Treatment of hypercholesterolemia

Abstract

A method for lowering elevated plasma cholesterol levels in a subject is disclosed. A method for treating hypercholesterolemia in a subject is also disclosed. The method comprises administering to the subject, in the absence of a cholesterol-lowering agent, an effective amount of Compound 1: JPEG2023538066000007.jpg35127 or a pharmaceutically acceptable salt thereof.

Description

[Technical Field]

[0001] Related Applications This application claims the benefit under 35 U.S.C. § 119 of U.S. Provisional Patent Application No. 63 / 067,786, filed August 19, 2020, the entire contents of which are incorporated herein by reference. [Background technology]

[0002] High cholesterol is one of many risk factors for heart attack and stroke. Poor diet and lack of exercise are common causes of high cholesterol. High cholesterol may also have underlying genetic factors, such as in familial hypercholesterolemia (FH). Although numerous cholesterol-lowering drugs are currently on the market, they are not without risks or contraindications with certain medical conditions or other drug treatments. These drugs include statins, fibrates, niacin, bile acid sequestrants (resins), phytosterols, or other compounds that prevent fat absorption, reduce cholesterol absorption, or target genes in the cholesterol tracking pathway. Due to the risks and contraindications associated with current cholesterol-lowering drugs, additional drug therapies to lower cholesterol in patients with high cholesterol levels are needed. Summary of the Invention

[0003] Compound 1, the structure of which is shown below, has now been shown to be an inhibitor of multiple enzymes in the cholesterol biosynthetic pathway, including LBR / TM7SF2 and EBP.

[0004] [ka]

[0005] Specifically, Compound 1 dose-dependently lowers cholesterol levels in healthy human volunteers (Example 1) and induces the accumulation of 7-dehydrocholesterol (7-DHC). The accumulation of 7-DHC is also reproduced in rat OPCs treated with Compound 1 (Example 2). Based on these findings, methods for lowering blood cholesterol levels in subjects in need thereof are disclosed herein.

[0006] One embodiment of the present invention is a method for lowering elevated plasma cholesterol levels in a subject, comprising administering to the subject an effective amount of Compound 1: [ka] or a pharmaceutically acceptable salt thereof.

[0007] Another embodiment of the present invention is a method of treating a subject with hypercholesterolemia, comprising administering to said subject an effective amount of Compound 1: [ka] or a pharmaceutically acceptable salt thereof.

[0008] Another embodiment of the present invention is an effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, for lowering elevated plasma cholesterol levels in a subject.

[0009] Another embodiment of the present invention is the use of Compound 1, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for lowering elevated plasma cholesterol levels in a subject.

[0010] Another embodiment of the present invention is an effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, for treating a subject with hypercholesterolemia.

[0011] Yet another embodiment of the present invention is the use of an effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for treating a subject with hypercholesterolemia. [Brief explanation of the drawings]

[0012] [Figure 1] 1 shows the time course of reduction in circulating mean total cholesterol levels in healthy volunteers administered placebo, 10 mg / day, 30 mg / day, or 60 mg / day of Compound 1 over a 28-day period. [Figure 2] 1 is a bar graph showing predicted steady-state concentrations of circulating cholesterol during treatment with Compound 1 for subjects receiving placebo, 1 mg / day, 3 mg / day, 10 mg / day, 30 mg / day, or 60 mg / day of Compound 1 at pharmacodynamic steady state. The predicted concentrations are derived from simulations based on data from three Phase 1 clinical trials of Compound 1. [Figure 3] 1 is a bar graph showing changes in 7-DHC, cholesterol, and desmosterol levels in rat OPC cultures treated with Compound 1. [Figure 4] FIG. 1 shows the biosynthetic pathways of cholesterol and desmosterol. DETAILED DESCRIPTION OF THE INVENTION

[0013] Treatment with Compound 1 inhibits cholesterol biosynthesis, thereby resulting in a reduction in plasma levels of cholesterol, particularly peripheral cholesterol, in patients. Based on the results, methods for lowering elevated plasma cholesterol levels in a subject and methods for treating hypercholesterolemia in a subject are disclosed herein. In accordance with the methods described herein, in some embodiments, based on animal data, Compound 1 or a pharmaceutically acceptable salt thereof reduces cholesterol in the periphery of humans, but does not significantly reduce cholesterol in the central nervous system.

