may be achievable due to reduced side effects, may amplify the impact on diseases caused by the harmful effects of the endothelin paracrine system, which is widely distributed in organs. Such combination therapy may improve the benefit / risk ratio. ERAs have been reported to reduce hematocrit (Hc) through hemodilution. Therefore, when used in combination with dapagliflozin, zibotentan may attenuate the most prominent side effects commonly associated with SGLT-2 inhibitors, such as hemoconcentration due to volume-depleting effects. ERAs have been reported to improve blood glucose levels through various mechanisms (increased blood flow, improved insulin signaling). Therefore, when used in combination with dapagliflozin, zibotentan may have additive or synergistic effects on blood glucose reduction. [Prior art documents] [Patent documents]

[0014] [Patent Document 1] International Publication No. 1996040681 Pamphlet [Patent Document 2] International Publication No. 2003099836 Brochure [Non-patent literature]

[0015] [Non-Patent Document 1] Grenda et al.,Nephrol Dial Transplant.2007;22(12):3487-3494 [Non-patent document 2] Kohan Am J Kidney Dis.1997;29(1):2-26 [Non-patent document 3] Goddard et al.,Circulation.2004;109(9):1186-1193 [Non-patent document 4] Heerspink et al., Diabetes Obes Metab.2018;20(8):1829-1835 [Non-Patent Document 5] Heerspink et al., Lancet 2019;393(10184):1937-1947 [Non-patent document 6] HJHeerspink et al.,Circulation(2016),134(10):752-772 [Non-Patent Document 7] Stephens et al., Diabetes Obes Metab.2020;22 Suppl 1:32-45 [Non-patent document 8] Morris et al.,British Journal of Cancer(2005),92,2148-2152 [Non-Patent Document 9] P. Martens et al.,Curr Treat Options Cardio Med(2017),19:23 Summary of the Invention [Means for solving the problem]

[0016] In a first aspect, there is provided zibotentan for use in the treatment of chronic kidney disease (CKD) in a human patient, wherein zibotentan is administered in combination with dapagliflozin.

[0017] In a further aspect, there is provided a method of treating chronic kidney disease (CKD) in a human patient in need of such treatment comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein zibotentan is administered in combination with a therapeutically effective amount of dapagliflozin.

[0018] In a further aspect, there is provided the use of zibotentan in the manufacture of a medicament for the treatment of chronic kidney disease (CKD) in a human patient, wherein zibotentan is administered in combination with dapagliflozin. [Brief explanation of the drawings]

[0019] [Figure 1] Example 1 shows the individual zibotentan blood concentrations in Experiment 1 after oral administration of zibotentan. [Figure 2] Example 1 shows individual zibotentan blood concentrations in Experiment 2 after oral administration of zibotentan alone or in combination with dapagliflozin. [Figure 3] Example 1 shows individual dapagliflozin blood concentrations in Experiment 2 after oral administration of dapagliflozin alone or in combination with zibotentan. [Figure 4] 1 shows the effect of zibotentan on Hct concentration in Example 1, Experiment 1. [Figure 5] Example 1, Experiment 1 shows the effect of zibotentan on body weight. [Figure 6] Example 1 shows the effects of zibotentan, dapagliflozin, and the combination on Hct in Experiment 2. [Figure 7] Example 1 shows the effects of zibotentan, dapagliflozin and the combination on body weight in experiment 2. [Figure 8]1 shows the effects of dapagliflozin and zibotentan on diabetes, water intake, and food intake in Example 1 and Experiment 2. [Figure 9] Figure 1 shows the UACR-lowering effect of dapagliflozin in patients with CKD and type 2 diabetes or without type 2 diabetes from the DAPA CKD Phase 3 clinical trial. [Figure 10] 1 shows regression and progression of UACR in patients with CKD stratified by diabetes status from the DAPA CKD Phase 3 clinical trial. DETAILED DESCRIPTION OF THE INVENTION

[0020] In a first aspect, there is provided zibotentan for use in the treatment of chronic kidney disease (CKD) in a human patient, wherein zibotentan is administered in combination with dapagliflozin.

[0021] In a further aspect, there is provided a method of treating chronic kidney disease (CKD) in a human patient in need of such treatment comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein zibotentan is administered in combination with a therapeutically effective amount of dapagliflozin.

[0022] In a further aspect, there is provided the use of zibotentan in the manufacture of a medicament for the treatment of chronic kidney disease (CKD) in a human patient, wherein zibotentan is administered in combination with dapagliflozin.

