Treatment and diagnosis of chronic inflammatory conditions in the lower urinary tract

Abstract

A method for treating a chronic inflammatory condition in the lower urinary tract is provided, comprising administering to a patient in need thereof an effective amount of a reagent selected from the group consisting of an IL-1β inhibitor and an MMP inhibitor, or a protein selected from ASC or NLRP-3. Diagnostic methods are also described and claimed. The present disclosure further relates to an IL-1 inhibitor for use in a method for treating, alleviating, or reducing pain and pain-related symptoms of chronic pelvic pain syndrome. The IL-1 inhibitor may be an IL-1 receptor antagonist. The IL-1 inhibitor may be anakinra. The chronic pelvic pain syndrome may be urinary pain syndrome, external genital gynecological pain syndrome, internal pelvic pain syndrome, or gastrointestinal pelvic pain syndrome.

Description

[Technical Field]

[0001] The present invention relates to methods for treating chronic inflammatory conditions and chronic pain in the lower urinary tract, and compositions for use in these therapies and related diagnostic methods. In particular, the present invention relates to IL-1 inhibitors for use in methods for treating, alleviating, or reducing pain and pain-related symptoms of chronic pelvic pain syndrome. [Background technology]

[0002] Chronic inflammatory conditions affect the bladder and lower abdomen. Bladder pain is often caused by acute infection, but in certain individuals, chronic pain may allow the absence of infection. Therefore, antibiotic therapy is not particularly useful for treating such conditions. Chronic cystitis (also known as interstitial cystitis (IC), bladder pain, or bladder pain syndrome) may be accompanied by epithelial erosion or chronic pain without obvious macroscopic inflammation. Chronic cystitis and bladder pain may be isolated conditions or part of a more complex condition that works together with inflammatory processes in the prostate and urethra (prostatitis and urethritis), all of which are included in chronic pelvic pain syndrome (CPPS).

[0003] Chronic pelvic pain (CPP) is defined by the European Association of Urology (EAU Guidelines on Chronic Pelvic Pain, 2019) as chronic or persistent pain perceived in structures related to the pelvis in both men and women. It is often associated with negative cognitive, behavioral, sexual, and emotional consequences, as well as symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, or gynecological dysfunction. Perception indicates that the patient and clinician have, to the best of their ability, localized the pain from history, examination, and investigations (when appropriate) as identified in the designated anatomical pelvic region.

[0004] Chronic pelvic pain can be subdivided into conditions with a clearly defined classical pathology (such as infection or cancer) and conditions without obvious pathology. The EUA proposes the term "pelvic pain associated with a specific disease" for the former and "chronic pelvic pain syndrome" (CPPS) for the latter.

[0005] Chronic pelvic pain syndrome is the occurrence of CPP in the absence of proven infection or other obvious local pathology that could explain the pain. It is often associated with negative cognitive, behavioral, sexual, or emotional consequences, as well as symptoms suggestive of lower urinary tract, sexual, bowel, or gynecological dysfunction. Chronic pelvic pain syndrome is a subcategory of CPP.

[0006] Pain perception in CPPS may be localized within a single organ, affect multiple pelvic organs, or even be associated with systemic conditions such as chronic fatigue syndrome (CFS), fibromyalgia (FM), or Sjögren's syndrome. When pain is localized to a single organ, some experts may wish to consider using end-organ terminology, such as bladder pain syndrome, prostate pain syndrome, or urethral pain syndrome. The use of such phrases with the term "syndrome" indicates that while peripheral mechanisms may exist, CNS neuromodulation may be more important and systemic involvement may occur. The EAU recommends that the term CPPS should be used when pain is localized to multiple organ sites. Many prefer not to subcategory by anatomy, but to refer to patients with perceived pain in the pelvis and no specific disease process as suffering from CPPS, subdivided by psychological and functional symptoms.

[0007] Treatment or management of CPPS includes conservative management and pharmacological management. Conservative management includes pain education, physical therapy, acupuncture, and psychotherapy. Pharmacological management includes the administration of anti-inflammatory drugs, alpha-blockers, antibiotic therapy (although CPPS is defined as chronic pelvic pain without proven infection), and analgesics, including morphine. Some patients have been shown to respond positively to various herbal medicines. Additionally, for example, antiepileptic drugs, muscle relaxants, and botulinum toxin type A have been tested, with inconclusive results. Many of the above-mentioned pharmacological management agents produce problematic side effects.

[0008] The molecular basis of CPPS, cystitis, and bladder pain remains a mystery. Chronic bladder inflammation can cause debilitating pain, urinary frequency and urgency, and in some cases is accompanied by bladder ulceration (interstitial cystitis), urethritis, or prostatitis. Numerous therapeutic approaches have been tested, but apart from the use of antibiotics and painkillers to treat infection, therapeutic success has been limited, and patients are often severely disabled. Summary of the Invention [Problem to be solved by the invention]

[0009] Specific treatments are currently lacking, and patients are often offered pain management, which often includes opiates due to the severity of the clinical condition.

[0010] There is a need for treatments for CPPS and other chronic inflammatory conditions of the lower urinary tract. [Means for solving the problem]

[0011] The present applicants have made the surprising discovery that in experimental animal models, chronic inflammatory conditions and pain in the lower urinary tract respond dramatically to treatments that inhibit IL-1 activity. Thus, the present applicants have identified that such conditions can be treated with agents such as interleukin-1 receptor antagonists and MMP inhibitors, as well as NK1R inhibitors. The effects of IL-1 inhibition have recently been confirmed in human clinical trials.

[0012] The present applicants have previously identified a novel mechanism of IL-1β activation in the bladder mucosa that involves the metalloproteinase MMP-7 in MMP-7-dependent processing and MMP-7 overexpression (WO2016 / 110818). - / - and Nlrp3 - / - This may be explained by a direct effect of ASC and NLPR-3 on the MMP7 promoter, leading to derepression of Mmp7 expression in mice. Consequently, we found that treatment of Asc- / - mice with immunomodulation using metalloproteinase inhibitors appears to reduce IL-1β levels.

[0013] IL-1β is a potent proinflammatory cytokine that initiates and amplifies innate immune responses. IL-1β production increases in response to viral, bacterial, fungal, and parasitic infections, and IL-1β is essential for defense against microbial attack. However, IL-1β responses can also be harmful, and dysregulation of IL-1β has been observed in autoimmune and autoinflammatory disorders such as rheumatoid arthritis, multiple sclerosis, Crohn's disease, or neurodegenerative diseases.

[0014] The NLRP-3 inflammasome is activated by several microbial stimuli, including LPS, MDP, bacterial RNA, poly(I:C), as well as ATP and bacterial pore-forming toxins. NLRP-3 activation stimulates the binding of ASC through its homotypic pyrin domain, and the caspase recruitment domain of ASC acts as an adaptor that connects NLRP-3 to procaspase-1 to form the inflammasome. As previously shown (WO 2016 / 110818), dysfunctional ASC or NLRP-3 proteins can have downstream effects, elevating IL-1β levels and causing or exacerbating conditions involving IL-1β, such as chronic inflammatory conditions in the lower urinary tract.

[0015] Proteolytic cleavage by MMP-7 was previously identified as a novel mechanism for IL-1β processing, and evidence for IL-1β fragmentation by MMP-7 was obtained by direct in vitro cleavage of purified components. MMP-7 possesses metalloendopeptidase activity and is known to degrade collagen, proteoglycans, fibronectin, elastin, and casein. MMP7 is activated following cellular stimulation with TNF-α or IL-1β. It is generally expressed in epithelial cells and has been shown to regulate defensin activity in the intestinal mucosa. Fragmentation of IL-1β by MMP-7 generates the active form of IL-1β; therefore, MMP inhibition represents an alternative route for the treatment of chronic inflammatory conditions in the lower urinary tract.

[0016] The present invention provides agents that modulate the IL-1 pathway for use in the treatment of chronic inflammatory conditions in the lower urinary tract, such as chronic pelvic pain syndrome.

[0017] An agent that modulates the IL-1 pathway is an agent that modulates the activity of any gene, protein, or other aspect of the pathway involved in IL-1 production, or the binding of IL-1 to its receptor or the effect of IL-1 binding to its receptor. This particularly refers to an agent that reduces IL-1 production, binding, or effect. For example, it can be an agent that reduces IL-1 production. Alternatively, it can be an agent that affects how IL-1 binds to its receptor, particularly reducing receptor binding. Alternatively, it can be an agent that prevents the effect of IL-1 binding to its receptor at any point along the pathway. For example, an agent can affect the IL-1 pathway through the interaction of IL1A, IL1B, IL1RN, IL1R1, NLRP3, PYCARD, MMP7, TAC1, and TACR1, or their products, or the receptors of these products.

[0018] In particular, the present invention provides one or more agents selected from an IL-1 inhibitor, an MMP inhibitor, and an NK1 inhibitor, or a pharmaceutical composition comprising said one or more agents, for use in treating chronic inflammatory conditions in the lower urinary tract. The present invention further provides one or more agents selected from an IL-1 inhibitor, an MMP inhibitor, and an NK1 inhibitor, or a pharmaceutical composition comprising said one or more agents, for use in treating CPPS, particularly in treating, alleviating, or reducing pain and pain-related symptoms of CPPS.

[0019] An IL-1 inhibitor is any agent that inhibits or reduces IL-1 activity. For example, it can be a compound or composition that regulates the production of IL-1 or interacts with IL-1 itself or the IL-1 receptor (IL-1R). In one embodiment, it is an IL-1R antagonist. IL-1R antagonists include small molecules such as anthraquinones, including diacerein, as described in U.S. Pat. No. 4,244,968, proteins and peptides, such as interleukin-1 receptor antagonists (IL-1 RA), including anakinra and rilonacept, as described in U.S. Pat. No. 5,075,222, or pharmaceutically acceptable salts thereof, or prodrugs or functional fragments thereof, and compounds that function in the same manner as those listed.

