Antifungal agents used in combination

Abstract

The present invention relates to the use of enfumafungin derivative triterpenoid antifungal compounds in combination with other antifungal agents, such as azoles, polyenes, lipopeptides, and allylamides, for treating fungal diseases. More particularly, the present invention relates to antifungal combinations of enfumafungin derivative triterpenoids that are inhibitors of (1,3)-β-D-glucan synthesis, in combination with other antifungal agents, such as fungal activators having activity against fungi, including but not limited to voriconazole, isavuconazole, posaconazole, itraconazole, and amphotericin B, for treating and / or preventing infections caused by fungi.

Description

Technology Field

[0001] The present invention relates to the use of enfumafungin derivative triterpenoid antifungal compounds in combination with other antifungal agents, such as azoles, polyenes, lipopeptides, and allylamides, for treating fungal diseases. More particularly, the present invention relates to antifungal combinations of (1,3)-β-D-glucan synthesis inhibitors of enfumafungin derivative triterpenoids (or pharmaceutically acceptable salts thereof) in combination with other antifungal agents, such as fungal activators having activity against fungi, including but not limited to voriconazole, isavuconazole, posaconazole, itraconazole, and amphotericin B, for treating and / or preventing infections caused by fungi. Background Technology

[0002] Fungal infections caused by mold are a major medical problem with a high mortality rate. Aspergillus ( Aspergillus ) species, Zygomycetes, Fusarium( Fusarium ) species, and Sedosporium ( Scedosporium Several fungi, including species, can cause systemic fungal infections. Among these, Aspergillus species are the most common, accounting for approximately 85% of cases. Invasive pulmonary aspergillosis is a life-threatening infection in immunocompromised patients with a high mortality rate (ranging from 20 to 40%), despite the availability of antifungal agents active against the causative pathogen (Aspergillus species). The first-line recommended treatment option for invasive aspergillosis is fungically active azole antifungal agents (e.g., voriconazole, isavuconazole, posaconazole, and itraconazole). Amphotericin B agents are a second-line option due to significant nephrotoxicity. Despite the availability of fungically active antifungal agents, treatment outcomes are not optimal, leading to frequent treatment failure and mortality.

[0003] Furthermore, the emergence of azole-resistant Aspergillus species has further limited treatment options for patients. Different and more effective therapeutic approaches are required, and combination therapy can play an important role. Effective combination therapy should include antifungal agents that exhibit synergistic interactions that, when administered together, can potentially increase antifungal efficacy and / or reduce toxicity and / or promote faster healing, prevent or avoid the emergence of resistance, or provide a broader spectrum of antifungal activity compared to monotherapy. However, combination therapy can also be harmful in the case of antagonistic interactions, reduce antifungal efficacy, or increase toxicity.

[0004] Enpumapunjin is Juniperus communis ( Common juniper Hormonema associated with the fresh leaves of ) Hormones It is a hemiacetal triterpene glycoside produced during the fermentation of ) species (U.S. Patent No. 5,756,472; literature [Pelaez et al., Systematic and Applied Microbiology , 23:333-343, 2000; Schwartz et al., JACK , 122:4882-4886, 2000; Schwartz, R.E.; Expert Opinion on Therapeutic Patents [ , 11(11):1761-1772, 2001]). Enfumafungin is one of several triterpene glycosides with in vitro antifungal activity. The mode of antifungal action of enfumafungin and other antifungal triterpenoid glycosides was determined to be the inhibition of fungal cell wall glucan synthesis by their specific action on (1,3)-β-D-glucan synthase (Onishi et al., Antimicrobial Agents and Chemotherapy , 44:368-377, 2000; Pelaez et al., Systematic and Applied Microbiology(1,3)-β-D-glucan synthase is present in many pathogenic fungi and thus provides a broad antifungal spectrum, making it an attractive target for antifungal drug action; furthermore, since there are no mammalian counterparts, consequently, these compounds have little to no mechanism-based toxicity. The triterpenoid compound derivatives of enfumafungin related to the present invention have been proven to be active against fungal isolates resistant to other glucan synthase inhibitors (e.g., lipopeptide agonists, echinocandins), which indicates that the biological and molecular targets of enfumafungin derivatives differ from those of other glucan synthase inhibitors.

[0005] Various enfumafungin derivatives have been disclosed, for example, in international patent publication numbers WO 2007 / 126900 and WO 2007 / 127012.

