Pharmaceutical composition for the treatment of autosomal dominant polycystic kidney disease

Abstract

The objective is to provide a dosage and administration method for an orally administered pharmaceutical composition containing the active ingredient tamibarotene for the treatment and / or prevention of autosomal dominant polycystic kidney disease. This disclosure provides a pharmaceutical composition containing tamibarotene for the treatment or prevention of autosomal dominant polycystic kidney disease, which is orally administered to patients with autosomal dominant polycystic kidney disease at a dose of 1.4-5.5 mg / day, particularly about 4 mg / day.

Description

[Technical Field]

[0001] This disclosure relates to the dosage and administration of an orally administered pharmaceutical composition containing the active ingredient tamibarotene for the treatment and / or prophylaxis of autosomal dominant polycystic kidney disease. [Background technology]

[0002] Autosomal dominant polycystic kidney disease (ADPKD), a refractory genetic disorder, progressively forms numerous cysts in the kidneys and progresses to end-stage renal failure in middle age or later. The causative genes for ADPKD are PKD1 in 85% of cases and PKD2 in 15% of cases. Research has been conducted using disease model mice and experimental animals such as rats with modified genes, but a complete understanding of the disease mechanism has not been achieved, and no curative treatment has been developed.

[0003] Tolvaptan, the only vasopressin V2 receptor antagonist approved and used as a treatment for ADPKD, suppresses cyst formation and renal dysfunction, but its effects are limited and it cannot be considered a curative treatment. Furthermore, tolvaptan can cause serious side effects such as severe liver dysfunction, and its strong diuretic effect requires patients to take it to prevent dehydration and hypernatremia, resulting in various behavioral restrictions such as frequent fluid intake and urination. Therefore, there is a need to develop a curative drug that can improve patients' quality of life.

[0004] In recent years, disease-specific iPS cells have been established by introducing causative gene mutations into iPS cells derived from somatic cells of patients with intractable diseases or iPS cells derived from healthy individuals. in vitro In this research, there is a growing effort to create disease models that reproduce the disease state by inducing differentiation into affected cell types, and to conduct detailed pathological analysis and drug discovery.

[0005] To develop therapeutic drugs for ADPKD, the inventors created a renal cyst model in which cysts spontaneously form in a 3D culture of renal collecting duct tissue, using a novel differentiation induction method developed by the inventors from disease-specific iPS cells created by introducing a mutation into the PKD1 gene, one of the causative genes of ADPKD, into iPS cells derived from healthy individuals. Using this disease model, they found that retinoic acid receptor agonists such as TTNPB and AM80 (tamibarotene) suppress cyst formation. Retinoic acid receptor agonists suppress cyst formation in the ADPKD mouse model. in vivo It was confirmed that this suppresses the process (Patent Document 1: WO 2024 / 090521).

[0006] Tamibarotene or AM80 (CAS number: 94497-51-5) is approved as a treatment for relapsed or refractory acute promyelocytic leukemia and is marketed as "Amnoleik® Tablets 2mg" (Non-Patent Literature 1). [Prior art documents] [Patent Documents]

[0007] [Patent Document 1] International Public Publication WO2024 / 090521 [Non-patent literature]

[0008] [Non-Patent Document 1] Amnolake(R) Tablets 2mg Package Insert (Revised October 2022 (1st Edition)) [Overview of the Initiative] [Problems that the invention aims to solve]

[0009] This disclosure aims to provide a pharmaceutical composition comprising tamibarotene for the treatment and / or prevention of autosomal dominant polycystic kidney disease (ADPKD) in humans. More specifically, this disclosure aims to provide a pharmaceutical composition for the treatment of ADPKD comprising a specific dose of tamibarotene. [Means for solving the problem]

[0010] This disclosure provides a pharmaceutical composition for the treatment or prevention of autosomal dominant polycystic kidney disease, comprising tamibarotene as an active ingredient, to be orally administered to human subjects at a dose of 1.4-5.5 mg / day.