[0020] In one embodiment, the IL-1 inhibitor may be selected from anakinra, canakinumab, and diacerein. In a specific embodiment, the IL-1 inhibitor is anakinra. The drug anakinra is an interleukin-1 receptor antagonist (r-metHuIL-1ra) produced in Escherichia coli cells. It is a recombinant, slightly modified version of the human interleukin-1 receptor antagonist protein, which is part of a feedback loop that balances the effects of cytokine-induced inflammation. Anakinra is used in the treatment of Still's disease and in combination with methotrexate to manage the symptoms of rheumatoid arthritis. Anakinra has also been suggested for use in the treatment of acute cystitis, i.e., bacterial infection of the bladder (WO2016 / 110818).

[0021] In particular, the IL-1 inhibitor is an IL-1β inhibitor.

[0022] In a preferred embodiment, the interleukin-1 receptor antagonist is anakinra or a functional fragment or variant thereof.

[0023] MMP inhibitors are compounds or compositions that inhibit or reduce the activity of MMP.For example, they can be compounds or compositions that regulate the production of MMP, or interact with MMP itself, or with the region or receptor that MMP interacts with.In certain embodiments, MMP inhibitors are MMP7 inhibitors.In one embodiment, they are agents that regulate MMP, particularly MMP7, to cause the concentration or activation of IL-1, particularly IL-1β.

[0024] A wide range of MMP inhibitors are known, as described, for example, in Durrant et al., Chem. Biol. Drug Des. 2011, No. 78, pp. 191-198, the contents of which are incorporated herein by reference. Specific examples include batimastat, periostat (doxycycline hyclate), marimastat, or salts or prodrugs thereof, especially batimastat.

[0025] NK1 inhibitor is a drug that inhibits or reduces the activity of NK1.For example, NK1 inhibitor can be a compound or composition that regulates the production of NK1 or interacts with NK1 itself or NK1 receptor (NK1R).In one embodiment, it is an NK1R inhibitor or antagonist.An example of NK1R antagonist is provided in WO2018 / 007920.

[0026] The agents may be used alone or in combination with each other or other active agents.

[0027] The medicament may be for use in treating humans.

[0028] Chronic inflammatory conditions in the lower urinary tract include, for example, chronic cystitis, chronic pelvic pain syndrome, and / or bladder-associated pelvic pain.

[0029] The chronic pelvic pain syndrome may be a urinary pain syndrome, an external genital gynecological pain syndrome, an internal pelvic pain syndrome, or a gastrointestinal pelvic pain syndrome. Specifically, the chronic pelvic pain syndrome may be a prostate pain syndrome, a bladder pain syndrome, or a urethral pain syndrome.

[0030] In particular, pelvic pain excludes pelvic pain occurring in conjunction with acute infection (acute cystitis). In one embodiment, the present invention relates to the treatment, alleviation, and reduction of pain and pain-related symptoms in subjects suffering from chronic pelvic pain syndrome, i.e., chronic pelvic pain in the absence of proven infection and other obvious local pathology. More specifically, the subject is a human. Treatment of CPPS according to the present disclosure aims to reduce pain and increase the subject's quality of life.

[0031] According to further embodiments, the chronic pelvic pain syndrome is selected from urinary pain syndromes, external genital gynecological pain syndromes, internal pelvic pain syndromes, and gastrointestinal pelvic pain syndromes.

[0032] According to a further embodiment, the urinary pain syndrome is selected from prostate pain syndrome, bladder pain syndrome, scrotal pain syndrome, testicular pain syndrome, epididymal pain syndrome, penile pain syndrome, urethral pain syndrome, and post-vasectomy scrotal pain syndrome.

[0033] Prostatic pain syndrome (PPS) is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of persistent or recurrent episodic pain (convincingly reproduced by prostate palpation) in the absence of proven infection or other obvious local pathology. Other commonly used terms for PPS, although not considered appropriate by the EUA, are chronic prostatitis and prostadynia.

[0034] Bladder pain syndrome (BPS) is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of persistent or recurrent pain perceived in the bladder area, accompanied by at least one other symptom, such as pain worsening with bladder filling and daytime and / or nocturnal urinary frequency, in the absence of proven infection or other obvious local pathology. Other terms that were used, but are no longer recommended, include interstitial cystitis, painful bladder syndrome, and PBS / IC or BPS / IC. In the case of CPPS with bladder pain, or BPS, several theories of etiology have been proposed, including a deficiency of glycosaminoglycans (GAGs) covering the urothelial surface leading to leaky urothelial infection, immunological etiology, activated mast cells, neural changes, and inflammation (Rourke et al., 2014). For example, intravesical treatment with solutions of dimethyl sulfoxide (DMSO), sodium hyaluronate (HA), and chondroitin sulfate (CS) has been used to replenish the GAG ​​layer, but with variable and largely unreliable results. In one embodiment, the agent is a treatment for BPS.

[0035] Scrotal pain syndrome (SPS) is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of persistent or recurrent episodic pain localized within the scrotal organs, which may be associated with symptoms suggestive of lower urinary tract or sexual dysfunction. There is no proven infection or other obvious local pathology. Scrotal pain syndrome is a generic term used when it is unclear whether the pain is located in the testis or epididymis.

[0036] Testicular pain syndrome (TPS) is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of persistent or recurrent episodic pain perceived in the testicles, which may be associated with symptoms suggestive of lower urinary tract or sexual dysfunction. There is no proven infection or other obvious local pathology. Other terms that were used, but are no longer recommended, include orchitis, orchialgia, and orchiodynia.

[0037] Epididymal pain syndrome (EPS) is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of persistent or recurrent episodic pain perceived in the epididymis, which may be associated with symptoms suggestive of lower urinary tract or sexual dysfunction, in the absence of proven infection or other obvious local pathology.

[0038] Penile pain syndrome (PPS) is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of pain primarily within the penis, but not in the urethra, in the absence of proven infection or other obvious local pathology.

[0039] Urethral pain syndrome (UPS) is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of chronic or recurrent episodic pain perceived in the urethra in the absence of proven infection or other obvious local pathology. UPS can occur in both men and women.

[0040] Post-vasectomy scrotal pain syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as scrotal pain syndrome following vasectomy. Post-vasectomy pain may occur in as many as 1% of men after vasectomy, and may be more prevalent in some cases. The mechanisms are poorly understood, and therefore, this is considered a special form of scrotal pain syndrome.

[0041] According to another embodiment, said urinary pain syndrome is selected from prostate pain syndrome, bladder pain syndrome, and urethral pain syndrome.

[0042] In another embodiment, the bladder pain syndrome is bladder pain syndrome type 3c. Bladder pain syndrome (BPS) type 3c is a subtype of BPS in combination with primary inflammatory lesions or inflammatory lesions in the bladder (Hunner's ulcer formation).

[0043] Patients with BPS3c are at increased risk of bladder contractions. Surgery using lesion excision or coagulation can provide longer-term pain relief, but if refractory to treatment, surgical removal of the bladder (cystectomy) combined with urinary diversion can be performed as a last-ditch treatment option.

[0044] Therefore, pharmaceutical treatment of BPS3c type according to the present disclosure has the advantage that surgical treatment can be avoided.

[0045] Furthermore, the bladder pain syndrome may be bladder pain syndrome without Hunner's ulcer (BPS).

[0046] According to another embodiment, said external genital gynecological pain syndrome is selected from vulvodynia syndrome, generalized vulvodynia syndrome, localized vulvodynia syndrome, vestibulodynia syndrome, and clitoral pain syndrome.

[0047] Vulvodynia syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of persistent or recurrent episodic vulvar pain in the absence of proven infection or other localized overt pathology. Another term used for this condition is vulvodynia.

[0048] According to the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019), generalized vulvodynia syndrome refers to a vulvar pain syndrome in which pain / burning pain cannot be consistently and accurately localized by pressure point mapping, which involves probing with a cotton-tipped applicator or similar device. Rather, the pain is diffuse and affects all parts of the vulva. The vulvar vestibule (the area between the labia minora (where the urethral and vaginal openings open)) may be involved, but discomfort is not limited to the vestibule. Previous terms, which are no longer recommended, include "vulvodynia paresthesia" and "essential vulvodynia."

[0049] Localized vulvodynia syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as pain that can be consistently and accurately localized by pressure point mapping to one or more parts of the vulva. Clinically, the pain usually occurs as a result of inhalation provocation (touch, pressure, or friction). Localized vulvodynia syndrome can be subdivided into vestibulodynia syndrome and clitoral pain syndrome.

[0050] Vestibular pain syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as pain that can be localized by vestibular pressure point mapping or is well perceived in the vestibular region.

[0051] Clitoral pain syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as pain that can be localized by pressure point mapping to the clitoris or that is well-perceived in the area of ​​the clitoris.

[0052] According to another embodiment, said internal pelvic pain syndrome is selected from endometriosis-associated pain syndrome, chronic pelvic pain syndrome with cyclical exacerbations, and dysmenorrhea.

[0053] Endometriosis-associated pain syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as chronic or recurrent pelvic pain in patients with laparoscopically confirmed endometriosis, and this term is used when symptoms persist despite adequate endometriosis treatment.

[0054] According to the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019), chronic pelvic pain syndromes with cyclical exacerbations encompass non-gynecological visceral pain (e.g., IBS or BPS) that frequently exhibit cyclical exacerbations, and pain similar to that associated with endometriosis / adenomyosis but without identified pathology. This condition differs from dysmenorrhea, in which pain is present only with menstruation.

[0055] Dysmenorrhea is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as pain associated with menstruation that is not associated with a clearly defined pathology. Dysmenorrhea should be considered a chronic pain syndrome if it is persistent and associated with negative cognitive, behavioral, sexual, or emotional consequences.

[0056] According to another embodiment, said gastrointestinal pelvic pain syndrome is selected from irritable bowel syndrome, chronic anal pain syndrome, and intermittent chronic anal pain syndrome.

[0057] Irritable bowel syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of chronic or recurrent episodic pain perceived in the bowel in the absence of proven infection or other obvious local pathology. Bowel dysfunction is frequent.

[0058] Chronic anal pain syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as the occurrence of chronic or recurrent episodic pain perceived in the anus in the absence of proven infection or other obvious local pathology.