[0014] Patients with hypercholesterolemia have elevated plasma cholesterol levels. "Elevated plasma cholesterol levels" refers to plasma levels greater than 170 mg / dL (milligrams per deciliter), greater than 200 mg / d, greater than 210 mg / dL, greater than 220 mg / dL, greater than 230 mg / dL, greater than 240 mg / dL, greater than 250 mg / dL, greater than 260 mg / dL, greater than 270 mg / dL, greater than 300 mg / dL, greater than 3300 mg / dL, or greater than 3600 mg / dL.

[0015] The disclosed method can be used to lower plasma cholesterol levels in diseases or conditions associated with or characterized by elevated blood cholesterol levels. "Diseases or conditions associated with or characterized by elevated blood cholesterol levels" refers to diseases or conditions in which elevated blood cholesterol levels are a common or typical symptom. Examples include familial hypercholesterolemia, atherosclerosis, acute coronary syndrome (ACS), coronary artery disease, peripheral artery disease (PAD), cerebrovascular disease, diabetic cardiovascular disease, macular degeneration, or congestive heart failure.

[0016] Compound 1 can be co-administered to a subject with elevated plasma cholesterol levels or to a subject with hypercholesterolemia in combination with an effective amount of another cholesterol-lowering agent. When co-administered with another agent effective to treat hypercholesterolemia or to lower elevated plasma cholesterol levels, Compound 1 and the other agent can be administered at the same time (in the same or different formulations) or at different times.

[0017] A "cholesterol-lowering drug" is a drug prescribed and / or administered to a human patient with elevated cholesterol levels for the purpose of lowering cholesterol. Examples include statins, PCSK9 inhibitors, selective cholesterol absorption inhibitors, bile acid sequestrants, fibrates, or lipid-lowering therapies.

[0018] Statins are cholesterol-lowering drugs that act by inhibiting HMG-CoA reductase. Examples include atorvastatin (LIPITOR®), fluvastatin (LESCOL XL®), lovastatin (ALTOPREV®), pitavastatin (LIVALO®), pravastatin (PRAVACHOL®), rosuvastatin (CRSTOR®, EZALLOR™), and simvastatin (ZOCAR®, FLOLIPID®).

[0019] PCSK9 inhibitors are cholesterol-lowering drugs that act by inhibiting the proprotein convertase subtilisin / kexin type 9 serine protease. Examples include alirocumab and evolocumab.

[0020] Selective cholesterol absorption inhibitors are cholesterol-lowering drugs that act by inhibiting cholesterol absorption in the intestine. For example, ezetimibe (ZEITA®) is a selective cholesterol cleavage inhibitor that acts by inhibiting the transporter Niemann-Pick C-1-like protein (NPC1L1).

[0021] Bile acid sequestrants are cholesterol-lowering drugs that work by binding bile acids in the intestine and increasing their excretion in the feces. This reduces the amount of bile acids returning to the liver, allowing the liver to produce more bile acids to replace those lost in the feces. To produce more bile acids, the liver converts more cholesterol into bile acids, thereby lowering blood cholesterol levels. Examples include cholestyramine (QUESTRAN®, PREVALITE®), colestipol (COLESTID®), and colesevelam (WELCHOL®).

[0022] Fibric acid derivatives (fibrates) are a type of medication that lowers blood triglyceride levels. Fibrates lower blood triglyceride levels by reducing VLDL (triglyceride-containing particles circulating in the blood) produced by the liver and accelerating the removal of triglycerides from the blood. Fibrates are also moderately effective in increasing blood HDL cholesterol levels. Examples of fibrates include gemfibrozil (LOPID®) and fenofibrate (TRJICOR®, FIBRICOR®).

[0023] Other cholesterol-lowering medications include fish oil, niacin (nicotinic acid) cholestin, bempedoic acid (NEXLETOL®), and probucol.

[0024] An "effective amount" refers to an amount of an agent that alleviates one or more symptoms of a disease or condition and / or slows the progression of the disease or condition. With respect to Compound 1 used to treat hypercholesterolemia or to lower elevated plasma cholesterol levels, an "effective amount" includes an amount that lowers plasma cholesterol levels or otherwise alleviates the symptoms of a disease or condition associated with elevated plasma cholesterol levels. Examples include, but are not limited to, reducing atherosclerosis, reducing arterial wall stiffness, and reducing isolated systolic hypertension. Exemplary effective amounts of Compound 1 for lowering elevated plasma cholesterol levels or treating hypercholesterolemia include, but are not limited to, 10 mg to 60 mg per day (or an amount of a pharmaceutically acceptable salt of Compound 1 equivalent to 10 to 60 mg of Compound 1), e.g., 10 mg per day, 30 mg per day, or 60 mg per day. Exemplary effective amounts of a pharmaceutically acceptable salt of Compound 1 include, but are not limited to, amounts equivalent to 10 mg / day to 60 mg / day of Compound 1, for example, an amount equivalent to 10 mg / day, 30 mg / day, or 60 mg / day of Compound 1. In some embodiments, an effective amount of Compound 1 can be 10 mg to 20 mg / day, 20 mg to 30 mg / day, 30 mg to 40 mg / day, 40 mg to 50 mg / day, or 50 mg to 60 mg / day. In some embodiments, an effective amount of a pharmaceutically acceptable salt of Compound 1 can be an amount equivalent to 10 mg to 20 mg / day, 20 mg to 30 mg / day, 30 mg to 40 mg / day, 40 mg to 50 mg / day, or 50 mg to 60 mg / day of Compound 1.