[0006] Previous studies have evaluated the efficacy of other antifungal agents combined for the treatment of Aspergillus species infections, but have not conclusively demonstrated improved outcomes (Marr K, et al., Ann Intern Med. 2015;162:81-89). These suboptimal outcomes with combination therapies of available antifungal agents may be related to the lack of availability of oral formulations (e.g., oral formulations for echinocandin and amphotericin B), which limits their long-term use (which is often necessary for the treatment of fungal infections) and, in particular, the emergence of resistance to azoles (the only agents available for oral and IV administration for Aspergillus infections). Other limitations of currently available antifungal agents for the treatment of fungal infections include the high risk of drug-to-drug interactions with azoles and nephrotoxicity associated with amphotericin B. There is a need in the relevant technology field for antifungal combinations suitable for long-term combination therapy as needed for the treatment of fungal infections, which provide improved healing and survival outcomes for fungal infections. Additionally, there is a need to use a combination of safe and effective antifungal agents that can reduce the use of amphotericin B and azoles (e.g., by reducing the daily dose or the duration of treatment), thereby minimizing the associated toxicity risks.

[0007] The present invention relates to enfumafungin derivatives used in combination with other fungically active antifungal agents for the treatment and / or prevention of fungal infections. Enfumafungin derivatives and pharmaceutically acceptable salts thereof are useful for inhibiting (1,3)-β-D-glucan synthase, and Aspergillus, Mucor ( I am sick.It is useful to combine with other fungal active agents in the prevention or treatment of fungal infections caused by one or more of various pathogens, including but not limited to species such as ), Fusarium, and Sedosporium. The present invention addresses the needs in the relevant technical field as described above because at least the enfumafungin derivatives are active against azole-resistant Aspergillus strains, can be administered both intravenously and orally, and have a very low risk of drug-to-drug interactions, and the use of these in the combinations described herein overcomes the limitations of other antifungal compounds and combinations.

[0008] The present invention

[0009] (a) a compound of the following formula (I), or a salt thereof that is permitted under the constraints;

[0010] (b) a second antifungal agent, e.g., a fungal activator having activity against fungi, e.g., an antifungal azole compound or a polyene, e.g., amphotericin B

[0011] Provides a combination of:

[0012]

[0013] In the above formula:

[0014] X is O or H, H and;

[0015] R e is C(O)NR f R g or a six-membered ring heteroaryl group containing one or two nitrogen atoms, wherein the heteroaryl group is optionally monosubstituted with fluoro or chloro on the ring carbon or monosubstituted with oxygen on the ring nitrogen;

[0016] R f , R g , R 6 and R 7 Each is independently hydrogen or C1-C3 alkyl;

[0017] R 8is a C1-C4 alkyl, C3-C4 cycloalkyl, or C4-C5 cycloalkyl-alkyl;

[0018] R 9 is methyl or ethyl;

[0019] R 8 and R 9 It forms a six-membered saturated ring containing one oxygen atom together.

[0020] The present invention also provides a method for treating or preventing fungal infections in a patient by using a compound of formula (I) in combination with a second antifungal agent. Brief explanation of the drawing

[0021] Figure 1 Aspergillus fumigatus that was not treated with an antifungal agent (control group), or subsequently treated with SCY-078 alone, isavuconazole alone, or a combination of SCY-078 and isavuconazole ( Aspergillus smoked This is a graph showing the cumulative survival probability from a study of New Zealand white rabbits inoculated with the isolate. Figure 2 This is a graph showing the pulmonary infarction score from the study mentioned in Figure 1. Figure 3 Figure 1 is a graph showing the level of galactomannan antigen detected in the serum of rabbits from the study mentioned in Figure 1. Specific details for implementing the invention

[0022] The present invention

[0023] (a) a compound of the following formula (I), or a salt thereof that is permitted under the constraints;

[0024] (b) a second antifungal agent, e.g., a fungal activator having activity against fungi, e.g., an antifungal azole compound or a polyene, e.g., amphotericin B

[0025] Provides a combination of:

[0026]

[0027] In the above formula:

[0028] X is O or H, H and;

[0029] R e is C(O)NR f R g or a six-membered ring heteroaryl group containing one or two nitrogen atoms, wherein the heteroaryl group is optionally monosubstituted with fluoro or chloro on the ring carbon or monosubstituted with oxygen on the ring nitrogen;

[0030] R f , R g , R 6 and R 7 Each is independently hydrogen or C1-C3 alkyl;

[0031] R 8 is a C1-C4 alkyl, C3-C4 cycloalkyl, or C4-C5 cycloalkyl-alkyl;

[0032] R 9 is methyl or ethyl;

[0033] R 8 and R 9 It forms a six-membered saturated ring containing one oxygen atom together.