[0059] Intermittent chronic anal pain syndrome is defined by the EAU (EAU Guidelines on Chronic Pelvic Pain, 2019) as severe, brief, episodic pain occurring at irregular intervals that appears to originate in the rectum or anal canal. It is unrelated to the urge or process of defecation. It can be considered a subgroup of chronic anal pain syndrome. Previous terms, no longer recommended, include transient rectal neuralgia.

[0060] Treating may refer to the reduction or alleviation of pain, which may also or alternatively refer to the reduction or alleviation of symptoms such as inflammation.

[0061] The present invention further provides a method for treating chronic inflammatory conditions in the lower urinary tract, particularly CPPS, comprising administering to a subject in need thereof an agent that modulates the IL-1 pathway, such as one or more agents selected from an IL-1 inhibitor, an MMP inhibitor, and an NK1 inhibitor, or a pharmaceutical composition comprising said one or more agents.

[0062] In one embodiment, the present invention provides a method of treating a chronic inflammatory condition in the lower urinary tract, comprising administering to a patient in need thereof an effective amount of an agent selected from the group consisting of an interleukin-1 receptor antagonist and an MMP inhibitor.

[0063] The present invention also provides methods for treating, alleviating, or reducing pain and pain-related symptoms of chronic pelvic pain syndrome in a subject, comprising administering to a subject in need thereof an agent that modulates the IL-1 pathway, particularly an IL-1 inhibitor.

[0064] For administration to a patient, the drug, reagent, or protein is suitably administered in the form of a pharmaceutical composition further comprising a pharmaceutically acceptable carrier, such compositions being known in the art.

[0065] Suitable pharmaceutical compositions are either in solid or liquid form. They can be adapted for administration by any convenient route, such as parenteral, oral, or topical administration, or for administration by inhalation or insufflation. Pharmaceutically acceptable carriers can include diluents or excipients that are physiologically tolerated and compatible with the active ingredient.

[0066] Parenteral compositions are prepared for injection, for example, either subcutaneously or intravenously. They can be liquid solutions or suspensions, or they can be in a solid form suitable for solution or suspension in liquid prior to injection. Suitable diluents and excipients are, for example, water, saline, dextrose, glycerol, and the like, and combinations thereof. In addition, if desired, the composition can contain minor amounts of auxiliary substances, such as wetting or emulsifying agents, stabilizers, or pH buffering agents.

[0067] In one embodiment the medicament, in particular the IL-1 inhibitor, is for administration by subcutaneous injection, intravenous injection, intramuscular injection, in particular subcutaneous injection.

[0068] Oral preparations may be in solid or liquid form, such as solutions, syrups, suspensions, tablets, pills, capsules, sustained-release formulations, or powders. Oral preparations may contain commonly used excipients, such as pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharin, cellulose, magnesium carbonate, and the like.

[0069] Topical formulations typically take the form of a suppository or nasal aerosol. For suppositories, traditional binders and excipients may include, for example, polyalkylene glycols or triglycerides, and such suppositories may be formed from a mixture containing the active ingredient.

[0070] The amount of reagent administered will vary in accordance with normal clinical practice, depending on factors such as the nature of the reagent used, the size and health of the patient, the nature of the condition being treated, etc. Typically, doses in the range of 1 μg to 50 mg / Kg, e.g., 2 to 20 mg / Kg, e.g., 5 to 15 mg / Kg, are expected to produce suitable effects.

[0071] In certain embodiments, when the agent is an IL-1 inhibitor, it may be for administration at a dose of 1 to 8 mg / kg body weight, preferably 1 to 4 mg / kg body weight, and more preferably 1 to 2 mg / kg body weight.

[0072] The IL-1 inhibitor may be for administration at a dose of 75 to 600 mg / dose, preferably 75 to 300 mg / dose, more preferably 75 to 150 mg / dose.

[0073] The IL-1 inhibitor may be for administration at a dose of 100 mg / dose.

[0074] The dose may be adjusted if the patient is overweight or underweight, so that an overweight patient may receive a dose higher than 100 mg, and an underweight person may receive a dose lower than 100 mg.

[0075] According to another embodiment, the IL-1 inhibitor is for administration at intervals of 24 hours to 6 months, preferably 48 hours to 2 months, more preferably 72 hours to 1 month.

[0076] Importantly, the specific time interval between administrations of the IL1-inhibitor will be determined for each patient depending on the specific condition, pain intensity, and effect of the IL1-inhibitor.

[0077] The IL-1 inhibitor may be administered once daily. If administered once daily, the IL-1 inhibitor is preferably administered at approximately the same time each day. The IL-1 inhibitor may be administered at 24-hour intervals.

[0078] The IL-1 inhibitor may be for administration once or twice a week.

[0079] The IL-1 inhibitor may be for administration at intervals of 1 to 3 weeks.

[0080] The IL-1 inhibitor may be for administration at intervals of 1 to 6 months, such as 2 to 5 months or 3 to 4 months.

[0081] Furthermore, according to another embodiment, the IL-1 inhibitor is for on-demand administration. Thus, the IL-1 inhibitor can be for administration when the patient needs it. Some patients may require more frequent and / or regular administration of the IL-1 inhibitor, while other patients may require on-demand administration of the IL-1 inhibitor when other methods of pain management are not possible.

[0082] The level of substance P in urine is elevated in patients suffering from chronic inflammatory conditions and pain in the lower urinary tract, and therefore this molecule serves as a diagnostic biomarker for pain.Therefore, the present invention further provides a method for diagnosing chronic inflammatory conditions in the lower urinary tract, comprising detecting elevated levels of substance P in the urine of a subject.Suitable detection methods are known in the art, including ELISA.This method is particularly useful for diagnosing BPS.

[0083] In a further aspect, the present invention provides a method for diagnosing a susceptibility to chronic inflammatory conditions and pain in the lower urinary tract, comprising detecting substance P in a urine sample obtained or obtainable from a subject, or detecting a mutation in a gene encoding a protein selected from ASC or NLRP-3 in a sample obtained or obtainable from a subject, which causes the downregulation of the gene and / or the expression of an inactive protein.Any suitable sample, such as blood, urine, or saliva sample, or buccal swab, can be used to identify gene mutations.As previously demonstrated by the applicants in WO2016 / 110818, the absence of these proteins leads to an increased susceptibility to IL-1β-mediated conditions, and chronic inflammatory conditions and pain in the lower urinary tract are herein identified as IL-1β-mediated conditions.

[0084] Diagnosis may be performed at the genetic level, where the Asc and / or Nlrp-3 sequences are determined in whole or in part and compared with the normal gene. For example, common mutation sites that result in inactivation or downregulation of the ASC or NLRP-3 protein may be analyzed, and the presence or absence of selected mutations may be used to assess the likelihood that a patient is susceptible to cystitis.

[0085] Alternatively, diagnosis may be performed at the protein level, where a suitable sample from a subject, such as a blood, serum, plasma, or urine sample, is analyzed for the presence of active substance P or ASC or NLRP-3 protein. Suitable methods in this case may include immunochemical assays such as ELISA, which use antibodies specific for the target protein.

[0086] Once diagnosed, administration of the protein or a functional equivalent thereof to the subject is expected to prevent or treat the disease. Thus, in a further aspect, the present invention provides a method for preventing or treating a chronic inflammatory condition in the lower urinary tract in a patient susceptible to such a condition as a result of a mutation affecting the expression of functional ASC or NLRP-3, comprising administering to said patient a protein selected from ASC or NLRP-3, or a functional fragment or variant thereof, or administering an effective amount of a reagent selected from the group consisting of an interleukin-1 receptor antagonist and an MMP inhibitor.

[0087] In a further aspect, the present invention provides a protein selected from ASC or NLRP-3, or a functional fragment or variant thereof, for use in treating a patient suffering from or susceptible to a chronic inflammatory condition in the lower urinary tract as a result of a mutation affecting expression of functional ASC or NLRP-3, respectively.

[0088] The present inventors have also surprisingly identified a further potential genetic basis for chronic pelvic pain syndromes, particularly chronic cystitis.

[0089] Thus, there is provided a method for diagnosing chronic pelvic pain syndrome, which comprises identifying one or more mutations in an IL-1 related gene in a sample obtained from a subject when compared to a predicted sequence, the presence of the mutations being indicative of the presence of or predisposition to chronic pelvic pain syndrome, in particular an increased predisposition thereto.

[0090] By expected sequence is meant the gene sequence found in the majority of the population to which the subject belongs.

[0091] The method can include identifying multiple mutations, for example, 2, 3, 4, 5, 6, 7, 8, 9, or more mutations.

[0092] The IL-1 related gene can be any gene involved in the IL-1 pathway, for example, IL1A, IL1B, IL1RN, IL1R1, NLRP3, PYCARD, MMP7, TAC1, and TACR1.

[0093] In one embodiment, the IL-1 related gene is IL1A, in another embodiment, the IL-1 related gene is IL1B, in another embodiment, the IL-1 related gene is IL1RN, in another embodiment, the IL-1 related gene is IL1R1, in another embodiment, the IL-1 related gene is NLRP3, in another embodiment, the IL-1 related gene is PYCARD, in another embodiment, the IL-1 related gene is MMP7, in another embodiment, the IL-1 related gene is TAC1, and in another embodiment, the IL-1 related gene is TACR1.

[0094] Where the method includes identifying multiple mutations, the second and / or additional mutations can be in any IL-1 related gene. In one embodiment, the IL-1 related gene is IL1A, in another embodiment, the IL-1 related gene is IL1B, in another embodiment, the IL-1 related gene is IL1RN, in another embodiment, the IL-1 related gene is IL1R1, in another embodiment, the IL-1 related gene is NLRP3, in another embodiment, the IL-1 related gene is PYCARD, in another embodiment, the IL-1 related gene is MMP7, in another embodiment, the IL-1 related gene is TAC1, and in another embodiment, the IL-1 related gene is TACR1.

[0095] In one embodiment, the method comprises identifying two or more, particularly three or more, mutations in the IL1RN gene.