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

[0024] In certain embodiments, the CKD is stage 2-3 CKD.

[0025] In certain embodiments, the CKD is stage 3-4 CKD.

[0026] In certain embodiments, the CKD is stage 4 CKD.

[0027] In certain embodiments, the CKD is stage 3a or 3b CKD.

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

[0029] Zibotentan is also called ZD4054.

[0030] In embodiments, zibotentan, or a pharmaceutically acceptable salt thereof, is administered once daily.

[0031] In an embodiment, the total daily dose of zibotentan is about 10 mg.

[0032] In an embodiment, the total daily dose of zibotentan is about 5 mg.

[0033] In an embodiment, the total daily dose of zibotentan is about 1.5 mg.

[0034] In an embodiment, the total daily dose of zibotentan is about 0.5 mg.

[0035] In an embodiment, the total daily dose of zibotentan is about 0.25 mg.

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

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

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

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

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

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

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

[0043] In some embodiments provided herein, the pharmaceutical composition comprising dapagliflozin comprises a dose equivalent to about 2.5 mg / day to about 10 mg / day of dapagliflozin administered to a patient. In some embodiments provided herein, the pharmaceutical composition comprising dapagliflozin comprises a dose equivalent to about 2.5 mg / day, about 5 mg / day, or about 10 mg / day of dapagliflozin administered to a patient. In some embodiments provided herein, the pharmaceutical composition comprising dapagliflozin comprises a dose equivalent to about 5 mg / day of dapagliflozin administered to a patient once daily. In some embodiments provided herein, the pharmaceutical composition comprising dapagliflozin comprises a dose equivalent to about 10 mg / day of dapagliflozin administered to a patient once daily.

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

[0045] In one aspect, a method of treating CKD in a human patient in need of such treatment is provided, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises separate, sequential, or simultaneous administration to the human patient of i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient.

[0046] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for the treatment of CKD in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient.

[0047] In one aspect, zibotentan is provided for use in reducing UACR in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0048] In one aspect, a method is provided for reducing UACR in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises administering to the human patient i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin separately, sequentially, or simultaneously. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

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

[0050] In one aspect, zibotentan is provided for use in reducing UACR to <300 mg / g in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0051] In one aspect, a method is provided for reducing UACR to <300 mg / g in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises administering to the human patient i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin separately, sequentially, or simultaneously. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0052] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing UACR to <300 mg / g in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0053] In one aspect, zibotentan is provided for use in reducing the risk of progression of UACR to ≧3000 mg / g in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0054] In one aspect, a method is provided for reducing the risk of progression of UACR to ≥ 3000 mg / g in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises separate, sequential, or simultaneous administration of i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0055] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing the risk of progression of UACR to ≧3000 mg / g in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0056] In one aspect, zibotentan is provided for use in reducing the risk of eGFR decline in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes. In some embodiments, the use reduces the risk of a ≥ 30% decline in eGFR. In some embodiments, the use reduces the risk of a ≧40% decline in eGFR.

[0057] In one aspect, a method is provided for reducing the risk of eGFR decline in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises separate, sequential, or simultaneous administration of i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes. In some embodiments, the method reduces the risk of a >= 30% decline in eGFR. In some embodiments, the method reduces the risk of a >= 40% decline in eGFR.

[0058] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing the risk of eGFR decline in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes. In some embodiments, the use reduces the risk of a ≥ 30% decline in eGFR. In some embodiments, the use reduces the risk of a ≧40% decline in eGFR.

[0059] In one aspect, zibotentan is provided for use in reducing the risk of fluid retention (edema) in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes. In some embodiments, the reduced risk of fluid retention (edema) can be measured, for example, by a decrease in Hct or an increase in weight.

[0060] In one aspect, a method is provided for reducing the risk of fluid retention (edema) in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises separate, sequential, or simultaneous administration of i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes. In some embodiments, a reduced risk of fluid retention (edema) can be measured, for example, by a lowered Hct or increased weight.

[0061] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing the risk of fluid retention (edema) in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes. In some embodiments, the reduced risk of fluid retention (edema) can be measured, for example, by a decrease in Hct or an increase in weight.