[0034] The present invention also,

[0035] (a) a compound of the following chemical formula (Ia), or a salt thereof that is permitted under the constraints;

[0036] (b) a second antifungal agent, e.g., a fungal activator having activity against fungi, e.g., an antifungal azole compound or a polyene, e.g., amphotericin B

[0037] Provides a combination of:

[0038]

[0039] In the above formula, the substituents are as provided for chemical formula (I).

[0040] In Embodiment 1: X is H, H, and other substituents are as provided for Chemical Formula (I).

[0041] In Embodiment 2: R e is optionally pyridyl or pyrimidinyl that is monosubstituted with fluoro or chloro on the ring carbon or monosubstituted with oxygen on the ring nitrogen, and other substituents are as provided in Embodiment 1 or Formula (I).

[0042] In Embodiment 3: R e is 4-pyridyl, and other substituents are as provided in Embodiment 1 or Formula (I).

[0043] In Embodiment 4: R e is C(O)NH2 or C(O)NH(C1-C3 alkyl), and other substituents are as provided in Embodiment 1 or Formula (I).

[0044] In Embodiment 5: R 8 is a C1-C4 alkyl and R 9 is methyl; other substituents are as provided in embodiments 1, 2, 3 or 4, or formula (I).

[0045] In Embodiment 6: R 8 is t-butyl, and R 9 is methyl; other substituents are as provided in embodiments 1, 2, 3 or 4, or formula (I).

[0046] In Embodiment 7: R 6 and R 7 Each is independently hydrogen or methyl, and other substituents are as provided in embodiments 1, 2, 3, 4, 5 or 6, or formula (I).

[0047] In embodiment 1': X is H, H, and other substituents are as provided for chemical formula (Ia).

[0048] In embodiment 2': R eis optionally pyridyl or pyrimidinyl that is monosubstituted with fluoro or chloro on the ring carbon or monosubstituted with oxygen on the ring nitrogen, and other substituents are as provided in Embodiment 1' or Formula (Ia).

[0049] In embodiment 3': R e is 4-pyridyl, and other substituents are as provided in embodiment 1' or formula (Ia).

[0050] In embodiment 4': R e is C(O)NH2 or C(O)NH(C1-C3 alkyl), and other substituents are as provided in Embodiment 1' or Formula (Ia).

[0051] In embodiment 5': R 8 is a C1-C4 alkyl and R 9 is methyl; other substituents are as provided in embodiment 1', 2', 3' or 4', or in formula (Ia).

[0052] In embodiment 6': R 8 is t-butyl, and R 9 is methyl; other substituents are as provided in embodiment 1', 2', 3' or 4', or in formula (Ia).

[0053] In embodiment 7': R 6 and R 7 Each is independently hydrogen or methyl, and other substituents are as provided in embodiments 1', 2', 3', 4', 5' or 6', or formula (Ia).

[0054] In a preferred embodiment, the present invention

[0055] (a) a compound of formula (II) which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazole-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenantro[1,2-c]pyran-7-carboxylic acid, or a pharmaceutically acceptable salt thereof;

[0056] (b) A second antifungal agent selected from voriconazole, isavuconazole, posaconazole, itraconazole, and amphotericin B

[0057] Provides a combination of:

[0058] .

[0059] In another preferred embodiment, the present invention

[0060] (a) a compound of formula (IIa) which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[(2R)-2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazole-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenantro[1,2-c]pyran-7-carboxylic acid (referred herein as SCY-078), or a pharmaceutically acceptable salt thereof;

[0061] (b) A second antifungal agent selected from voriconazole, isavuconazole, posaconazole, itraconazole, and amphotericin B

[0062] Provides a combination of:

[0063] .

[0064] In another preferred embodiment, the present invention provides: a combination of a citrate salt of a compound of formula (II) and a second antifungal agent selected from voriconazole, isavukonazole, posaconazole, itraconazole and amphotericin B.

[0065] In another preferred embodiment, the present invention provides: a combination of a citrate salt of a compound of formula (IIa) and a second antifungal agent selected from voriconazole, isavukonazole, posaconazole, itraconazole, and amphotericin B.

[0066] Another embodiment of the present invention includes the following:

[0067] (aa) a compound of formula (I), (Ia), (II), or (IIa), or a pharmaceutically acceptable salt thereof, and a composition comprising a carrier, ajuvant, or vehicle; and a combination of a second therapeutic agent.

[0068] (bb) A pharmaceutical composition comprising a compound of formula (I), (Ia), (II), or (IIa), or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, ajuvant, or vehicle; and a combination of a second therapeutic agent.