[0011] This disclosure also provides a pharmaceutical composition for the treatment or prevention of autosomal dominant polycystic kidney disease, comprising tamibarotene as an active ingredient, to be orally administered to human subjects at approximately 4 mg / day as tamibarotene. [Brief explanation of the drawing]

[0012] [Figure 1] Figure showing the results of Reference Example 1. An in vitro renal cyst model of ADPKD, an artificial collecting tubule organoid with cystic structure (ADPKD), was developed from human iPS cell line 1383D2 with PKD1 knockout. Treatment with tamibarotene 0.01 μM and 0.1 μM for 3 days showed an inhibitory effect on cyst growth. Data from three independent experiments are shown as mean ± SD (n=3). Student's t-test was performed. [Figure 2] Results of Example 1. Adult-onset ADPKD mouse models were orally administered tamibarotene once daily at 0.2 mg / kg and 1.0 mg / kg for 28 days. The figure shows the difference in body weight between mice that received tamibarotene and those that did not. [Figure 3] This figure shows the difference in urea nitrogen (UN) levels between mice administered tamibarotene and those not administered tamibarotene in Example 1. [Figure 4-1]Cross-sectional images of cystic kidneys of model mice administered with or without Tamibarotene in Example 1. [Figure 4-2] Kidney weight-to-body weight ratio (2KW / BW) and kidney Cystic index of model mice administered with or without Tamibarotene in Example 1. [Figure 5-1] Cross-sectional views of the livers of model mice administered with or without Tamibarotene in Example 1. [Figure 5-2] Changes in liver weight-to-body weight ratio (LW / BW) and liver Cystic index of model mice administered with or without Tamibarotene in Example 1. [Figure 6] Correlation between the dose of Tamibarotene administered to mice and Cmax. [Figure 7] Correlation between the dose of Tamibarotene administered to mice and AUC0-inf. [Figure 8] Graph showing the results up to the 28th week after the start of a clinical trial in which Tamibarotene is administered daily at 4 mg / day to patients with autosomal dominant polycystic kidney disease.

Mode for Carrying Out the Invention

[0013] In the present disclosure, when a numerical value is accompanied by the term "about", it is intended to include a range of ±10% of that value. For example, "about 20" shall include "18 to 22". A numerical range includes all numerical values between the two endpoints and the numerical values of the two endpoints. "About" with respect to a range is applied to both endpoints of the range. Thus, for example, "about 20 to 30" shall include "18 to 33".

[0014] In the present disclosure, "treatment" means reducing or eliminating the cause of a disease, delaying or stopping the progression of a disease, reducing, alleviating, improving or eliminating its symptoms, and / or suppressing the worsening of its symptoms in a subject having the disease.

[0015] In this disclosure, “prevention” means preventing the onset of the disease in a subject, reducing the likelihood of developing the disease, or reducing or alleviating symptoms if the disease does develop. Here, the onset of the disease includes relapse after cure or remission. Subjects include, for example, subjects who are at high risk of developing the disease but have not yet developed or relapsed. Subjects with a genetic predisposition to ADPKD are included. Examples include genetic mutations in the causative genes of ADPKD (such as PKD1 and PKD2).

[0016] The inventors investigated the effective dose of tamibarotene when administered orally using ADPKD model mice. By obtaining pharmacokinetic parameters at the dose in which efficacy was confirmed in the model mice, and calculating the dose that would yield equivalent pharmacokinetic parameters in humans, they determined the dosage and administration method that would be expected to be effective in humans. A clinical trial was then conducted in ADPKD patients based on this dosage and administration method to confirm its effectiveness.

[0017] Based on studies using a mouse model, it was found that an oral dose of 1.4–5.5 mg / day of tamibarotene is suitable for efficacy in humans. Based on this information, a Phase II clinical trial is being conducted with a dose of 4.0 mg / day of tamibarotene. As a result, cases have been reported in which the administration of 4.0 mg / day of tamibarotene improved subjective symptoms of renal pain. Furthermore, interim results of the clinical trial showed a clear decrease in the rate of increase in bilateral kidney volume (TKV) with tamibarotene administration up to 28 weeks.

[0018] The pharmaceutical composition containing tamibarotene of this application may contain pharmaceutically acceptable carriers or additives. Examples of such carriers or additives include isotonic agents, thickeners, sugars, sugar alcohols, preservatives, bactericides, antibacterial agents, pH adjusters, stabilizers, chelating agents, oily bases, gel bases, wetting agents, surfactants, suspending agents, binders, excipients, lubricants, disintegrants, foaming agents, fluidizing agents, dispersants, emulsifiers, buffers, solubilizers, and antioxidants. A single pharmaceutically acceptable carrier or additive may be used, or two or more may be used in combination.