[0062] In one aspect, zibotentan is provided for use in reducing total body water in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0063] In one aspect, a method for reducing total body water in a human patient in need of such treatment is provided, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises administering to the human patient i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin separately, sequentially, or simultaneously. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 CKD patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 CKD patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 CKD patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b CKD patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 CKD patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0064] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing total body water in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0065] In one aspect, zibotentan is provided for use in lowering blood pressure in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0066] In one aspect, a method of lowering blood pressure in a human patient in need of such treatment is provided, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises separate, sequential, or simultaneous administration of i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0067] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for lowering blood pressure in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0068] In one aspect, zibotentan is provided for use in reducing the risk of elevated blood pressure in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0069] In one aspect, a method is provided for reducing the risk of elevated blood pressure in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises administering to the human patient i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin separately, sequentially, or simultaneously. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0070] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing the risk of elevated blood pressure in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0071] In one aspect, zibotentan is provided for use in reducing a ≥ 40% decline in eGFR, the achievement of end-stage kidney disease (ESKD), and the incidence of a composite endpoint of cardiovascular and renal death in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0072] In one aspect, a method is provided for reducing the incidence of a ≥ 40% decline in eGFR, the achievement of end-stage kidney disease (ESKD), and a composite endpoint of cardiovascular and renal death in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises separate, sequential, or simultaneous administration of i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0073] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing a ≥ 40% decline in eGFR, the achievement of end-stage kidney disease (ESKD), and the incidence of a composite endpoint of cardiovascular and renal death in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

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

[0075] In one aspect, a method is provided for reducing the incidence of reaching end-stage kidney disease (ESKD) in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises administering to the human patient i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin separately, sequentially, or simultaneously. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0076] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing the incidence of reaching end-stage kidney disease (ESKD) in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0077] In one aspect, zibotentan is provided for use in reducing the incidence of cardiovascular or renal death in a human patient, comprising administering to the human patient, separately, sequentially, or simultaneously: i) zibotentan and ii) dapagliflozin. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In other embodiments, the human patient is a CKD human patient without type 2 diabetes.

[0078] In one aspect, a method is provided for reducing the incidence of cardiovascular or renal death in a human patient in need of such treatment, comprising administering to the human patient a therapeutically effective amount of zibotentan, wherein the treatment comprises separate, sequential, or simultaneous administration of i) a therapeutically effective amount of zibotentan and ii) a therapeutically effective amount of dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a Stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0079] In one aspect, there is provided a use of zibotentan in the manufacture of a medicament for reducing the incidence of cardiovascular or renal death in a human patient, wherein the treatment comprises separate, sequential, or simultaneous administration of i) zibotentan and ii) dapagliflozin to the human patient. In a further embodiment, the human patient is a CKD human patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 1-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3-4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 4 patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 3a or 3b patient. In a further embodiment, the human patient is a CKD human patient classified as a stage 2-3 patient. In a further embodiment, the human patient is a CKD human patient with type 2 diabetes. In another embodiment, the human patient is a CKD human patient without type 2 diabetes.

[0080] In any of the above embodiments, the methods and uses thereof may also relate to human patients receiving at least one SGLT2-I (e.g., dapagliflozin, empagliflozin, canagliflozin, etc.), alone or in combination with at least one standard of care CKD medication. In such embodiments, the standard of care CKD medication may be an ACE-I (e.g., captopril, enalapril, and lisinopril) and / or an ARB (valsartan, losartan, and irbesartan).

[0081] In any of the above aspects, the methods and uses thereof may be in relation to a baseline patient, hi some embodiments, the methods and uses thereof may be in relation to a baseline patient that is compared to a patient receiving at least one SGLT2-I alone or in combination with at least one standard of care CKD.

[0082] In one embodiment, a first pharmaceutical composition comprising zibotentan and a pharmaceutically acceptable carrier; and A second pharmaceutical composition comprising dapagliflozin and a pharmaceutically acceptable carrier. A kit is provided comprising:

[0083] Terms such as "treat" or "treatment" or "treating" or "alleviate" or "alleviating" refer to therapeutic measures that cure, slow, relieve the symptoms, and / or halt the progression of a diagnosed condition or disorder. Thus, those in need of treatment include those already diagnosed with the disorder or suspected of having the disorder. Patients or subjects in need of treatment can include those diagnosed with CKD.