[0069] (cc) A combination of (bb) in which the second therapeutic agent is an azole, polyene, purine or pyrimidine nucleotide inhibitor, orotomide, Gwt1 inhibitor, pneumocandin or echinocandin derivative, protein elongation factor inhibitor, chitin inhibitor, mannan inhibitor, bactericidal / penetrative inducer (BPI) protein product, or immunomodulator.

[0070] (dd) A combination of (cc) in which the second therapeutic agent is itraconazole, ketoconazole, miconazole, fluconazole, voriconazole, posaconazole, amphotericin B, flucytosine, anidulafungin, micapungin, or caspofungin.

[0071] (ee) a compound of formula (I), (Ia), (II), or (IIa), or a pharmaceutically acceptable salt thereof; and a pharmaceutical combination of a second therapeutic agent, wherein said compound (or pharmaceutically acceptable salt thereof) and the second therapeutic agent are used in amounts that make the combination effective for treating or preventing fungal and / or bacterial infections.

[0072] (ff) A combination of (ee) in which the second therapeutic agent is an azole, polyene, purine or pyrimidine nucleotide inhibitor, orotomide, Gwt1 inhibitor, pneumocandin or echinocandin derivative, protein elongation factor inhibitor, chitin inhibitor, mannan inhibitor, bactericidal / penetrative inducer (BPI) protein product, or immunomodulator.

[0073] (gg) A combination of (ff) in which the second therapeutic agent is itraconazole, ketoconazole, miconazole, fluconazole, voriconazole, posaconazole, amphotericin B, flucytosine, anidulafungin, micapungin, or caspofungin.

[0074] (hh) A method for treating or preventing a fungal infection in a subject who requires treatment or prevention of a fungal infection, comprising administering to the subject a combination of a first therapeutic agent which is a compound of formula (I), (Ia), (II), or (IIa) or a pharmaceutically acceptable salt thereof; and a second therapeutic agent effective against fungal and / or bacterial infections.

[0075] (ii) a second therapeutic agent being an azole, polyene, purine or pyrimidine nucleotide inhibitor, orotomide, Gwt1 inhibitor, pneumocandin or echinocandin derivative, protein elongation factor inhibitor, chitin inhibitor, mannan inhibitor, bactericidal / penetrative inducer (BPI) protein product, or immunomodulator, in the method of (hh).

[0076] (jj) Method of (hh) in which the second therapeutic agent is itraconazole, ketoconazole, miconazole, fluconazole, voriconazole, posaconazole, amphotericin B, flucytosine, anidulafungin, micapungin, or caspofungin.

[0077] (kk) A method of (hh) in which the first therapeutic agent is administered sequentially or jointly with the second therapeutic agent.

[0078] (ll) A method of (hh) in which the therapeutic agent is administered intravenously, orally, and / or topically.

[0079] (mm) The method of (hh) in which a fungal infection is caused by Aspergillus species.

[0080] (nn) A method for treating or preventing invasive pulmonary aspergillosis in a subject who requires treatment or prevention of invasive pulmonary aspergillosis, comprising administering to the subject a combination of a first therapeutic agent which is a compound of formula (I), (Ia), (II), or (IIa) or a pharmaceutically acceptable salt thereof; and a second therapeutic agent effective against fungal and / or bacterial infections.

[0081] (oo) A method of (nn) in which the second therapeutic agent is an azole, polyene, purine or pyrimidine nucleotide inhibitor, orotomide, Gwt1 inhibitor, pneumocandin or echinocandin derivative, protein elongation factor inhibitor, chitin inhibitor, mannan inhibitor, bactericidal / penetrative inducer (BPI) protein product, or immunomodulator.

[0082] (pp) Method of (nn) in which the second therapeutic agent is itraconazole, ketoconazole, miconazole, fluconazole, voriconazole, isavuconazole, posaconazole, amphotericin B, flucytosine, anidulafunzine, micapungin, or caspofungin.

[0083] (qq) A method of (nn) in which the first therapeutic agent is administered sequentially or jointly with the second therapeutic agent.

[0084] (rr) A method of (nn) in which the therapeutic agent is administered intravenously, orally, and / or topically.

[0085] (ss) A method for treating a fungal and / or mold infection in a subject requiring treatment for a fungal and / or mold infection, comprising administering to the subject a therapeutically effective amount of: a compound of formula (I), (Ia), (II), or (IIa), or a pharmaceutically acceptable salt thereof, and a carrier, ajuvant, or vehicle; and a second antifungal agent, wherein the combination is synergistic.