[0096] In certain embodiments, the mutation is a single nucleotide polymorphism, or SNP.

[0097] In one embodiment, the method comprises identifying mutations in at least one, at least two, or at least three, at least four, or at least five of rs113540343 (IL1A), rs4251972 (IL1RN) and rs10754558 (NLRP3), rs145268073 (NLRP3), and rs45507693 (IL1RN).

[0098] The sample can be any sample on which a genetic analysis can be performed, such as saliva, blood, or urine.

[0099] In the diagnostic method, as in other aspects of the invention, the chronic pelvic pain syndrome may be selected from urinary pain syndrome, external genitalia gynecological pain syndrome, internal pelvic pain syndrome, and gastroenterological pelvic pain syndrome, which may further be as defined in other aspects of the invention.

[0100] The method may also include treating a subject identified by the steps of the method as having or predisposed to chronic pelvic pain syndrome. Treatment may include administering an IL1 inhibitor as previously defined. This may also, or alternatively, include administering a compound or composition that corrects or modulates the effects of the mutation in other ways.

[0101] In the methods of treatment or medical use provided by the present invention, the subject may be a subject carrying at least one mutation in an IL-1 related gene as previously defined.

[0102] As used herein, the expressions "fragment" and "active fragment" refer to a peptide or protein that lacks one or more amino acids found in the full-length protein, yet still possesses the function of the full-length protein.

[0103] As used herein, the expressions "variant" and "active fragment" refer to peptide sequences whose amino acid sequence differs from that of the base protein or peptide sequence in that one or more amino acids in the sequence have been replaced with other amino acids, but the variant produces a biological effect similar to that of the base sequence.

[0104] Amino acid substitutions may be considered "conservative" when an amino acid is replaced with a different amino acid within the same class that has broadly similar properties. Non-conservative substitutions are when an amino acid is replaced with an amino acid of a different type or class.

[0105] The amino acid classes are defined as follows: Class Amino Acid Examples Non-polar: A, V, L, I, P, M, F, W Uncharged polarity: G, S, T, C, Y, N, Q Acidic: D, E Basic: K, R, H.

[0106] As is well known to those skilled in the art, altering the primary structure of a peptide by conservative substitutions may not significantly alter the activity of the peptide, since the side chain of the amino acid inserted into the sequence may be able to form similar bonds and contacts as the side chain of the amino acid substituted out, even when the substitution is in a region critical in determining the conformation of the peptide.

[0107] Non-conservative substitutions may also be possible as long as they do not interfere with the function of the protein or peptide.

[0108] Generally speaking, fewer non-conservative substitutions are possible without altering the biological activity of the polypeptide.

[0109] Generally, a variant has an amino acid sequence that is at least 70%, for example at least 71%, 75%, 79%, 81%, 84%, 87%, 90%, 93%, or 96% identical to the base sequence. Identity in this context can be determined using the BLASTP computer program, using the base native protein sequence as the base sequence. BLAST software is publicly available at http: / / blast.ncbi.nlm.nih.gov / Blast.cgi (accessed March 12, 2009).

[0110] Variants may also include additional sequences, such as, for example, tag sequences that may be used to facilitate purification or detection of the peptide. Thus, for example, variants may further include affinity tags, such as chitin-binding protein (CBP), maltose-binding protein (MBP), glutathione-S-transferase (GST), FLAG, myc, biotin, or poly(His) tags, as known in the art. In another embodiment, variants may include fluorescent proteins, such as green fluorescent protein (GFP).

[0111] Other objects, features and advantages of the present invention will become apparent from the following detailed disclosure and from the appended claims. It is noted that the invention relates to all possible combinations of features.

[0112] In general, all terms used in the claims should be interpreted according to their ordinary meaning in the art unless expressly defined otherwise herein. All references to "a / an / the [element, component, etc.]" should be interpreted openly as referring to at least one instance of said element, component, etc., unless expressly stated otherwise.

[0113] As used herein, the term "comprises" and variations of this term are not intended to exclude other components or integers.

[0114] The invention will now be described, by way of example only, with reference to the following figures: [Brief explanation of the drawings]

[0115] [Figure 1] FIG. 1 shows an overview of the treatment of patients with chronic pelvic pain. [Figure 2] 1 is a chart showing elevated urinary substance P (SP) levels in patients with chronic cystitis before treatment. [Figure 3] 1 is a series of charts showing reduced urinary SP levels following anakinra treatment in patients with chronic cystitis. [Figure 4] 1 is a chart showing no change in urinary IL-1β in patients with chronic cystitis before anakinra treatment. [Figure 5] 1 is a series of charts showing that urinary IL-1β levels are unchanged after anakinra treatment in patients with chronic cystitis. [Figure 6] This is a schematic diagram showing the IL-1β / substance P loop, as described in Butler, DSC et al. (2018), "Neuroepithelial control of mucosal inflammation in acute cystitis" in Scientific Reports. [Figure 7] Figure 7a shows the treatment summary of patients with chronic pelvic pain syndrome (Fig. 7a), patient description (Fig. 7b), pain score (Fig. 7c), frequency score (Fig. 7d), quality of life score (Fig. 7e), and urinary SP concentration (Fig. 7f). [Figure 8] FIG. 1 shows the study protocol and summary of results for Example 3. [Figure 9]Figure 1. Therapeutic effect of IL-1RA treatment in patients with bladder pain syndrome. a) Ten patients with a long history of BPS were enrolled after informed consent and asked to complete a questionnaire detailing urination frequency, pain, and quality of life. Laboratory samples were obtained at diagnosis, after initiation of anakinra treatment, during a "treatment break," and during long-term follow-up. b) Outcome variables demonstrating increased quality of life due to decreased pain and frequency (red = pre-treatment samples; blue = post-treatment samples). Urinary SP levels were significantly reduced. Data are shown for individual patients, and the line indicates the group median. Wilcoxon signed-rank test, P value. c) Table showing the effect of treatment, side effects, and long-term treatment regime for each patient. [Figure 10] Figure 1: IL-1RA treatment alters gene expression in patients with bladder pain syndrome. a) Inhibition of gene expression after anakinra treatment. Heatmap of pathways significantly regulated in individual patients. Orange = upregulated, blue = downregulated (cutoff FC1.5, compared to individual pretreatment samples). Inhibited pathways included neuroinflammation, IL-1 and inflammasome signaling, pattern recognition, and adaptive immunity. b) IL-1R1-dependent gene expression network of PI showing significant inhibition of downstream genes (red = activated genes, blue = inhibited genes). c) Histogram of SNPs in rs113540343, rs4251972, rs10754558, and rs10199359 comparing the frequencies of minor and major alleles between patients and the control NOMAD population. d) Table of the 10 most differential SNPs between patients and the 1000 genomes control population. [Figure 11]Structural diagrams of rs145268073 (NLRP3) and rs45507693 (IL1RN). a) IL1RN (magenta) (PDB ID: 1IRA) complexed with ILR1 (cyan) is shown, with the location of rs45507693 boxed. b) The local environment of rs45507693 is shown, with its side chain extending within 4 Å of the beta carbon of alanine 90 (magenta). Mutation to threonine (yellow) reduces local hydrophobicity. c) NLRP3 (PDB ID: 6NPY) complexed with NEK7 kinase (salmon) is shown, with the location of rs145268073 boxed. The mutation is located near the ADP-binding site and the interface between the NB1-HD1 (red) and WHD-HD2-LRR (blue) modules. d) The local environment of rs145268073, illustrating its close proximity to the WHD-HD2-LRR (blue) / NB1-HD1 (red) interface, which undergoes major structural changes upon inflammasome formation. Also shown is the arginine 488 distal guanidinium group and its side chain, which extends within 4 Å of the ADP molecule in the NB1-HD1 module. DETAILED DESCRIPTION OF THE INVENTION [Example]

[0116] Example 1: IL1 inhibitors for the treatment of CPPS The present teachings relate to the treatment of pain and pain-related symptoms of chronic pelvic pain syndrome, comprising administering an IL1 inhibitor to a subject in need thereof.

[0117] The present teachings also relate to alleviating pain and pain-related symptoms of chronic pelvic pain syndrome, comprising administering an IL1 inhibitor to a subject in need thereof.

[0118] The present teachings also relate to methods of reducing pain and pain-related symptoms of chronic pelvic pain syndrome, comprising administering an IL1 inhibitor to a subject in need thereof.

[0119] According to a specific embodiment, an IL-1 inhibitor, such as an IL-1 receptor antagonist, is used in a method for treating, alleviating, or reducing pain and pain-related symptoms of chronic pelvic pain syndrome. Chronic pelvic pain syndrome can be urinary pain syndrome, external genitalia gynecological pain syndrome, internal pelvic pain syndrome, or gastrointestinal pelvic pain syndrome. Specifically, chronic pelvic pain syndrome can be prostatic pain syndrome, bladder pain syndrome, or urethral pain syndrome. The IL-1 receptor antagonist is preferably administered at a dose of 1 to 8 mg / kg body weight, preferably 1 to 4 mg / kg body weight, and more preferably 1 to 2 mg / kg body weight. The IL-1 receptor antagonist is administered at intervals of 24 hours to 6 months, preferably 48 hours to 2 months, and more preferably 72 hours to 1 month. In certain cases, the IL-1 receptor antagonist is administered on demand. The IL-1 receptor antagonist is administered by subcutaneous, intravenous, or intramuscular injection, preferably subcutaneous injection. The IL-1 inhibitor may be selected from anakinra, canakinumab, and diacerein.