[0084] A "therapeutically effective amount" or "effective amount" refers to an amount of at least one compound of the present disclosure, or a pharmaceutical composition comprising at least one such compound, that is effective to produce at least one therapeutic effect when administered to a patient as a single dose or as part of a series. Optimal doses may generally be determined using experimental models and / or clinical trials. The design and execution of preclinical and clinical studies for each of the therapeutic agents described herein (including those administered for prophylactic benefit) is well within the skill of those in the relevant art. Optimal doses of a therapeutic agent may depend on the patient's body mass, weight, and / or blood volume. Patients may generally be monitored for therapeutic effectiveness using assays suitable for the disease, disorder, and / or condition being treated or prevented, which assays will be familiar to those of skill in the art and are described herein. The level of a compound administered to a patient may be monitored by determining the level of the compound (or a metabolite of the compound) in a bodily fluid, such as blood, a blood fraction (e.g., serum), and / or urine, and / or other biological sample from the patient. Any method practiced in the art for detecting a compound or its metabolites can be used to measure compound levels during a treatment regimen. Alternatively, the pharmacological and / or physiological effect can be prophylactic, i.e., the effect completely or partially prevents a disease or its symptoms. In this regard, the disclosed methods include administering a "prophylactically effective amount" of a drug (e.g., zibotentan or a pharmaceutically acceptable salt, solvate, mixed solvate, complex, or prodrug thereof, and dapagliflozin or a pharmaceutically acceptable salt, solvate, mixed solvate, complex, or prodrug thereof). A "prophylactically effective amount" refers to an amount effective, at dosages and for periods necessary, to achieve a desired prophylactic result (e.g., prevention of CKD or disease onset).

[0085] As used herein, the terms "subject" and "patient" are used interchangeably. In some embodiments, the subject is a human.

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

[0087] The terms "administer," "administering," "administration," and the like, as used herein, refer to methods that can be used to enable delivery of drugs, such as zibotentan or a pharmaceutically acceptable salt, solvate, mixed solvate, complex, or prodrug thereof as described herein, and dapagliflozin or a pharmaceutically acceptable salt, solvate, mixed solvate, complex, or prodrug thereof. Administration techniques that can be utilized with the agents and methods described herein can be found, for example, in Goodman and Gilman, *The Pharmacological Basis of Therapeutics*, current edition, Pergamon; and Remington's, *Pharmaceutical Sciences*, current edition, Mack Publishing Co., Easton, Pa. In some embodiments, zibotentan and dapagliflozin are administered orally.

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

[0089] A "pharmaceutically acceptable carrier" refers to a non-toxic solid, semi-solid, or liquid filler, diluent, encapsulating material, formulation aid, or carrier conventional in the art for use with therapeutic agents that together comprise a "pharmaceutical composition" for administration to a subject. A pharmaceutically acceptable carrier is non-toxic to a recipient at the dosage and concentration employed and is compatible with other ingredients of the formulation. A pharmaceutically acceptable carrier is appropriate for the formulation being employed.

[0090] A "sterile" formulation is aseptic or essentially free of living microorganisms and their spores.

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

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

[0093] Whenever an embodiment is described herein with the word "comprising," it is understood that similar embodiments described with the terms "consisting of" and / or "consisting essentially of" are also provided. In this disclosure, "comprises," "comprising," "containing," and "having" and the like can mean "includes," "including," and the like; "consisting essentially of" or "consisting essentially of" is open-ended, allowing for the presence of other things than those recited, as long as the basic or novel characteristics of what is recited are not altered by the presence of other things, but excluding prior art embodiments.