[0025] As used herein, when a range of values ​​is expressed, the range includes both endpoints. For example, an amount of 10 mg to 60 mg includes 10 mg and 60 mg. Similarly, an amount of 10 mg to 20 mg includes 10 mg and 20 mg.

[0026] "Subject" and "patient" may be used interchangeably and refer to a mammal in need of treatment, such as companion animals (e.g., dogs, cats, etc.), livestock (e.g., cows, pigs, horses, sheep, goats, etc.), and laboratory animals (e.g., rats, mice, guinea pigs, etc.). Typically, the subject is a human in need of treatment.

[0027] The synthetic preparation of Compound 1 and suitable formulations for Compound 1 are described in US Pat. No. 9,340,527, the teachings of which are incorporated herein by reference in their entirety.

[0028] The two substituents on the cyclohexyl group of Compound 1 have a cis configuration relative to each other. When Compound 1 is referred to by name or structure, its stereochemical purity is at least 90%, at least 95%, at least 98%, or at least 99% by weight. Stereochemical purity is the weight ratio of compounds in the cis configuration to the sum of compounds in the cis and trans configurations.

[0029] The present invention is illustrated by the following examples, which are not intended to be limiting in any way. [Example]

[0030] Example 1-7 - Compound 1 inhibits the activity of DHCR7 as demonstrated by the accumulation of DHC Forty-two healthy volunteers received Compound 1 QD for 28 days (or until early withdrawal). Six participants per cohort received 1 mg (Cohort 1), 3 mg (Cohort 2), 10 mg (Cohort 3), 30 mg (Cohort 4), a 60 mg loading dose with a 10 mg maintenance dose (Cohort 5), 60 mg Compound 1 (Cohort 6), or a 90 mg loading dose on Day 1 and a 30 mg maintenance dose on Day 2 (Cohort 7). Fourteen patients also received placebo in this study. One patient in Cohort 4 accidentally dosed on Day 19 and appeared to have received at least one 30 mg dose of Compound 1. The following variations in the following procedures were reported in participants in Cohorts 1–5: they received water ad libitum before dosing (with no restrictions for 1 h before and after dosing) and food 30 min after dosing (rather than 4 h after dosing). A total of 49 patients completed treatment, including 37 patients who received active treatment.

[0031] Participants received their first dose of study treatment (Compound 1 or placebo) on Day 1 and continued to receive study treatment once daily through Day 28. Participants remained in the clinic throughout the treatment period. Participants were discharged on Day 29 after completing all assessments.

[0032] Blood was collected periodically from each volunteer and immediately stored at −80° C. To measure metabolite concentrations in human serum, samples were centrifuged and the resulting supernatant was used for further analysis.

[0033] Free oxysterols were extracted from samples with methanol using a filter plate from the Biocrates Kit. The plate was pre-loaded with an internal standard mixture. Metabolite concentrations were measured by UHPLC-MS / MS in multiple reaction monitoring (MRM) in positive mode using a SCIEX API 5500 QTRAP® (AB SCIEX, Darmstadt, Germany) instrument equipped with electrospray ionization (ESI). Data were quantified using appropriate mass spectrometry software and imported into Biocrates Met / DQ™ software for further analysis.

[0034] The mean circulating total cholesterol levels in healthy volunteers are shown in Figure 1, which demonstrates a progressive, time- and dose-dependent reduction in total circulating cholesterol.

[0035] Based on these observations, we used Monolix to develop a population PK / PD model that describes circulating cholesterol concentrations as a function of Compound 1 plasma concentration and exposure. The model was developed from cholesterol data from the study described above (Study 1) as well as two additional clinical studies in healthy volunteers (Studies 2 and 3). In Study 2, 30 healthy volunteers received a single dose of Compound 1, with six individual patients per cohort: 3 mg (Cohort 1), 10 mg (Cohort 2), 30 mg (Cohort 3), 60 mg (Cohort 4), and 100 mg (Cohort 5). Nine patients also received placebo in this study. In Study 3, eight healthy adult volunteers received a single 30 mg dose of Compound 1.