[0120] According to another specific embodiment, the IL-1 inhibitor anakinra is used in a method for treating, alleviating, or reducing pain and pain-related symptoms of chronic pelvic pain syndrome. Chronic pelvic pain syndrome can be urinary pain syndrome, external genitalia gynecological pain syndrome, internal pelvic pain syndrome, or gastrointestinal pelvic pain syndrome. Specifically, chronic pelvic pain syndrome can be prostatic pain syndrome, bladder pain syndrome, or urethral pain syndrome. Anakinra is administered at a dose of 1 to 8 mg / kg body weight, preferably 1 to 4 mg / kg body weight, and more preferably 1 to 2 mg / kg body weight. Anakinra is administered at intervals of 24 hours to 6 months, preferably 48 hours to 2 months, and more preferably 72 hours to 1 month. In certain cases, anakinra is administered on demand. Anakinra is administered by subcutaneous, intravenous, or intramuscular injection, preferably subcutaneous. Generally, anakinra is administered as a 100 mg subcutaneous injection at intervals of one injection every two weeks to two injections per week. Preferably, the dose of anakinra is 100 mg or less subcutaneously administered up to once daily or intermittently at shorter or longer intervals (for days to months) as needed to reduce symptoms and according to clinical response.

[0121] In other words, the IL-1 receptor inhibitor anakinra can be administered at a dose of 1 to 8 mg / kg body weight, preferably 1 to 4 mg / kg body weight, and more preferably 1 to 2 mg / kg body weight. Therefore, anakinra can be administered at a dose of 75 to 600 mg / dose, preferably 75 to 300 mg / dose, and more preferably 75 to 150 mg / dose. Therefore, anakinra can be administered at a dose of 100 mg / dose.

[0122] The dose of anakinra may be adjusted if the patient is overweight or underweight, so that an overweight patient may receive a dose higher than 100 mg, and an underweight person may receive a dose lower than 100 mg.

[0123] Anakinra may be administered at intervals of 24 hours to 6 months, preferably 48 hours to 2 months, and more preferably 72 hours to 1 month. Importantly, the specific time interval between administrations of anakinra is determined for each patient depending on the specific condition, pain intensity, and effect of anakinra. Thus, anakinra may be administered once a day. When administered once a day, anakinra is preferably administered at approximately the same time each day. Thus, anakinra may be administered at 24-hour intervals.

[0124] Anakinra may be administered once or twice a week, or at intervals of 1 to 3 weeks or at intervals of 1 to 6 months, for example 2 to 5 months or 3 to 4 months.

[0125] Additionally, anakinra can be administered on demand.

[0126] Anakinra may be administered by subcutaneous injection, intravenous injection, or intramuscular injection. Preferably, anakinra is administered by subcutaneous injection.

[0127] Specifically, the present teachings disclose anakinra for use in the method for treating, alleviating or reducing the pain and pain-related symptoms associated with urinary pain syndrome.Urinary pain syndrome can be prostate pain syndrome, bladder pain syndrome, scrotal pain syndrome, testicular pain syndrome, epididymal pain syndrome, penile pain syndrome, urethral pain syndrome or post-vasectomy scrotal pain syndrome, particularly prostate pain syndrome, bladder pain syndrome or urethral pain syndrome.Preferably, the dose of anakinra is 100mg or less as subcutaneous injection, and is administered at most once a day, or intermittently at shorter or longer intervals (several days to several months), according to the need to reduce symptoms and according to clinical response.

[0128] Therefore, the present teachings disclose anakinra for use in a method for treating, alleviating, or reducing pain and pain-related symptoms associated with bladder pain syndrome (BPS). BPS can be bladder pain syndrome type 3c. Preferably, the dose of anakinra is 100 mg or less as a subcutaneous injection, and is administered at most once a day, or intermittently at shorter or longer intervals (for several days to several months), as needed to reduce symptoms and according to clinical response.

[0129] The present teachings also disclose anakinra for use in a method for treating, alleviating, or reducing pain and pain-related symptoms associated with prostatic pain syndrome (PPS).Preferably, the dose of anakinra is 100 mg or less as a subcutaneous injection, administered at most once a day, or intermittently at shorter or longer intervals (for days to months), as needed to reduce symptoms and according to clinical response.

[0130] Additionally, the present teachings disclose anakinra for use in a method for treating, alleviating, or reducing pain and pain-related symptoms associated with urethral pain syndrome (UPS). Preferably, the dose of anakinra is 100 mg or less as a subcutaneous injection, administered up to once daily or intermittently at shorter or longer intervals (for days to months) as needed to reduce symptoms and according to clinical response.

[0131] Example 2: Anakinra for use in chronic inflammatory conditions Here, we identify that IL-1RA treatment may be useful for alleviating bladder pain. This hypothesis was evaluated by enrolling 10 patients with chronic pelvic pain syndrome (CPPS) in an investigator-initiated, open-label clinical trial (see below and Figure 7). Patients received anakinra treatment (100 mg) once daily until a stable response was observed. Treatment was then temporarily discontinued and resumed if symptoms reappeared. Patient 10 remained asymptomatic.

[0132] Dramatic clinical responses were observed in 9 / 10 patients, who experienced reduced symptom scores (pain and frequency, P<0.01) and increased quality of life (P<0.02). Urinary neuropeptide levels were significantly reduced (P<0.001), and at the RNA level, anakinra treatment inhibited neuroinflammation and IL-1-dependent gene expression. One patient did not respond.

[0133] Current treatment options for patients with CPPS include antibiotics, nonsteroidal anti-inflammatory drugs, opioids such as morphine, and antidepressants. Bladder ulcers can be removed surgically, but in most cases, surgery does not provide lasting relief. This study suggests that IL-1R inhibition may offer a new molecular approach to treating cystitis and bladder pain, with the potential to improve quality of life in patients who have previously offered little to alleviate their suffering.

[0134] Applicants conducted an open-label anakinra trial in patients with chronic inflammatory conditions in the lower urinary tract, specifically chronic cystitis and CPPS. This structured, observational study investigated the effects of treatment with anakinra in patients with chronic cystitis and CPPS.

[0135] Patient Visit Overview Enrolment visit: Patients were given information about the study and enrolled after signed informed consent was obtained. A structured interview and clinical survey were conducted. Disease severity was assessed using symptom scores. Follow-up visits were scheduled.

[0136] Samples: Blood and urine samples for investigation of inflammatory processes and genetic and proteomic analysis.

[0137] Visit 1: Conduct a structured interview and clinical examination. Record the severity of symptoms.

[0138] Treatment with anakinra is initiated and continued for 7 days (until the next visit).

[0139] Samples: Blood and urine samples for investigation of inflammatory processes and genetic and proteomic analysis.

[0140] Visit 2: Evaluation of efficacy after one week of treatment with anakinra. A structured interview and clinical investigation will be performed. The severity of symptoms will be assessed. Patients who do not respond to treatment will be excluded from further treatment.

[0141] Patients who experience a positive effect of treatment will have treatment discontinued for two weeks (or at least long enough for the clinical effect of treatment to wane).

[0142] Samples: Blood and urine samples for investigation of inflammatory processes and genetic and proteomic analysis.

[0143] Visit 3: Follow-up after cessation of treatment. Conduct structured interview and clinical examination. Assess severity of symptoms. If patient relapses, resume anakinra treatment.

[0144] Samples: Blood and urine samples for investigation of inflammatory processes and genetic and proteomic analysis.

[0145] Visit 4: Follow-up and evaluation of efficacy after 3 weeks of treatment with anakinra. Structured interview and clinical survey will be conducted. Severity of symptoms will be evaluated.

[0146] Patients will discontinue treatment for two weeks (or at least long enough for the clinical effects of treatment to wane).

[0147] Samples: Blood and urine samples for investigation of inflammatory processes and genetic and proteomic analysis.

[0148] Visit 5: Final visit after cessation of treatment with anakinra. A structured interview and clinical investigation will be performed. The severity of symptoms will be assessed.

[0149] Samples: Blood and urine samples for investigation of inflammatory processes and genetic and proteomic analysis.

[0150] The visiting program is illustrated in Figure 1.

[0151] method Clinical assessment of symptom severity: During patient visits, a structured interview and clinical survey assessing symptoms (including medication consumption) will be conducted. Throughout the study period, patients will complete daily symptom scores for pain, urination, urgency, and quality of life according to a structured formula.

[0152] Inflammatory parameters: To assess the level of systemic and local inflammatory processes, serum and urine CRP, neutrophil counts, and interleukins are analyzed.

[0153] Genomics and Proteomics Blood samples for DNA and RNA analysis and urine samples for proteomics will be obtained throughout the study.

[0154] monitoring: Results will be continuously registered in each patient's clinical chart. Patient visits during the study will, in most cases, be part of regular patient management visits.

[0155] result Clinical assessment of symptom severity Treatment proved effective in 60% of patients, as determined by a reduction in symptom scores. Interestingly, all nine responding patients had Hunner lesions, indicating that treatment may be more effective in this patient population. Patients were subsequently removed from treatment to determine whether treatment was curative or if symptoms would reappear. Symptoms eventually returned, and patients were placed back on anakinra treatment.

[0156] [Table 1]

[0157] Inflammatory parameters: To define treatment groups in which anakinra may serve as an effective therapeutic option, we searched for urinary biomarkers. To compare urinary concentrations of IL-1β and substance P (SP), we collected urine samples from patients as well as healthy controls. Surprisingly, IL-1β was absent in either patient or control urine during peak symptoms (13.2 vs. 11.6 pg / ml) (Figure 4), and urinary IL-1β levels remained unchanged after anakinra treatment in patients (Figure 5). In contrast, SP concentrations increased in patients during peak symptoms (209 vs. 75 pg / ml, P = 0.003), representing a biomarker of bladder inflammation (Figure 2). Subsequently, SP concentrations during peak symptoms were analyzed together with paired samples from minimal symptoms, showing a significant decrease after treatment (243 vs. 136 pg / ml, P = 0.02) (Figure 3).

[0158] Study Protocol and Results Ten patients with a long history of CPPS were enrolled after informed consent (age, sex, disease profile) and instructed to complete a questionnaire detailing urination frequency, pain, frequency of analgesics, and quality of life.

[0159] The time to symptom relief after the first dose varied (1–6 hours) and duration (0.5–8 days), resulting in a personalized treatment regimen (Figure 7a). Two patients reported local irritation at the injection site, and one patient developed neutropenia (Figure 7b). Common response patterns included an initial response, recurrence of pain when treatment was discontinued, and recurrence of pain relief and ease of voiding when treatment was resumed.