[0019] The pharmaceutical composition of this application is administered orally. Dosage forms of the pharmaceutical composition include granules, fine granules, powders, coated tablets, tablets, suppositories, powders, capsules, microcapsules, chewable tablets, liquids, suspensions, emulsions, and the like.

[0020] Preferably, the pharmaceutical composition of this application is a tablet containing tamibarotene as the active ingredient. Excipients and additives for the tablet, though not limited to these, include lactose monohydrate, corn starch, hydroxypropyl cellulose, and magnesium stearate. As a pharmaceutical composition containing tamibarotene, commercially available Amnoleik tablets can be used.

[0021] The amount of tamibarotene in a single tablet is not limited, but examples include tablets containing 1 mg, 2 mg, or 4 mg of tamibarotene.

[0022] Tamibarotene should be administered orally once daily at a dose of approximately 4.0 mg / day. The duration of administration can be continued as long as there are no tolerable issues. (Reference Example 1)

[0023] Using PKD1 knockout iPS cells of strain 1383D2, artificial collecting duct organoids with cystic structures were induced by the method described above. The inhibitory effect of tamibarotene on renal collecting duct cyst enlargement was confirmed using the protocol described below. 1. Organoids showing cyst formation were collected in a tube. 2. Remove the culture medium and add 2 mL of Cell Recovery Solution. (4°C, 30 minutes) 3. The gel was dissolved by gently pipetting with a P-1000 pipettor and then centrifuged. (500g, 2 minutes) 4. The supernatant from step 3 was removed, 5 mL of FBS-containing medium (STO medium) was added, and the cysts were separated from the organoids by pipetting. 5. Using a stereomicroscope, the cysts were collected in a 15 mL tube. 6. Remove the supernatant, add 2 mL of Accutase, and treat at 37°C for 5 minutes. 7. The cells were dissociated into single cells by pipetting with a P-1000 pipettor. 8. After passing through the filter, the number of cells was measured. 9. After counting the number of cells, the cell suspension containing the required number of cells was transferred to a tube, and 5 mL of FBS-containing medium (STO medium) was added to stop the Accutase reaction. 5x10 4 To seed cells per well, we calculated the required amount of cell suspension. 10. Centrifugation (200g, 5 minutes) was performed to prepare pellets. 11. Remove the supernatant completely, add DMEM / F12+B27 w / o VA medium (10% Afamin / Wnt3a CM, 200 ng / mL R-Spondin 1, 200 ng / mL FGF1, 10 μM Forskolin, 2.5 μM AVP, 10 μM Y27632), and suspend. 5x10 4 Since we were seeding cells per well, we calculated the required amount of culture medium. 12. Place the cell suspension from step 11 into 50% Matrigel plates that have been prepared in advance, in 5x10 cubic meters. 4 Cells were seeded at a rate of one cell per well. To prevent the Matrigel from breaking down, the cell suspension was added slowly. 13. Cystic structures were created by culturing at 37°C and 5% CO2 for 2 days. 14. The medium was removed, 200 ng / mL FGF1 and 2.5 μM AVP were added to DMEM / F12 + B27 w / o V.A. medium, and tamibarotene was further added to a concentration of 0.01 μM or 0.1 μM, followed by culturing at 37 °C and 5% CO2 for 3 days. DMSO was added to the control. 15. The inside of the well was photographed at 9 locations with a 4× objective lens using a fluorescence microscope (Keyence, BZ-X700), and the cyst area was measured with BZ-X Analyzer to calculate the average value. The results are shown in Figure 1. The inhibitory effect on cyst enlargement was observed at both concentrations of 0.01 μM and 0.1 μM of tamibarotene.