[0036] Circulating cholesterol levels in this model are reduced at all daily doses above 10 mg. Although variability in the data affects the predicted effect, the model provides clear evidence for a dose-dependent reduction in circulating cholesterol levels. The EC 50is approximately 3 μg / mL, which approximates the steady-state concentration of Compound 1 at a daily dose of 60 mg.

[0037] Healthy patients receiving a 60 mg dose in Study 1 experienced an average reduction in total cholesterol of approximately 20%, which is currently believed to be greater than the high-density lipoprotein fraction, with the low-density lipoprotein fraction contributing more. The model predicts that circulating cholesterol will decrease by approximately 35% at the 60 mg QD dose level. Higher doses of Compound 1 may reduce circulating cholesterol levels to a greater extent, but are also more likely to cause neutropenia. The reduction in circulating cholesterol is expected to occur over a time frame consistent with the increase in steady-state concentrations of Compound 1 in plasma (approximately 15 days), after which circulating cholesterol levels are expected to stabilize over the treatment period. The model predicts that circulating cholesterol will return to baseline within approximately 30 days after discontinuing Compound 1 treatment. The model also predicts that both the rate of reduction and the rate of recovery of circulating cholesterol levels will be limited by the rate of accumulation and clearance of Compound 1 in plasma. The predicted steady-state concentrations of circulating cholesterol during treatment with Compound 1 at the dose range used in the clinical study are shown in Figure 2.

[0038] Example 2 - Compound 1 induces 7-DHC accumulation, desmosterol reduction, and no change in cholesterol in rat OPCs Enriched populations of oligodendrocytes from postnatal day 2 (P2) female Sprague-Dawley rats were grown in culture. Briefly, forebrains were dissected and placed in Hank's buffered salt solution (HBSS) (Life Technologies). Tissue was cut into 1 mm fragments and incubated in 0.01% trypsin and 10 μg / mL DNase for 15 minutes at 37°C. Dissociated cells were placed in poly-D-lysine (PDL)-coated T75 tissue culture flasks and grown in Dulbecco's modified Eagle's medium (DMEM) containing 20% ​​fetal bovine serum (Life Technologies) at 37°C for 10 days. Oligodendrocyte precursors (A2B5+) were harvested by shaking the flasks overnight at 200 rpm at 37°C, resulting in a 95% pure population. Cultures were maintained for 2–3 days in defined growth medium (high-glucose DMEM, 0.1% BSA, 50 μg / mL apotransferrin, 5 μg / mL insulin, 30 nM sodium selenite, 10 nM biotin, and hydrocortisone) containing 10 ng / mL fibroblast growth factor / platelet-derived growth factor (FGF / PDGF). To measure the ability of compound 1 to promote the differentiation of rat A2B5+ progenitor cells into mature myelin basic protein-positive (MBP+) myelinating oligodendrocytes, A2B5+ cells were plated into 10 cm PDL-coated culture plates in FGF / PDGF-free growth medium supplemented with 10 ng / mL CNTF and 15 nM T3 and immediately treated with compound 1. Cell pellets were collected at 24 and 72 hours in culture and stored at -80°C. The cell pellets were then shipped to Metabolon (Morrisville, NC, USA) and kept at -80°C during shipping and storage until processing. Cell pellet samples were extracted with methanol for 2 minutes with vigorous agitation (Glen Mills GenoGrinder 2000) to precipitate proteins and separate small molecules bound to proteins or trapped in the precipitated protein matrix, followed by centrifugation to recover chemically diverse metabolites. The resulting extracts were then aliquoted and analyzed on Metabolon's HD4 platform.Several types of quality control samples were applied during sample preparation and analysis for quality assessment and screening of failed samples, including recovery standards added before extraction, technical replicates from pools combined from each experimental sample, process, and solvent controls and spiked with a cocktail of QC standards.

[0039] Metabolon data revealed that compound 1 treatment increased DHCR7 substrate 7-DHC accumulation and decreased or trended toward decreased accumulation of the DHCR7 products desmosterol and cholesterol in cultures compared to vehicle controls at the same time points. At 24 hours, OPC cultures treated with compound 1 showed 8.3-fold increased 7-DHC (p=2.5e-5, q=0.005), 0.44-fold increased desmosterol (p=0.002, q=0.15), and 0.64-fold increased cholesterol (p=0.018, q=0.15). By 72 hours, OPC cultures treated with compound 1 showed 12.86-fold increased 7-DHC (p=8.1e-8, q=2.6e-5), 0.4-fold increased desmosterol (p=0.001, q=0.022), and minimal changes in cholesterol. Please refer to Figure 3.