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

[0095] As used herein, the terms "about" and "approximately," when used to modify a numerical value or numerical range, indicate a deviation of up to 10% above and below that value or range while remaining within the intended meaning of the recited value or range. Whenever embodiments are described herein in conjunction with the term "about" or "approximately" a certain numerical value or range, it is understood that otherwise similar embodiments that refer to that particular numerical value or range (without "about") are also provided. The present invention includes the following aspects. [Item 1] Zibotentan, N-(3-methoxy-5-methylpyrazin-2-yl)-2-[4-(1,3,4-oxadiazol-2-yl)phenyl]pyridine-3-sulfonamide, for use in treating chronic kidney disease in human patients; [ka] or a pharmaceutically acceptable salt thereof, wherein zibotentan or a pharmaceutically acceptable salt thereof is selected from the group consisting of dapagliflozin, (1S)-1,5-anhydro-1-{4-chloro-3-[(4-ethoxyphenyl)methyl]phenyl}-D-glucitol, [ka] or a pharmaceutically acceptable salt thereof, administered in combination with zibotentan, or a pharmaceutically acceptable salt thereof. [Item 2] The use according to Item 1, wherein zibotentan or a pharmaceutically acceptable salt thereof is administered once daily in combination with dapagliflozin or a pharmaceutically acceptable salt thereof. [Item 3] The use of Item 1 or 2, wherein zibotentan or a pharmaceutically acceptable salt thereof is administered once daily in combination with dapagliflozin or a pharmaceutically acceptable salt thereof at a dose of about 5 mg, and dapagliflozin is administered at a dose of 10 mg. [Item 4] The use of Item 1 or 2, wherein zibotentan or a pharmaceutically acceptable salt thereof is administered once daily in combination with dapagliflozin or a pharmaceutically acceptable salt thereof at a dose of about 1.5 mg, and dapagliflozin is administered at a dose of 10 mg. [Item 5] The use of Item 1 or 2, wherein zibotentan or a pharmaceutically acceptable salt thereof is administered once daily in combination with dapagliflozin or a pharmaceutically acceptable salt thereof at a dose of about 0.25 mg, and dapagliflozin is administered at a dose of 10 mg. [Item 6] The use according to any one of Items 1 to 5, wherein the human patient is a chronic kidney disease patient classified as a stage 1 to 4 patient with an eGFR of 20 to 60 ml / min / 1.73 m2. [Item 7] The use according to Item 6, wherein the human patient is a patient with chronic kidney disease classified as a stage 3 or 4 patient. [Item 8] The use according to Item 6, wherein the human patient is a chronic kidney disease patient classified as a stage 4 patient. [Item 9] The use according to Item 6, wherein the human patient is a chronic kidney disease patient classified as a stage 3a or 3b patient. [Example]

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

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

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

[0099] The study was divided into two experiments.

[0100] In the first experiment (Experiment 1), the effect of zibotentan on hematocrit (Hct) concentrations was determined when zibotentan was administered orally (po) QD for 14 days. Three days before the first dose of test drug, animals were randomized based on body weight (BW) into the following groups: 1) vehicle, 2) zibotentan (30 mg / kg), 3) zibotentan (100 mg / kg), and 4) zibotentan (300 mg / kg). Animals were weighed daily before dosing throughout the experiment. Blood samples (20 μL) for bioanalysis were collected from conscious animals via the tail vein 4 and 24 hours after the first dose and from anesthetized animals via the retroorbital route 24 hours after the last dose. Blood samples (100 μL) were collected via the tail vein for Hct concentration and hemoglobin (Hb) measurement 1–2 hours after dosing on days 7 and 14. Between the ninth and tenth doses, 24-hour urine was collected for measurement of urinary glucose, urine volume, and electrolytes. Animals were sacrificed 24 hours after the final dose. On the day of sacrifice, animals were anesthetized using 5% isoflurane, and blood was collected via the retroorbital route (in a heparin-coated microvette, Sarsted) and centrifuged at 3,500 rpm for 10 minutes at 4°C. Plasma was collected and stored at -80°C before analysis. Animals were then euthanized by removal of the heart. Both the heart and kidney were removed and weighed. Four-mm-thick tissue sections were collected from the right kidney and fixed in 4% formaldehyde for subsequent histological analysis. Renal cortical tissue and portions of cardiac tissue were collected for gene expression analysis.

[0101] In the second experiment (Experiment 2), the effects of zibotentan and dapagliflozin (alone or in combination) on Hct and Hb concentrations were determined. Seventy-two animals were randomized into the following groups based on BW and Hct concentrations 2–3 days before administration of the test drugs: 1) vehicle, 2) zibotentan (30 mg / kg), 3) zibotentan (100 mg / kg), 4) dapagliflozin (3 mg / kg), 5) zibotentan (30 mg / kg) + dapagliflozin (3 mg / kg), and 6) zibotentan (100 mg / kg) + dapagliflozin (3 mg / kg). For practical reasons, the study was performed in two consecutive time frames with 36 animals (6 animals / group) in each time frame. The compounds were administered poQD for 7 days. Blood samples for bioanalysis were collected 4 and 24 hours after the first dose and 24 hours after the final dose for Hct concentration and Hb analysis on days 3 and 7 as described for Experiment 1. 24-hour urine was collected between the third and fourth doses. 24-hour food and water intakes were measured between days 2 and 3 and between days 6 and 7. With two animals per cage, food and water intake per animal in a cage was estimated by dividing the cage food and water intake by two.