Example

[0024] Creation of ADPKD model mice Pkd1 established by Shibazaki et al. flox / flox The Pkd1 mouse established by Shibazaki S., Hum Mol Genet. 2008, 1505 - 1516 was crossed with the Mx1-Cre mouse (The Jackson Laboratory, Maine, USA) to generate Pkd1 flox / + : Mx1-Cre mice. Furthermore, Pkd1 flox / + : Mx1-Cre mice were crossed with Pkd1 flox / flox mice to generate Pkd1 flox / flox : Mx1-Cre mice. In Pkd1 flox / flox : Mx1-Cre mice, Cre gene expression is under the control of the promoter of the interferon-responsive Mx1 gene by using polyinosinic-polycytidylic acid (pI-pC) that induces interferon production, enabling deletion of Pkd1 at any time (Cre-loxP site-specific recombination). Pkd1 flox / flox : For Pkd1:Mx1-Cre mice, 10 μg / g (BW) of pI-pC was intraperitoneally administered continuously for 6 days from day 10 after birth to delete Pkd1, thereby generating an adult-onset type ADPKD mouse model.

[0025] Tamibarotene was diluted with 100% DMSO, and then further diluted 250-fold with methylcellulose to prepare the tamibarotene solution. Adult-onset ADPKD mouse models were orally administered the tamibarotene solution once daily at a dose of 0.2 mg / kg or 1.0 mg / kg starting at 28 days postnatal. A methylcellulose solution in 0.4% DMSO was administered as a control.

[0026] Urine samples were obtained by collecting urine over a 24-hour period 22 days after the start of administration (50 days after birth). Body weight was measured 28 days after the start of administration (56 days after birth), and all animals were euthanized. The kidneys and livers were removed and their respective weights were measured.

[0027] Measurement of UN (urea nitrogen) Mouse uninhibited urine (UN) levels were measured using the UN-L kit (A666-00, Cerotec Corporation).

[0028] Hematoxylin-eosin (HE) staining and measurement of cystic index The kidneys and livers were fixed with a 4% paraformaldehyde solution, and 4 μm thick paraffin sections were prepared. After deparaffinization, HE staining was performed, and the tissues were photographed with a light microscope. The cystic index was calculated using image analysis and measurement software (WinROOF, Mitani Corporation) as a multiplier of 100 for the entire cystic area / entire kidney tissue area or the entire cystic area / entire liver area. Statistical analysis was performed using the maximum comparison method. The results are shown in Figures 2 to 5.

[0029] There was no difference in body weight between the control (solvent only) and the tamibarotene-administered group (Figure 2), but urea nitrogen (UN) and kidney weight-to-body weight ratio (2KW / BW) were significantly reduced with tamibarotene administration (Figures 3 and 4). There was no difference in renal cystic index with tamibarotene administration (Figure 4), but both liver weight-to-body weight ratio (LW / BW) and liver cystic index were significantly reduced with tamibarotene administration (Figure 5).

[0030] The results from Example 1 confirmed that doses of 0.2 and 1.0 mg / kg / day were effective in suppressing cyst formation in the ADPKD mouse model. [Examples]

[0031] Pharmacokinetics in mice The pharmacokinetics of tamibarotene after oral administration were measured using C57BL / 6J mice. Table 1 and Figure 6 show the pharmacokinetic parameters in mice orally administered tamibarotene. The pharmacokinetics of tamibarotene dose and AUC are also shown. 0-inf The correlation is shown in Figure 7.

[0032] In Example 1, the Cmax at a dose of 0.2 mg / kg in mice in which cyst formation inhibition was confirmed in the ADPKD mouse model was approximately 67 ng / mL. in vitro This concentration was approximately 20 times higher than the 0.01 μM (3.5 ng / mL) concentration at which a cyst enlargement inhibitory effect was observed in the renal cyst model.

[0033] [Table 1]

[0034] Calculation of Human Dosage In the ADPKD mouse model, doses of 0.2 and 1.0 mg / day were confirmed to be effective in suppressing cyst formation, as shown in Table 1 and Figure 7 (AUC). 0-inf And, AUC in APL patients 0-inf Based on the following data (128.37 ng·h / mL when administered tamibarotene 2.0 mg / day, 320.41 ng·h / mL when administered 4.0 mg, and 430.26 ng·h / mL when administered 6.0 mg, from the Amnolake Tablets 2 mg Interview Form), the human dose equivalent to the mouse dose was calculated, and the dose expected to be effective in clinical trials in humans was estimated to be 1.4 to 5.5 mg / body (Table 2).