[0160] Significant reductions in pain, urgency, and urination frequency were noted in 9 / 10 patients (Figures 7c, 7d, and 7e). Laboratory samples were obtained at diagnosis, after initiation of anakinra treatment (n = 10), during a "treatment break," and after continued anakinra treatment (n = 9). Urinary neuropeptide (substance P), involved in pain responses, was inhibited, accompanied by a biphasic response following symptom scores (Figure 7f).

[0161] Gene expression analysis of peripheral blood RNA revealed a reduction in neuroinflammation after anakinra treatment.

[0162] clinical results The efficacy of anakinra in treating CPPS was investigated in a clinical study. Inclusion criteria were CPPS with a predominantly bladder pain phenotype, but also with a urethral and prostatodynia phenotype. Exclusion criteria were uncontrolled diabetes mellitus, treatment for malignant disease within the previous 10 years, pregnancy, age <18 years, infectious diseases including ongoing urinary tract infection, and neutropenia (<1.5 × 10 9The mean urinary tract infection rate was 1.2% (cells / L). Patients provided informed consent for the use of anonymous, personal clinical data for research purposes. Included patients were examined using clinical standard methods to exclude ongoing disease, if present. Blood and serum for hemoglobulins, liver and kidney function tests, and white blood cell (WBC) counts were analyzed. Urine was obtained for dipstick tests (leukocytesteras for WBC estimation, nitur test to exclude bacteriuria), standard urinary interleukins (IL6, IL8, and IL1b), and urine culture. Cystoscopy and CT urography were performed in all patients. Blood and serum analyses and cystoscopy were repeated approximately 2 weeks and 3 months after the start of treatment. Nine patients were recruited (Table 2).

[0163] After enrollment, patients were treated with 100 mg of anakinra by self-administered subcutaneous injection, up to once daily, or (in case of symptom and pain relief) repeated on demand when symptoms or pain recurred. Periodic symptom scoring of frequency, suprapubic / bladder pain / prostate / urethral pain, and quality of life was used to assess the effect of treatment.

[0164] [Table 2] Notes for Table 2 M = male, F = female, CIC = clean intermittent catheterization, Cath = indwelling catheter, CPPS = chronic pelvic pain syndrome, BPS type 3c = bladder pain syndrome type 3c, BPS = bladder pain syndrome, UPS = urethral pain syndrome, PPS = prostatic pain syndrome, cystoscopy revealed type 3c = Hunner's ulcer, inflamm. = inflammation corresponding to Hunner's ulcer. In patient 5, a nonspecific scattering of red lesions was found during cystoscopy. No histological specimen was obtained. Repeat cystoscopy 2 weeks after treatment revealed normal bladder mucosa. In patient 9, cystoscopy revealed "cystitis cystica," or cystitis glandularis, a specific benign inflammation caused by chronic irritation or of unknown etiology. In all other patients, cystoscopy was normal. All cystoscopic findings refer to findings at the time of study inclusion, except for patient 3, who was diagnosed with Hunner's ulcer one year prior to study inclusion (see detailed patient description below). nd = not determined, COPD = chronic obstructive pulmonary disease.

[0165] Notably, all patients responded with dramatically reduced symptoms, as measured by symptom scoring (Table 2). The maximum effect on symptoms after a single subcutaneous injection of 100 mg of anakinra was seen within 1 to 24 hours, and the maximum effect generally lasted 2 to 3 days. One patient (number 5) experienced a maximum effect for 8 days. In one patient (number 3), the maximum effect lasted only 13 hours, but generally, the maximum effect remained for several days. Therefore, for the majority of patients, anakinra is administered at a subcutaneous dose of 100 mg once or twice weekly.

[0166] Notably, daytime voiding frequency decreased in all patients, and nocturnal voiding frequency generally decreased as well.

[0167] The pain experienced by the patients decreased, and five out of nine patients even achieved complete pain relief.

[0168] Furthermore, quality of life (QoL) experience increased in all patients.

[0169] [Table 3] Notes for Table 3 Treatment was given to all patients with 100 mg of anakinra as a subcutaneous (sc) injection (inj.) at a maximum frequency of once daily or after recurrence of symptoms. Obs. / Treatm. = observation / treatment, Onset = time to maximum effect on symptoms after a single subcutaneous injection of 100 mg anakinra, Duration = time of duration of maximum effect after a single subcutaneous injection of 100 mg anakinra, d / h = days / hours, Frequency (nocturia) = number of urinations during the day and night (the latter number is given in brackets), QoL = quality of life. Pain and QoL impairment were estimated by interview and scored from 0 to 6, with 0 meaning no symptoms / no impairment of QoL and 6 meaning severe pain and severely impaired QoL. Side effects: Reported side effects were mild. Local subcutaneous irritation: Red, edematous skin reaction approximately 4 cm in size at the injection site, symptomatic, treated with topical hydrocortisone. Post-injection headache: Moderate headache, treated with analgetic such as paracetamol.

[0170] Long-term follow-up (Table 3) revealed that all nine patients experienced a greatly increased or increased quality of life. The treatment effect in all patients was consistent during long-term follow-up.

[0171] Urinary estimated WBC and interleukins were not significantly increased before, during, or after treatment.

[0172] In cases where cystoscopy revealed a Hunner's ulcer before the procedure, this finding remained unchanged on follow-up cystoscopy.In one patient (patient 5), a nonspecific scattering of small red lesions disappeared after the procedure.

[0173] Side effects were scattered and mild, consisting of two cases of skin reactions at the injection site, which were treated with topical hydrocortisone, and one case of post-injection headache (patient 5), which was occasionally treated with paracetamol and an NSAID.

[0174] [Table 4]

[0175] A detailed description of each patient follows.

[0176] Patient 1: A 61-year-old male with a history of traumatic spinal cord injury resulting in neurogenic bladder dysfunction (combined hyperreflexia and poor detrusor function) treated with clean intermittent catheterization. Two years before enrollment, the patient developed dysuria, urgency, and bladder pain, and urine cultures only intermittently demonstrated uropathogenic growths. Antibiotic treatment did not alleviate symptoms. Cystoscopy demonstrated a Hunner's ulcer. Treatment with transurethral resection and coagulation of the lesion and intravesical therapy with intravesical glycosaminoglycan (GAG) replacement therapy did not result in subjective improvement. The patient experienced minimal benefit from treatment with maximum doses of oral urgency medications (mirabegron and anticholinergics) and non-morphine analgesics. After administration of 100 mg of anakinra subcutaneously at a dose of approximately one injection per week, the patient showed significant subjective improvement with a clear reduction in frequency and local pain from the bladder. He has now been self-treated with anakinra on an intermittent basis for over a year, with stable therapeutic effects and no side effects.

[0177] Patient 2: Male, 67 years old. Over 20 years of history of benign prostatic hyperplasia with bladder pain syndrome and outflow obstruction. Five years prior to enrollment, transurethral resection of the prostate, including coagulation / resection of a Hunner's ulcer in the bladder, provided long-term symptomatic relief. One year prior, the patient experienced recurrent symptoms with bladder pain, urgency, and frequent nocturia, which he managed with nonmorphine analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). Cystoscopy revealed a primary Hunner's ulcer. Anakinra treatment was initiated, with significant symptom and pain relief continuing. The patient is currently self-treating on demand with 100 mg injections of anakinra approximately once every 2–3 weeks.

[0178] Patient 3: Female, 77 years old. More than 20 years prior to enrollment, she had been successfully treated for gynecological cancer with radiation and hysterosalpingo-oophorectomy. She had chronic obstructive pulmonary disease. Urgency and frequency, including localized pain, began 1 year prior to enrollment. Cystoscopy revealed a Hunner's ulcer in the bladder. Treatment with transurethral resection and coagulation of the lesion, as well as intravesical therapy with intravesical glycosaminoglycan (GAG) replacement therapy, did not result in subjective improvement. After several months, the bladder atrophied, forcing the patient to undergo treatment with an indwelling catheter. Bladder pain worsened and was treated with morphine and corticosteroids. At the time of enrollment, the patient was awaiting cystectomy. Preprocedural cystoscopy did not reveal any bladder inflammation beyond that typically found with the use of an indwelling catheter. After initiation of anakinra treatment, analgesia followed immediately, and morphine and corticosteroid treatment were discontinued. The patient is currently being treated with regular self-administered once-daily anakinra and cystectomy has been postponed.

[0179] Patient 4: Female, 67 years old. An otherwise healthy woman with a history of bladder pain syndrome going back more than 10 years. After initial resection and coagulation, the patient was asymptomatic. One year before enrollment, symptoms recurred with urgency and localized pain, but treatment with nonmorphine analgesics and NSAIDs was only minimally effective. Cystoscopy revealed a primary Hunner's ulcer, and treatment with anakinra was initiated, which provided consistent relief of symptoms. The patient is currently receiving weekly subcutaneous injections of 100 mg of anakinra with complete symptomatic relief.

[0180] Patient 5: Female, 39 years old. She is otherwise healthy but experiences occasional migraine attacks. Six months before enrollment, her urgency and frequency, including localized pain from the bladder, gradually worsened. Cystoscopy revealed small red lesions in the bladder, but there was no inflammation. The patient received only minimal benefit from treatment with maximum doses of oral urgency medications (mirabegron and anticholinergics) and non-morphine analgesics. Anakinra treatment provided consistent relief of symptoms. The patient is currently on self-administered subcutaneous anakinra 100 mg once every 1 to 2 weeks. After each injection, the patient experiences a mild headache, which she treats with an NSAID and paracetamol. Repeat cystoscopy demonstrated normal bladder mucosa.

[0181] Patient 6: Female, 70 years old. Diagnosed with Mb Dercum (adiposa dolorosa) more than 20 years prior to enrollment, and contemporaneously with bladder pain, including urgency and frequency resulting in urination once per hour (including at night). Cystoscopy revealed normal bladder mucosa. Treatment with nonmorphine analgesics, corticosteroids, anticholinergics, and mirabegron was ineffective. After initiation of anakinra treatment, the patient experienced no or few symptoms from adalimumab, and a dramatic reduction in urgency, frequency, and bladder pain. She is currently receiving anakinra treatment, 100 mg subcutaneously, injected twice weekly.