[0086] The present invention also relates to a method for reducing the level of galactomannan in a subject who requires the reduction of the level of galactomannan (a component of the cell wall of Aspergillus species), comprising administering to the subject a combination of a first therapeutic agent, which is a compound of formula (I), (Ia), (II), or (IIa), or a pharmaceutically acceptable salt thereof; and a second therapeutic agent effective against fungal and / or bacterial infections. In certain embodiments, the first therapeutic agent is a compound of formula (II) or a pharmaceutically acceptable salt thereof; and the second therapeutic agent is voriconazole, isavuconazole, posaconazole, itraconazole, or amphotericin B. In further embodiments, the first therapeutic agent is a compound of formula (IIa) or a pharmaceutically acceptable salt thereof; and the second therapeutic agent is voriconazole, isavuconazole, posaconazole, itraconazole, or amphotericin B. Galactomannan levels in subjects can be determined, for example, by measuring galactomannan in serum or plasma from blood samples collected from such subjects, or by bronchoalveolar lavage.

[0087] The present invention also comprises any of the aforementioned combinations for use in treating or preventing a fungal infection in a subject requiring treatment or prevention of a fungal infection, for use as a medicine for treating or preventing a fungal infection, or for use in manufacturing a medicine for treating or preventing a fungal infection; or for use in treating or preventing invasive pulmonary aspergillosis in a subject requiring treatment or prevention of invasive pulmonary aspergillosis, for use as a medicine for treating or preventing invasive pulmonary aspergillosis, or for use in manufacturing a medicine for treating or preventing invasive pulmonary aspergillosis.

[0088] In the description of the compounds in the embodiments presented above, the indicated substituents are included only to the extent that such substituents provide a stable compound in accordance with this definition.

[0089] Compounds of chemical formulas (I), (Ia), (II), and (IIa), and their pharmaceutically acceptable salt and / or hydrate forms are acremonium ( Acremonium ), Absidia( Absidia ) [For example, Absidia Corimbiphera( Absinthe corymbifera )], Alternaria( Alternaria ), Aspergillus [e.g., Aspergillus clavatus( Aspergillus clavatus ), Aspergillus flavus( Aspergillus flavus ), Aspergillus fumigatus, Aspergillus nidulans( Aspergillus nesting ), Aspergillus niger( Aspergillus black ), Aspergillus tereus( Aspergillus earthly ), and Aspergillus versicolor ( Aspergillus multicolored )], non-Polaris( Bipolar ), Blastomyces( Blastomyces ) [For example, Blastomyces dermatitidis( Blastomyces dermatitidis )], Blastoszyzomyces( Blastoschizomyces ) [For example, Blastoszymyces capitatus( Blastoschizomyces capitatus )], Candida( White ) [For example, Candida albicans( Candida albicans ), Candida glabrata( Candida glabrata ) (Torulopsis glabrata( Torulopsis glabrata )), Candida gulièremondii( Candida guilliermondii ), Candida kefir( Candida kefir ), Candida Crusae ( Candida krusei ), in Candida Lusitania ( Candida lusitania ), Candida parapsilosys( Candida parapsilosis ), Candida pseudotropicalis( Candida pseudotropical ), Candida Stellatoidea( Candida stellate ), Candida tropicalis( Candida tropicalis ), Candida uutilis( Useful Candida ), Candida repolitica( Candida lipolytica ), Candida farma( Famous white ) and Candida lugosa( White wrinkled )], Cladosporium( Cladosporium ) [For example, Cladosporium carionii( Cladosporium carrionii ) and Cladosporium tricloides ( Cladosporium trichloides )], Cosidioides( Coccidioides ) [For example, Cosidioides imitis( Coccidioides immitis )], Cryptococcus( Cryptococcus ) [For example, Cryptococcus neoformans( Cryptococcus neoformans )], curbularia( Curved ), Kuninghamela( Cunninghamella ) [For example, Kuninghamela Elegans( Cunninghamella elegans )], dermatofite( Dermatophyte ), Exopialla( Exophial ) [For example, Exophiala dermatitidis( Exophiala dermatitidis ) and Exopiala spinifera ( Spiny Exophiala )], Epidermophyton( Epidermophyton ) [For example, epidermophyton flocosum( Epidermophyton floccosum )], Fonsecaea( Fonsecaea ) [For example, Fonsecaea Pedrosoi( Fonsecaea pedrosoi)], Fusarium [e.g., Fusarium solani( Fusarium solani )], Geotrichum( Geotrichum ) [For example, Geotrichum candidum( Geotrichum candidum ) and Geotrichum clavatum ( Geotrichum clavatum )], histoplasma( Histoplasma ) [For example, Histoplasma capsulatum variant capsulatum( Histoplasma capsulatum var. capsulatum )], Malassezia( Malassezia ) [For example, Malassezia purpur( Malassezia furfur )], microsporum( Microsporum ) [For example, Microsporum canis( Microsporum canis ) and Microsporum House Construction ( Microsporum gypseum )], mucor, paracosidioides( Paracoccidioides ) [For example, Paracosidioides brasiliensis( Paracoccidioides brasiliensis )], Penicillium( Penicillium ) [For example, Penicillium marnephei( Penicillium marneffei )], phialophora( Phialophora ), Pitirosforum Ovalle ( Pityrosporum ovale ), Pneumocystis( Pneumocystis ) [For example, Pneumocystis carinii( Pneumocystis carinii )], Sudalesqueria( Pseudallescheria ) [For example, *Schdalescheria voidii*( Pseudallescheria boydii )], Rhizopus( Rhizopus ) [For example, Rhizopus microsporus variant Rhizopodiformis( Rhizopus microsporus var. rhizopodiformis ) and Rhizopus oryzae( Rhizopus oryzae )], Saccharomyces( Saccharomyces ) [For example, to Saccharomyces cerevisiae( Saccharomyces cerevisiae )], Sedosporium [e.g., Sedosporium apiosperum( Scedosporium apiosperum )], Scopulariopsis( Scopulariopsis ), Sporotrix( Sporothrix ) [For example, Sporotrix Shenkii( Sporothrix schenckii )], Trichoderma( Trichoderma ), Trichophyton( Trichophyton ) [For example, Trichophyton mentagropithus( Trichophyton mentagrophytes) and Trichophyton rubrum ( Trichophyton rubrum )], and trichosporon( Trichosporon ) [For example, Trichosporon Asahi( Trichosporon asahii ), Trichosporon beigelii( Trichosporon beigelii ) and Trichosporon kutaneum ( Trichosporon cutaneum It has antimicrobial (e.g., antifungal) activity against yeasts and other fungi, including one or more of )]. The compound is useful against organisms that cause systemic human pathogenic fungal infections, as well as against organisms that cause superficial fungal infections, such as Trichoderma species and other Candida species. The compound is particularly effective against Aspergillus flavus, Aspergillus fumigatus, Candida albicans, Candida parapsilosis, Cryptococcus neoformans, Saccharomyces cerevisiae, and Trichophyton mentagrophytes.