[0102] The investigator was blinded to the treatment assignment of the animals during terminal, blood collection and sample analysis.

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

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

[0105] Sample concentrations were determined by weighted linear regression (1 / X) using Waters TargetLynx software version XS V4.2 SCN986 2 ) were applied to matrix-spiked calibration standards over the range of 0.010 μM to 10.0 μM for dapagliflozin and 0.75 μM to 376 μM for zibotentan. Calibration sample residues showed homoscedastic distributions. Analytical bias was <15% across the concentration range for both analytes.

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

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

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

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

[0110] The lower limit of quantitation (LLOQ) was 0.010 μM and the analytical bias was <15%, except for the lowest QC-standard, which had a CV% of 13.6% and a bias of 21.0%.

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

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

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

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

[0115] Data for each measured characteristic were checked for normal distribution, and logarithmic transformation was applied to data with non-normal distributions using R, as necessary. Because data were categorized by single-factor zibotentin administration or combination therapy, one-way ANOVA was used to analyze characteristics measured at a single time point (GraphPad version 8 or the emmeans package in R statistics). Linear mixed-effects models in R (nlme package) were used to analyze data for multiple measures related to body weight. Differences between groups were tested using either Dunnett's test (emmeans package in R or GraphPad v8) when comparing treatment groups to vehicle groups or Tukey's comparison (emmeans package in R or GraphPad v8) for specific pairwise comparisons of treatment groups. All model hypotheses were confirmed using model diagnostic plots in R statistics. Results are expressed as mean ± standard error of the mean (SEM) for pharmacodynamic parameters and mean ± standard deviation (SD) for blood and urinary compound concentrations. Significance was set at p < 0.05.

[0116] result Concentrations of zibotentan above the LLOQ were measured in all blood samples collected from animals receiving zibotentan 4 or 24 hours after the first dose or 24 hours after the last dose, confirming exposure to zibotentan (Tables 1 and 2, Figures 1 and 2).

[0117] [Table 1]

[0118] [Table 2]

[0119] Dapagliflozin concentrations above the LLOQ were measured in all blood samples collected from animals receiving dapagliflozin 4 or 24 hours after the first dose or 24 hours after the last dose, confirming exposure to dapagliflozin (Figure 3, Table 2). In experiment 2, zibotentan concentrations above the LLOQ were measured in all urine samples collected overnight between days 3 and 4 from animals receiving zibotentan (Table 3), and dapagliflozin concentrations above the LLOQ were measured in all urine samples from animals receiving dapagliflozin (Table 3).

[0120] [Table 3]

[0121] In Experiment 1, quantifiable concentrations of zibotentan were detected in six of the blood samples from control animals on Day 14. The apparent zibotentan concentrations in these positive samples were at least 13-fold lower than the mean blood concentrations in the low-dose group (30 mg / kg) (highest observed (0.54 μM) in vehicle animals compared to the mean (7.39 μM) in the 30 mg / kg group). In Experiment 2, no zibotentan or dapagliflozin concentrations exceeded the LLOQ in blood samples from control animals, but zibotentan concentrations exceeding the LLOQ were detected in five of the urine samples from control animals. The amount of zibotentan excreted in urine in these samples was at least 190-fold lower than the mean amount excreted in the zibotentan-treated group (30 mg / kg zibotentan + 3 mg / kg dapagliflozin), which showed the smallest amount in urine.

[0122] In experiment 2, zibotentan blood concentrations 24 hours after the last dose were 3 to 4 times lower in the group in which zibotentan was combined with dapagliflozin compared to the group receiving zibotentan alone.

[0123] Zibotentan resulted in a significant (p<0.05) reduction in Hct concentrations compared to vehicle at all doses (30 mg / kg, 100 mg / kg, and 300 mg / kg) on ​​day 7 and at 100 mg / kg and 300 mg / kg on day 14 (Figure 4).

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

[0125] [Table 4]

[0126] Zibotentan produced significant reductions in Hb compared to vehicle at all three doses (30, 100, and 300 mg / kg) on ​​day 7 and at the two higher doses (100 and 300 mg / kg) on ​​day 14 (Table 5).

[0127] [Table 5]

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

[0129] [Table 6]

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

[0131] [Table 7]

[0132] After 14 days of zibotentan treatment, there was an increase in kidney weight with or without normalization by tibia length for the 300 mg / kg dose and an increase in heart weight for the 100 mg / kg zibotentan dose compared to vehicle, but this increase was not statistically significant after normalization by tibia length (Table 8).