[0182] Patient 7: Female, 20 years old. Otherwise healthy. Six months before enrollment, she had increased urethral pain and urgency, resulting in voiding every two hours, day and night. Treatment with topical intraurethral corticosteroid infusions, nonmorphine analgesics, corticosteroids, anticholinergics, and mirabegron was ineffective. Cystoscopy was normal. After treatment with anakinra, her urgency symptoms dramatically decreased. Urethral pain significantly decreased but recurred transiently. She is currently receiving subcutaneous anakinra treatment at 100 mg once weekly.

[0183] Patient 8: Male, 70 years old. Under treatment for hypertension and atrial fibrillation. Six months prior to enrollment, significant symptoms with severe urgency and frequency combined with prostatodynia were present. The patient felt compelled to urinate hourly, day and night. Examination revealed a normal but tender benign prostate; cystoscopy and MR of the true pelvis and prostate were all normal. Treatment with antibiotics (ex juvantibus), anticholinergics, and mirabegron was ineffective. After initiating treatment with 100 mg subcutaneous anakinra, the urgency and frequency dramatically decreased. Prostatodynia significantly decreased but recurred transiently. The patient is currently under treatment with 100 mg subcutaneous anakinra on demand.

[0184] Patient 9: Male, 65 years old. He had had intermittent fever and joint pain for more than 10 years, with no known cause despite extensive investigation by the rheumatology department. Ten years prior to enrollment, he had been diagnosed with cystitis cystica (benign granulomatous inflammation) of the bladder. He had increased urgency and frequency, but no treatment was required. After treatment with 100 mg subcutaneous anakinra, the patient reported relief of fever attacks and joint pain, and a decrease in urgency and frequency. He is currently on 100 mg subcutaneous anakinra twice weekly.

[0185] Example 3: Treatment of BPS Bladder pain syndrome (BPS) disrupts careers, social lives, and sexual health as patients experience debilitating pain, extreme urinary frequency, and urgency. Numerous treatment approaches have been tested, but apart from the use of antibiotics or painkillers to treat superinfections, therapeutic success has been limited, and patients are often severely disabled. The molecular basis of BPS also remains a mystery, hindering the development of more specific therapeutic alternatives.

[0186] Analysis of the inflammatory phenotype in acute cystitis revealed that IL-1, a factor in acute bladder pathology, was recently identified as a cause of the disease, exacerbated by genetic factors affecting the inflammasome components Asc and Nlrp3. The IL-1 receptor antagonist, Kineret (anakinra), dramatically reduced bladder inflammation and increased bacterial clearance in a murine cystitis model (see reference). IL-1R blockade also affected the pain receptor NK1R in the bladder mucosa, linking IL-1-dependent inflammation to pain responses.

[0187] We tested the hypothesis that IL-1RA treatment may be useful for relieving bladder pain. Ten patients with BPS were enrolled in an investigator-initiated, open-label trial. Patients received Kineret treatment (100 mg) once daily for 7 days. Treatment was then temporarily discontinued, and if symptoms recurred, treatment was resumed.

[0188] Dramatic clinical improvement was observed in 9 / 10 patients. A common pattern of response included an initial response, recurrence of pain when treatment was discontinued, and return of pain relief and ease of voiding when treatment was resumed. One patient responded only transiently.

[0189] Patients experienced reduced symptom scores (pain and frequency, P<0.01) and a significant increase in quality of life (P<0.02). At enrollment, elevated levels of neuropeptides that regulate pain responses were detected in the urine. A rapid decline occurred after the initial Kineret treatment period and recurred when treatment was resumed after a treatment interruption (P<0.001). Gene expression was also inhibited, affecting neuroinflammation, Toll-like receptor-dependent pattern recognition, and IL-1 signaling.

[0190] Current treatment options for patients with BPS include nonsteroidal anti-inflammatory drugs, opioids such as morphine, and experimental intravesical treatments. Bladder ulcers can be surgically removed, but in most cases surgery does not provide lasting relief. This study suggests that IL-1R inhibition may offer a new molecular approach to treating cystitis and bladder pain, with the potential to improve quality of life in patients who have previously offered little to alleviate their suffering.

[0191] a) Schematic of the study protocol. Ten patients with a long history of BPS (see EAU guidelines) were enrolled after informed consent and asked to complete a questionnaire detailing urination frequency, pain, analgesic frequency, and quality of life. Laboratory samples were obtained at diagnosis, after initiation of Kineret treatment (n = 10), during a "treatment break," and after continued Kineret treatment (n = 9). Substance P, a neuropeptide involved in pain response, was quantified in urine. Peripheral blood RNA was subjected to genome-wide transcriptomics analysis to define the molecular effects of Kineret treatment.

[0192] b) Study outcome variables demonstrating increased quality of life and decreased frequency, pain, and urinary SP levels (red = pre-treatment samples; blue = post-treatment samples). Time to symptom relief after the first dose varied (1-6 hours) as did duration (0.5-8 days), resulting in a personalized treatment regimen. Two patients reported local irritation at the injection site, which was treated with topical steroids. Data are presented as individual patients and medians. Data were analyzed using the Wilcoxon signed-rank test, with a P value of less than 0.05 considered significant.

[0193] c) Patient characteristics, underlying disease, and outcome. Bladder inflammation in six patients was defined by cystoscopy and confirmed by histology. Mucosal cell infiltrates included mast cells and lymphocytes (see ).

[0194] d) Inhibition of gene expression after Kineret treatment. Heatmap of significantly regulated pathways in individual patients. Orange = upregulated, blue = downregulated (cutoff FC1.5, compared to each individual pretreatment sample). Inhibited pathways included neuroinflammation, IL-1 and inflammasome signaling, pattern recognition, and adaptive immunity. The fold change of significantly regulated genes is shown in Table 2 (average of 9 patients).

[0195] Example 4 The immune response to infection must be exquisitely controlled and balanced. Deficiencies affecting cellular immune function result in inadequate defense and increased susceptibility to infection. Conversely, overactive immune responses are classically associated with diseases such as asthma, rheumatoid arthritis, and diabetes, and treatments aim to restore immune balance and prevent disease progression.

[0196] Innate immunity controls the immediate response to infection, particularly at mucosal surfaces where initial contact between microorganisms and their hosts usually occurs. Detailed genetic studies have clearly demonstrated that single gene defects control susceptibility to acute infection as well as the risk of chronicity and tissue damage. Specific immune activation pathways and immune effector functions have been identified, including Toll-like receptors, transcription factors, inflammasomes, and inflammatory cells.

[0197] The damaging potential of innate immune hyperactivation is highly relevant to the urinary tract, where everyone is exposed to bacteria but only a subset of individuals develops disease. UTIs are highly common, with approximately 50% of all women experiencing at least one episode during their lifetime. Many develop socially debilitating recurrent infections, and increasing antibiotic resistance has severely limited treatment options.

[0198] The molecular basis of acute cystitis remained unresolved until recently, when it was shown that hyperactivation of interleukin-1 (IL-1) drives acute disease severity and tissue damage. Paradoxically, disruption of the NACHT, LRR, PYD domain-containing protein 3 (Nlrp3) inflammasome resulted in severe acute cystitis in infected mice, accompanied by hyperactivation of IL-1 and a pain-sensing loop involving the neurokinin 1 receptor (NK1R) and substance P (SP). - / - and Nlrp3 - / - Mice developed rapid, fulminant bladder inflammation and tissue damage, accompanied by massive neutrophil infiltration, hyperactivation of IL-1beta, and IL-1beta-dependent gene networks. The severe disease phenotype was explained by a noncanonical processing mechanism in Nlrp3 inflammasome-deficient mice, in which overexpression of matrix metallopeptidase 7 (MMP7) led to highly efficient pro-IL-1beta processing. Finally, Asc and Nlrp3 may explain why MMP7 regulates Asc. - / - and Nlrp3 - / - In stark contrast, Il1 was identified as a transcriptional repressor of mmp7, explaining why it is overexpressed in mice. - / - Mice were protected from infection and did not show any signs of bladder inflammation, further highlighting the importance of IL-1 as a driver of symptomatology and pathology.

[0199] The IL-1 receptor antagonist (IL1-RA) anakinra (brand name Kineret) is a biological immunomodulator with an excellent safety record when used for indications such as rheumatoid arthritis. The therapeutic potential of IL-1 inhibition was examined in inflammasome-deficient mice developing severe cystitis. Anakinra was shown to dramatically reduce bladder inflammation and accelerate bacterial clearance. Blockade of IL-1R also reduced the expression of the pain receptor NK1R and its ligand SP in the bladder mucosa, linking IL-1-dependent inflammation to pain responses in the bladder mucosa. 3The dramatic disease phenotype in NLRP3 inflammasome-deficient mice and the therapeutic effect of anakinra suggested that these mechanisms may be relevant in patients with chronic pelvic pain, often due to recurrent bouts of cystitis.

[0200] In this study, we addressed whether IL-1RA treatment could be effective in patients with chronic bladder pain. We conducted an exploratory, open-label clinical trial in patients with BPS (Figure 9, Table 4). The study plan is outlined in Figure 9a. Patients received subcutaneous injections of anakinra (100 mg) once daily for 7 days, and treatment efficacy was recorded. To address potential placebo effects, treatment was temporarily interrupted for up to 14 days and resumed if symptoms reappeared, continuing with individual treatment regimens. At enrollment, cystoscopy revealed signs of Hunner's lesions in six of the patients, which were confirmed by histopathology. No bladder pathology was detected in the remaining patients. During the study, patients were instructed to keep a symptom diary recording pain sensations and urination frequency.