[0090] In terms of antifungal activity, compounds of chemical formulas (I), (Ia), (II), and (IIa), and their pharmaceutically acceptable salt and / or hydrate forms are useful for the treatment and / or prevention of one or more of various superficial, cutaneous, subcutaneous, and systemic fungal infections in the skin, eyes, hair, nails, oral mucosa, gastrointestinal tract, bronchi, lungs, endocardium, brain, meninges, urinary tract, uterine tract, oral cavity, ophthalmology, systemic, kidneys, bronchi, heart, external auditory canal, bones, nasal cavity, paranasal sinuses, spleen, liver, subcutaneous tissue, lymphatic vessels, gastrointestinal tract, joints, muscles, tendons, interstitial plasma cells of the lungs, blood, etc.

[0091] Accordingly, compounds of chemical formulas (I), (Ia), (II), and (IIa), and pharmaceutically acceptable salt and / or hydrate forms thereof, are used for various infectious diseases, e.g., dermatophytosis (e.g., ringworm, tinea, or ringworm infection), athlete's foot, paronychia, pityriasis versicolor, erythematosus, intertrigo, fungal diaper rash, candidal vulvitis, candidal balanitis, otitis externa, candidiasis (cutaneous and mucocutaneous), chronic mucocandidiasis (e.g., thrush and vaginal candidiasis), cryptococcosis, geotrichum, trichosporonosis, aspergillosis, penicillosis, fusarium, zygomycosis, sporotrichum, pilosomycosis, coccidioidomycosis, histoplasmosis, blastomyces, paracoccidioidomycosis, schudalescheriosis, It is useful for preventing or treating one or more of mycosis, fungal keratitis, otomycosis, pyerocysticercosis, and mycemia. The compound may also be used as a prophylactic agent to prevent systemic and local fungal infections. Use as a prophylactic agent may be appropriate, for example, as part of a selective intestinal decontamination regimen to prevent infection in immunocompromised patients (e.g., AIDS patients, patients undergoing cancer therapy, or transplant patients). Prevention of fungal overgrowth during antibiotic treatment may also be desirable in certain disease syndromes or iatrogenic conditions.