[0035] [Table 2] [Examples]

[0036] Pharmacokinetics of administration to human ADPKD patients The pharmacokinetics of tamibarotene in patients with ADPKD were investigated in an early Phase II clinical trial. AUC after a single dose of tamibarotene 4 mg / body in 7 ADPKD patients 0-inf The average was 282.1 ng h / mL, and the AUC after repeated administration for 7 days. 0-inf The average dose was 270.6 ng h / mL. These translate to doses of 0.57 mg / body and 0.54 mg / body, respectively, when administered to mice (Table 3). Therefore, the human dose of 3.3 to 5.5 mg / body, which corresponds to the mouse dose of 0.365 to 0.905 mg / kg in Table 2 of Example 2, is approximately the same, confirming that the clinical dose predicted from the PK results of tamibarotene in APL patients is also appropriate in ADPKD patients.

[0037] [Table 3] [Examples]

[0038] Phase 2 Clinical Trial Study objective: To evaluate the efficacy, safety, and pharmacokinetics of tamibarotene when administered to patients with autosomal dominant polycystic kidney disease (ADPKD).

[0039] Participants: A Phase II clinical trial was conducted in patients diagnosed with ADPKD according to the modified Pei-Ravine criteria described below. • Equivalent to Class 1C, 1D, and 1E according to the Mayo classification system. • Estimated glomerular filtration rate (eGFR) value [Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) cr-cys] is 60 mL / min / 1.73m²2 That's all. • At the time of obtaining consent, it was determined that treatment with tolvaptan was difficult, or the patient did not wish to receive treatment with tolvaptan. • Systolic blood pressure is 140 mmHg or less and diastolic blood pressure is 90 mmHg or less Furthermore, for patients receiving angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists, the dosage must have remained constant for at least 6 weeks prior to obtaining informed consent.

[0040] Patient Exclusion Criteria • Pregnant women or patients who may be pregnant • Breastfeeding patients • Female subjects of childbearing age or male subjects with childbearing partners who are unable to use contraception during the following periods. 1) Female: From obtaining consent until 2 years after the last administration of the investigational drug. 2) Male: From obtaining consent until 6 months after the last dose of the investigational drug. • Patients who have used medications that affect renal cysts (tolvaptan, immunosuppressants, somatostatin analogs, sodium glucose cotransporter 2 (SGLT2) inhibitors, biguanide-type diabetes medications, pioglitazone-containing preparations) and whose period from the last dose to the first dose of the investigational drug is within 12 weeks. • Patients with complications of intracranial aneurysms requiring treatment • Patients with concomitant malignant tumors Patients who have been diagnosed with diabetes and are receiving treatment but whose hemoglobin A1c (HbA1c) is 7.0% or higher. • Patients with lumbar spine bone mineral density < 70% by dual-energy X-ray absorptiometry (DEXA), or those with fragility fractures in any part of the body. Patients whose low-density lipoprotein (LDL) cholesterol is 160 mg / dL or higher, or triglycerides (TG) are 175 mg / dL or higher, despite treatment for dyslipidemia. Patients in whom either aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels exceed the upper limit of the normal range.

[0041] Usage, dosage Administer tamibarotene 4.0 mg (tablet) or placebo tablet orally once daily for 52 weeks.

[0042] Confirmation of the effect CT images of the kidney region of the study subjects were obtained at the time of obtaining informed consent to participate in the clinical trial, at the start of tamibarotene administration, and 28 weeks after the start of administration. The period from obtaining informed consent to the start of administration was less than one year. Using the image analysis software SYNAPSE VINCENT (Fujifilm Corporation), a radiologist obtained bilateral kidney volume (TKV) from the CT image data in accordance with standard procedures.

[0043] Clinical trial progress report Table 4 and Figure 8 show the changes (slope) in bilateral kidney volume (TKV) in 7 patients who received oral administration of tamibarotene 4.0 mg (tablets) once daily for 28 weeks (6 months).

[0044] [Table 4]

[0045] As is clear from Figure 8, in 5 out of 7 cases, administration of tamibarotene clearly reduced the rate of increase in TKV kidney volume.

Claims

1. A pharmaceutical composition containing tamibarotene for the treatment or prevention of autosomal dominant polycystic kidney disease, administered orally at a dose of 1.4–5.5 mg / day to patients with autosomal dominant polycystic kidney disease.

2. A pharmaceutical composition containing tamibarotene for the treatment or prevention of autosomal dominant polycystic kidney disease, administered orally at approximately 4 mg / day to patients with autosomal dominant polycystic kidney disease.

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