[0040] Data suggest that Compound 1, although shown to lower peripheral cholesterol levels in humans, does not lower cholesterol levels in rat OPCs. The claims as filed are set forth below. [Claim 1] 1. A method for lowering elevated plasma cholesterol levels in a subject, comprising administering to the subject an effective amount of Compound 1: [ka] or a pharmaceutically acceptable salt thereof. [Claim 2] 1. A method for treating a subject with hypercholesterolemia, comprising administering to said subject an effective amount of Compound 1: [ka] or a pharmaceutically acceptable salt thereof. [Claim 3] 10. The method of claim 1, wherein the elevated plasma cholesterol levels are associated with familial hypercholesterolemia, atherosclerosis, acute coronary syndrome (ACS), coronary artery disease, peripheral artery disease (PAD), cerebrovascular disease, diabetic cardiovascular disease, macular degeneration, or congestive heart failure. [Claim 4] 4. The method of claim 1, further comprising co-administering to the subject an effective amount of a second pharmaceutically active agent, wherein the second pharmaceutically active agent is a cholesterol-lowering agent. [Claim 5] 5. The method of claim 4, wherein the cholesterol-lowering agent is a statin, a PCSK9 inhibitor, a selective cholesterol absorption inhibitor, a bile acid sequestrant, a fibrate, or a lipid-lowering therapy. [Claim 6] 6. The method of claim 1, wherein the subject is administered 10 mg to 60 mg per day of Compound 1, or a pharmaceutically acceptable salt thereof in an amount equivalent to 10 mg to 60 mg per day of Compound 1. [Claim 7] The method according to any one of claims 1 to 5, wherein the subject is administered 10 mg to 60 mg of compound 1 per day. [Claim 8] The method of any one of claims 1 to 5, wherein the subject is administered 10 mg / day of Compound 1. [Claim 9] The method according to any one of claims 1 to 5, wherein the subject is administered 30 mg / day of Compound 1. How to do it. [Claim 10] The method of any one of claims 1 to 5, wherein the subject is administered 60 mg / day of Compound 1.

Claims

1. 1. A formulation for use in a method for lowering elevated plasma cholesterol levels in a subject, comprising: The formulation comprises an effective amount of Compound 1 or a pharmaceutically acceptable salt thereof: 【Chemistry 1】 Including, The formulation, wherein the method comprises administering an effective amount of Compound 1 or a pharmaceutically acceptable salt thereof.

2. 1. A formulation for use in a method of treating a subject with hypercholesterolemia, comprising: The formulation comprises an effective amount of Compound 1 or a pharmaceutically acceptable salt thereof: 【Chemistry 2】 Including, The formulation, wherein the method comprises administering an effective amount of Compound 1 or a pharmaceutically acceptable salt thereof.

3. The formulation of claim 1, wherein the subject has a disease or condition characterized by elevated blood cholesterol levels, and the disease or condition is familial hypercholesterolemia, atherosclerosis, acute coronary syndrome (ACS), coronary artery disease, peripheral arterial disease (PAD), cerebrovascular disease, diabetic cardiovascular disease, macular degeneration, or congestive heart failure.

4. 4. The formulation of any one of claims 1 to 3, wherein the method further comprises co-administering to the subject an effective amount of a second pharmaceutically active agent, wherein the second pharmaceutically active agent is a cholesterol-lowering agent.

5. 5. The formulation of claim 4, wherein the cholesterol-lowering drug is a statin, a PCSK9 inhibitor, a selective cholesterol absorption inhibitor, a bile acid sequestrant, or a fibrate.

6. 6. The formulation of any one of claims 1 to 5, wherein the subject is administered 10 mg to 60 mg per day of Compound 1, or a pharmaceutically acceptable salt thereof in an amount equivalent to 10 mg to 60 mg per day of Compound 1.

7. The formulation of any one of claims 1 to 5, wherein the subject is administered 10 mg to 60 mg / day of Compound 1.

8. The formulation of any one of claims 1 to 5, wherein the subject is administered 10 mg / day of Compound 1.

9. The formulation of any one of claims 1 to 5, wherein the subject is administered 30 mg / day of Compound 1.

10. The formulation of any one of claims 1 to 5, wherein the subject is administered 60 mg / day of Compound 1.

Images