[0092] Compounds of formulas (I), (Ia), (II), and (IIa), and their pharmaceutically acceptable salt and / or hydrate forms may be prepared according to the synthesis method disclosed in U.S. Patent No. 8,188,085 (the contents thereof are incorporated herein by reference in their entirety).

[0093] Compounds of chemical formulas (I), (Ia), (II), and (IIa), and can be used in combination with their pharmaceutically acceptable salt and / or hydrate forms AzolExamples include, but are not limited to, voriconazole, isavuconazole, itraconazole, ketoconazole, miconazole, labuconazole, detoconazole, clotrimazole, and posaconazole. Compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with pharmaceutically acceptable salt and / or hydrate forms thereof. polyene Examples include, but are not limited to, amphotericin B, nystatin, liposomes and their lipid forms, e.g., ABELCET®, AMBISOME®, and AMPHOCIL®. Compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with their pharmaceutically acceptable salt and / or hydrate forms. Purine or pyrimidine nucleotide inhibitors Examples of: flucytosine or folixin, such as nicomycin, particularly nicomycin Z or nicomycin X, but not limited thereto. Chitin inhibitors is another class of therapeutic agents that can be used in combination with compounds of chemical formulas (I), (Ia), (II), and (IIa), and their pharmaceutically acceptable salt and / or hydrate forms. Kidney factor inhibitor Examples include, but are not limited to, sordarin and its analogs. Compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with their pharmaceutically acceptable salt and / or hydrate forms. Orotomid Examples include, but are not limited to, F901318, compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with their pharmaceutically acceptable salt and / or hydrate forms. Gwt1 inhibitorExamples include, but are not limited to, APX001. Compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with their pharmaceutically acceptable salt and / or hydrate forms. Pneumocandin or echinocandin derivatives Examples include, but are not limited to, silofungin, anidulafungin, micapungin, and caspofungin. Compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with their pharmaceutically acceptable salt and / or hydrate forms. Mannat inhibitor Examples include, but are not limited to, predamycin. Compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with pharmaceutically acceptable salt and / or hydrate forms thereof. Bactericidal / penetration-inducing (BPI) protein products Examples include, but are not limited to, XMP.97 and XMP.127. Compounds of formulas (I), (Ia), (II), and (IIa), and compounds that may be used in combination with their pharmaceutically acceptable salt and / or hydrate forms. Immunomodulators Examples of: interferons (e.g., IL-1, IL-2, IL-3, and IL-8), defensin, tacrolimus, and G-CSF (granulocyte colony-stimulating factor), but are not limited thereto.

[0094] As used herein, the term "alkyl" refers to any linear or branched chain alkyl group having a number of carbon atoms within the specified range. Thus, for example, "C 1-6 "alkyl" (or "C1-C6alkyl") refers not only to hexylalkyl and pentylalkyl isomers but also to all n-, iso-, sec-, and t-butyl, n- and isopropyl, ethyl, and methyl. As another example, "C 1-4 "Alkyl" refers to n-, iso-, sec- and t-butyl, n- and isopropyl, ethyl and methyl.

[0095] The term "cycloalkyl" refers to any cyclic ring of an alkane having a number of carbon atoms within a specified range. Thus, for example, "C 3-4 "Cycloalkyl" (or "C3-C4-cycloalkyl") refers to cyclopropyl and cyclobutyl.

[0096] As used herein, the term “cycloalkyl-alkyl” (or equivalently “alkyl-cycloalkyl”) refers to a system comprising an alkyl moiety as described above and a cycloalkyl moiety as described above. Attachment to “cycloalkyl-alkyl” (or “alkyl-cycloalkyl”) may be through either the cycloalkyl or alkyl moiety. The specified number of carbon atoms in the “cycloalkyl-alkyl” system refers to the total number of carbon atoms in both the alkyl moiety and the cycloalkyl moiety. Examples of C4-C5 cycloalkyl-alkyl include, but are not limited to, methylcyclopropyl, dimethylcyclopropyl, methylcyclobutyl, ethylcyclopropyl, cyclopropylmethyl, cyclopropylethyl, and cyclobutylmethyl.

[0097] The term "halogen" (or "halo") refers to fluorine, chlorine, bromine, and iodine (also referred to as fluoro, chloro, bromo, and iodo).

[0098] As used herein, the term "or" indicates alternatives that may be combined where appropriate.