[0133] [Table 8]

[0134] Hct data were analyzed using a linear mixed-effects model to estimate marginal means and standard deviations within vehicle and treatment groups, estimated overall for days 3, 7, and the entire study for post-hoc comparisons. Treatment groups were compared to vehicle to determine if there was an effect on Hct compared to the vehicle-treated control group (Dunnett's test), and zibotentan-treated groups were compared to the zibotentan + dapafliglozin group (using Tukey's test) to determine if the combination therapy attenuated the effect of zibotentan on Hct.

[0135] Baseline absolute Hct levels did not differ between groups (Figure 6A). On day 3, zibotentan (30 mg / kg and 100 mg / kg) administered with or without dapagliflozin (3 mg / kg) reduced Hct compared to vehicle (Figure 6B, Table 9A). On day 7, zibotentan (30 mg / kg and 100 mg / kg) reduced Hct compared to vehicle, and when coadministered with dapagliflozin (3 mg / kg), both doses resulted in Hct similar to vehicle (Figure 6C, Table 9B). Overall, zibotentan 100 mg / kg plus dapagliflozin had higher Hct levels than zibotentan 100 mg / kg alone (Table 9C).

[0136] [Table 9]

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

[0138] [Table 10]

[0139] [Table 11]

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

[0141] [Table 12]

[0142] Vehicle-treated animals gained weight during the treatment period, as expected, and dapagliflozin monotherapy prevented this BW gain compared to vehicle (p<0.05), whereas zibotentan alone or in combination with dapagliflozin did not (Figure 7).

[0143] Dapagliflozin increased urinary glucose excretion, while zibotentan had no effect (Figure 8A). Coadministration of zibotentan did not alter the dapagliflozin-mediated increase in urinary glucose (Figure 8A). Fluid and food intake were unchanged by zibotentan compared to vehicle. Dapagliflozin treatment increased fluid and food intake compared to vehicle, as shown in Figures 8B and 8C. Animals coadministered with dapagliflozin and zibotentan significantly increased fluid and food intake to levels similar to those observed in animals administered dapagliflozin alone compared to vehicle (Figures 8B and 8C, respectively).

[0144] [Table 13]

[0145] Plasma Na, K, glucose, and urea concentrations were unchanged by treatment with zibotentan, dapagliflozin, or their combination compared to vehicle, as shown in Table 12. Zibo (100 mg / kg) monotherapy or Zibo (100 mg / kg) in combination with Dapa (3 mg / kg) significantly increased plasma creatinine compared to vehicle (p<0.05), as shown in Table 12.

[0146] [Table 14]

[0147] Twenty-four-hour urine volume and urea excretion were increased in all dapagliflozin treatment groups with or without coadministration of zibotentan. No differences were observed in the zibotentan monotherapy group compared to vehicle. As shown in Table 13, no changes in Na, K, and creatinine were observed in any of the treatment groups compared to vehicle.

[0148] [Table 15]

[0149] After 7 days of treatment, kidney weights were increased in the Zibo 100 mg / kg + Dapa 3 mg / kg group compared to vehicle, and heart weights were increased in the Zibo 30 mg / kg group compared to vehicle alone, with or without normalization to tibia length, as shown in Table 14.

[0150] [Table 16]

[0151] The endothelial receptor A antagonist, zibotentan, significantly reduced Hct concentrations in male Wistar rats fed a 4% salt diet. Coadministration of the SGLT-2 inhibitor dapagliflozin for 7 days significantly reduced the effect of zibotentan on Hct concentrations. Dapagliflozin attenuates zibotentan-induced fluid retention (hematocrit) reduction in rats.

[0152] Example 2 The effect of dapagliflozin on albuminuria was examined in patients with CKD with or without type 2 diabetes. In this analysis from the Phase 3 DAPA CKD clinical trial, the efficacy of dapagliflozin was evaluated to determine whether treatment with dapagliflozin reduces the level of albuminuria in patients with CKD.

[0153] In this clinical trial, the estimated glomerular filtration rate was 25-75 mL / min / 1·73 m 2A total of 4304 patients with a urinary UACR of 200 to 5000 mg / g were randomized to dapagliflozin (10 mg) or placebo. Changes in albuminuria were assessed as the mean change in log-transformed UACR from baseline to the end of the study. UACR stage regression, defined as a transition from macroalbuminuria (≥ 300 mg / g) to microalbuminuria or negative microalbuminuria (< 300 mg / g), and UACR stage progression, defined as a transition from < 3000 mg / g to ≥ 3000 mg / g, were additional endpoints.