[0201] The immediate subjective response of patients was remarkable. Dramatic clinical improvement was observed in 9 / 10 patients. A common initial response pattern included rapid symptom relief at the onset of treatment (median = 2 hours) and sustained therapeutic effect (3 days). After the first 7 days, dramatic clinical improvement was observed in all patients, who experienced a decrease in symptom scores (pain and frequency, P<0.02) and improved quality of life (P<0.002). One 47-year-old patient with very severe BPS / ICS since age 17 noticed symptom relief within 1-2 hours of the first injection and reported a return to normal activity. The patient with the slowest onset of action reported improvement after 1 week of treatment. One patient reported a partial response. Nine of the patients reported complete or near-complete clinical responses, and these patients continue to receive anakinra treatment and have been followed for a median of 428 days (range 80-706 days). One patient responded only transiently and discontinued treatment after 80 days.

[0202] This clinical response was accompanied by changes in urinary neuropeptide levels. 3 The SP receptor, NK1R, is activated during inflammatory bowel disease, and its inhibitor reduces inflammation and pain in inflammatory bowel disease-susceptible mice. SP levels were reduced in 9 / 10 patients during the first round of treatment (Figure 9). When treatment was discontinued, pain returned with increasing frequency, accompanied by an increase in SP levels. When treatment was resumed, the return of pain relief and ease of urination was accompanied by a decrease in SP levels.

[0203] To further understand the molecular basis of these effects, gene expression in the resulting RNA samples was analyzed longitudinally: at baseline, when patients were experiencing pain, at the time of maximum treatment effect during the first round, when pain reappeared during treatment discontinuation, after reintroduction of anakinra, and at 1-2 years of follow-up after treatment. Treatment inhibited gene expression, including canonical pathways involved in neuroinflammation, TLR-dependent pattern recognition, and IL-1 signaling. Given the significant effect on IL-1-related genes, we further investigated the gene network downstream of IL-1R1. In 8 of 10 patients, we detected a significant decrease in the expression of IL-1R1-dependent genes, primarily CXCL1, IL1RAP, CXCL3, and the IL1R1 gene itself.

[0204] Whole-exome sequencing detected single nucleotide polymorphisms (SNPs) in IL-1-related genes, including IL1A, IL1B, IL1RN, IL1R1, NLRP3, PYCARD, MMP7, TAC1, and TACR1. Allele frequencies in the patient population were compared with those in the NOMAD European database and 1000 Genomes. Several SNPs were found in the introns of these genes, including strong differences between patient and control populations for rs113540343 (IL1A), rs4251972 (IL1RN), and rs10754558 (NLRP3).

[0205] Several SNPs were identified in the IL1RN gene, which encodes the human IL-1 receptor antagonist from which anakinra was engineered. This suggests that the receptor antagonist may be defective in these patients and, therefore, that a precisely expressed IL-1 receptor antagonist in the form of anakinra is needed. PYCARD encodes ASC, a component of the inflammasome identified as a susceptibility gene for cystitis in mice. NLRP3 encodes the inflammasome component NLRP3 protein. Finally, SNPs were detected in TAC1 and TACR1, which encode the precursor of SP and its receptor NK1R, which drive pain sensing from the bladder to the dorsal root ganglion. These results suggest a genetic association between patients with bladder pain and IL-1-related genes, which needs to be further evaluated in larger patient cohorts.

[0206] To further analyze the functional consequences of SNPs, we evaluated the effect of specific SNPs on the experimentally determined three-dimensional structures. Among the identified SNPs, rs145268073 and rs45507693 predict changes in the amino acid sequences of NLRP3 and IL1RN, respectively. In ILR1N, aa99 is changed from alanine to threonine, and in NLRP3, arginine 488 is replaced by either lysine or threonine. The atomic structures of both proteins have been analyzed individually and in complex with biological binding partners (Figure 12). The structure of ILR1N complexed with ILR1 (Figure 12A, PDB ID: 1IRA) shows that the mutated A99 is located in a central hydrophobic pocket, with several relatively short nonpolar contact points adjacent to the beta carbon of the alanine (Figure 12B). It is not inconceivable that the addition of a polar hydroxyl moiety might sufficiently disturb this environment to indirectly alter the conformation of nearby loops at the interface with ILR1.

[0207] In the complex structure of NLRP3 with its activator, the mitotic NEK7 kinase, Arg488 is positioned in close proximity to a key functional feature of NLRP3 (Figure 12C) (Sharif, H. et al., Structural mechanism for NEK7-licensed activation of NLRP3 inflammasome. Nature, 570, 338-343 (2019)). While NLRP3 is found in an inactive conformation, earlier studies of the related NLRC4 have shown that activation and inflammasome formation are likely achieved through a 90-degree rigid-body movement of the NBD-HB1 module relative to the remaining WHD-HD2-LRR module of NLRP3 (Zhang, L. et al., Cryo-EM structure of the activated NAIP2-NLRC4 inflammasome reveals nucleated Polymerization. Science, Vol. 350, pp. 404–409 (2015)). Although the exact mechanism that triggers this event is unknown, it has been shown that ADP increases the stability of the NEK7 / NLRP3 complex. R488, which extends into the central pocket of the WHD, has no obvious contact points with ADP and does not appear to be directly part of the interface between the WHD-HD2-LRR and NBD-HB1 modules, but it is located at the central junction for NLRP3 inflammasome formation. It can be speculated that this residue may play a central role in the formation of active NLRP3, the structure of which is not yet available. JPEG0007817832000005.jpg85153

Claims

1. A pharmaceutical composition comprising anakinra or an active fragment or active variant thereof for use in the treatment of a chronic inflammatory condition in the lower urinary tract selected from chronic cystitis, chronic pelvic pain syndrome, and / or bladder-associated pelvic pain and / or in the treatment of CPPS.

2. 2. The composition for use according to claim 1, for use in a subject having a mutation in an IL-1 related gene.

3. A pharmaceutical composition comprising anakinra or an active fragment or active variant thereof for use in a method for treating, alleviating, or reducing the pain and pain-related symptoms of chronic pelvic pain syndrome.

4. 4. A composition for use according to claim 3, comprising anakinra.

5. 5. The composition for use according to claim 3 or 4, wherein anakinra or an active fragment or variant thereof is administered at a dose of 1 to 8 mg / kg body weight, preferably 1 to 4 mg / kg body weight, more preferably 1 to 2 mg / kg body weight.

6. The composition for use according to any of claims 3 to 5, administered at intervals of from 24 hours to 6 months, preferably from 48 hours to 2 months, more preferably from 72 hours to 1 month.

7. 7. A composition for use according to any one of claims 3 to 6, administered on demand.

8. 8. The composition for use according to any one of claims 3 to 7, which is administered by subcutaneous injection, intravenous injection, or intramuscular injection.

9. 9. The composition for use according to any one of claims 3 to 8, wherein the chronic pelvic pain syndrome is selected from urinary pain syndromes, external genital gynecological pain syndromes, internal pelvic pain syndromes, and gastrointestinal pelvic pain syndromes.

10. 10. The composition for use according to claim 9, wherein the urinary pain syndrome is selected from prostate pain syndrome, bladder pain syndrome, scrotal pain syndrome, testicular pain syndrome, epididymal pain syndrome, penile pain syndrome, urethral pain syndrome, post-vasectomy scrotal pain syndrome.

11. The composition for use according to claim 10, wherein the urinary pain syndrome is selected from prostate pain syndrome, bladder pain syndrome, and urethral pain syndrome.

12. The composition for use according to claim 10 or 11, wherein the bladder pain syndrome is bladder pain syndrome type 3c.

13. 10. The composition for use according to claim 9, wherein the external genital gynecological pain syndrome is selected from vulvodynia syndrome, generalized vulvodynia syndrome, localized vulvodynia syndrome, vestibulodynia syndrome, and clitoral pain syndrome.

14. 10. The composition for use according to claim 9, wherein the internal pelvic pain syndrome is selected from endometriosis-associated pain syndrome, chronic pelvic pain syndrome with cyclical exacerbations, and dysmenorrhea.

15. 10. The composition for use according to claim 9, wherein the gastrointestinal pelvic pain syndrome is selected from irritable bowel syndrome, chronic anal pain syndrome, and intermittent chronic anal pain syndrome.

16. The composition for use according to any one of claims 3 to 15, which is intended to be administered to a subject having a mutation in an IL-1 related gene.

17. 17. The composition for use of claim 2 or 16, wherein the subject has multiple mutations in one or more IL-1 related genes.

18. 18. The composition for use of claim 17, wherein the subject has a mutation in one or more of IL1A, IL1B, IL1RN, IL1R1, NLRP3, PYCARD, MMP7, TAC1, and TACR1.

19. 19. The composition for use according to claim 17 or 18, wherein the subject has a mutation in IL1A.

20. The composition for use according to any one of claims 17 to 19, wherein the subject has a mutation in IL1B.

21. The composition for use according to any one of claims 17 to 20, wherein the subject has a mutation in IL1RN.

22. The composition for use according to any one of claims 17 to 21, wherein the subject has a mutation in IL1R1.

23. The composition for use according to any one of claims 17 to 22, wherein the subject has a mutation in NLRP3.

24. The composition for use according to any one of claims 17 to 23, wherein the subject has a mutation in PYCARD.

25. The composition for use according to any one of claims 17 to 24, wherein the subject has a mutation in MMP7.

26. The composition for use according to any one of claims 17 to 25, wherein the subject has a mutation in TAC1.

27. The composition for use according to any one of claims 17 to 26, wherein the subject has a mutation in TACR1.

28. 28. The composition for use of any of claims 17 to 27, wherein the subject has a mutation in one or more of rs113540343 (IL1A), rs4251972 (IL1RN), and rs10754558 (NLRP3), rs145268073 (NLRP3), and rs45507693 (IL1RN).

29. The composition for use according to any one of claims 17 to 28, wherein the subject has a mutation in rs113540343 (IL1A).

30. The composition for use according to any one of claims 17 to 29, wherein the subject has a mutation in rs4251972 (IL1RN).

31. The composition for use according to any one of claims 17 to 30, wherein the subject has a mutation in rs10754558 (NLRP3).

32. The composition for use according to any one of claims 17 to 31, wherein the subject has a mutation in rs145268073 (NLRP3).

33. The composition for use according to any one of claims 17 to 32, wherein the subject has a mutation in rs45507693 (IL1RN).

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