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

[0155] Among 3,860 patients with a baseline UACR of ≥ 300 mg / g, dapagliflozin increased the likelihood of UACR stage regression (hazard ratio [HR] 1.81; 95% CI, 1.60-2.05). Among 3,820 patients with a baseline UACR of < 3,000 mg / g, dapagliflozin reduced the risk of UACR stage progression (HR 0.41; 95% CI, 0.32-0.52). Albuminuria regression and progression were further stratified by diabetes status and are shown in Figures 9 and 10. As demonstrated by this analysis, treatment with dapagliflozin reduced UACR in patients with CKD, regardless of diabetes status.

[0156] Example 3 Preclinical studies of dapagliflozin in combination with zibotentan are underway to demonstrate the effects of the single agents and the combination on certain biomarkers indicative of renal and cardiovascular function in male Dahl salt-sensitive (DSS) rats.

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

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

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

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

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

[0162] [Table 17]

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

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

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

[0166] Study design The study will be conducted in two parts, Part A and Part B. In both study parts, participants will be randomized to 12 weeks of treatment and 2 weeks of follow-up. All variables will be collected to verify the inclusion criteria and additional demographic data such as race / ethnicity, serum creatinine, and height. All analyses (except for the interim analysis during Part A) will include data from both parts of the study.

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

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

[0169] An interim analysis of Part A data will be performed when approximately 30 participants in each arm (120 participants) have completed 6 weeks of treatment to evaluate changes in fluid-related measures (weight gain or BNP). If fluid-related measures meet specified criteria in at least 5 participants in the zibotentan 5 mg monotherapy arm, this arm will be discontinued from the remaining intervention period of the study.

[0170] If the specified discontinuation criteria for the zibotentan 5 mg monotherapy arm are not met at the week 6 interim analysis, the available Part A data will be subjected to a second interim analysis to evaluate changes in fluid-related measures when all randomized Part A participants complete 12 weeks of treatment. If fluid-related measures meet the specified criteria in at least five participants in the zibotentan 5 mg monotherapy arm at the second interim analysis (week 12 of treatment), this arm will be discontinued for the remainder of the intervention period of the study.

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

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

[0173] Participants will be stratified by diabetes (DKD vs. non-DM CKD) and baseline eGFR (< vs. >45 mL / min / 1.73 m2) at randomization to ensure approximate balance between treatment groups within each subpopulation. The number of randomized participants in each stratum will be monitored to ensure the non-DM CKD subpopulation represents a minimum of approximately 30% and a maximum of approximately 33% of the total number of randomized participants.

[0174] For each participant, the overall duration of participation will be approximately 17-19 weeks. In each study part, the screening period may be up to 4 weeks prior to randomization. The first dose will be taken after randomization at the baseline visit on Day 1. In addition to the baseline visit, participants will visit the clinic five times during the following 12 weeks of treatment. Approximately two weeks after the last dose, participants will return to the clinic for a follow-up assessment.

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

[0176] [Table 18]

[0177] [Table 19]

Claims

1. 1. A medicament for the treatment of chronic kidney disease in a human patient, comprising zibotentan, wherein zibotentan is administered in combination with dapagliflozin.

2. The pharmaceutical composition of claim 1, wherein zibotentan is administered once daily in combination with dapagliflozin.

3. 3. The pharmaceutical composition according to claim 1, wherein zibotentan is administered once daily in combination with dapagliflozin at a dose of about 5 mg, and dapagliflozin is administered at a dose of 10 mg.

4. 3. The pharmaceutical composition according to claim 1, wherein zibotentan is administered once daily in combination with dapagliflozin at a dose of about 1.5 mg, and dapagliflozin is administered at a dose of 10 mg.

5. 3. The pharmaceutical composition according to claim 1, wherein zibotentan is administered once daily in combination with dapagliflozin at a dose of about 0.25 mg, and dapagliflozin is administered at a dose of 10 mg.

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

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

8. The method of claim 6, wherein the human patient is a chronic kidney disease patient classified as a stage 4 patient.

9. The method of claim 6, wherein the human patient is a chronic kidney disease patient classified as a stage 3a or 3b patient.

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