[0099] Unless otherwise explicitly stated, all scopes cited herein are inclusive. For example, a heterocyclic ring described as containing "1 to 4 heteroatoms" means that such a ring may contain 1, 2, 3, or 4 heteroatoms. Any scope cited herein should be understood to include all sub-scopes within said scopes within its scope. Thus, for example, a heterocyclic ring described as containing "1 to 4 heteroatoms" is intended to include, in its aspect, a heterocyclic ring containing 2 to 4 heteroatoms, 3 or 4 heteroatoms, 1 to 3 heteroatoms, 2 or 3 heteroatoms, 1 or 2 heteroatoms, 1 heteroatom, 2 heteroatoms, etc.

[0100] Any of the various cycloalkyl and heterocyclic / heteroaryl rings and ring systems defined herein may be attached to any ring atom (i.e., any carbon atom or any heteroatom) of the rest of the compound, provided that a stable compound is formed. Suitable pentagonal or hexaagonal heteroaromatic rings include, but are not limited to, pyridyl, pyrazinyl, pyrimidinyl, pyridazinyl, and triazolyl.

[0101] A "stable" compound is a compound that can be manufactured and isolated and whose structure and properties remain essentially unchanged or can be caused to remain essentially unchanged for a sufficient period of time to enable the compound to be used for the purposes described herein (e.g., for therapeutic or prophylactic administration to a subject). References to the compound also include stable complexes of the compound, e.g., stable hydrates.

[0102] As a result of the selection of substituents and substituent patterns, specific compounds of formulas (I), (Ia), (II), and (IIa) may have an asymmetric center and may occur as a mixture of stereoisomers, as individual diastereomers, or as enantiomers. Unless otherwise indicated, all isomer forms of these compounds (and their pharmaceutically acceptable salt and / or hydrate forms) are within the scope of the invention, whether isolated or in a mixture. Tautomeric isomer forms of the compounds (and their pharmaceutically acceptable salt and / or hydrate forms) as described are also included within the scope of the invention.

[0103] Where any component or any variable in formulas (I), (Ia), (II), or (IIa) occurs more than once, its definition for each occurrence is independent of its definition in all other occurrences. Additionally, combinations of substituents and / or variables are permitted only if such combinations result in a stable compound.

[0104] The term “substituted” includes monosubstitution and polysubstitution by named substituents to the extent that single and multiple substitutions (including multiple substitutions at the same site) are chemically acceptable. Unless otherwise explicitly stated, substitution by named substituents is permitted on any atom within a ring (e.g., aryl, cycloalkyl, heteroaryl, or heterocyclyl), provided that such ring substitution results in a chemically acceptable and stable compound.

[0105] Bonds terminated by a wavy line are used herein to indicate attachment points of substituents or substructures. Such usage is illustrated by the following examples:

[0106]

[0107] Compounds of chemical formulas (I), (Ia), (II), and (IIa), and their pharmaceutically acceptable salt and / or hydrate forms, are also useful for the preparation and execution of screening assays for antifungal compounds. For example, said compounds are useful for isolating mutants, which are excellent screening tools for identifying additional antifungal compounds.

[0108] Compounds of formulas (I), (Ia), (II), and (IIa) may be administered in the form of a "pharmaceutical acceptable salt" or hydrate. However, other salts may be useful for the preparation of said compounds or their pharmaceutically acceptable salts. For example, if the compounds contain basic amine groups, they may be conveniently isolated as trifluoroacetate salts (e.g., after HPLC purification). Converting trifluoroacetate salts into other salts, including pharmaceutically acceptable salts, can be achieved by a number of standard methods known in the art. For example, the desired salt can be produced using a suitable ion exchange resin. Alternatively, converting trifluoroacetate salts into a parent free amine may be achieved by standard methods known in the art (e.g., neutralization with a suitable inorganic base, e.g., NaHCO3). Subsequently, other desired amine salts may be prepared in a conventional manner by reacting the free base with a suitable organic or inorganic acid. Representative pharmaceutically acceptable quaternary ammonium salts include the following: hydrochloride, sulfate, phosphate, carbonate, acetate, tartrate, citrate, maleate, succinate, lactate, stearate, fumarate, hypochlorite, maleate, gluconate, ascorbate, adipate, glutamate, glucoronate, propionate, benzoate, mesylate, tosylate, oleate, lactobionate, lauryl sulfate, besylate, caprylate, isethionate, gentisate, malonate, napsylate, edicilate, pamoate, xinapoate, napadisilate, hydrobromide, nitrate, oxalate, cinnamate, mandelate, undecylenate, and camsylate.Many compounds of chemical formulas (I), (Ia), (II) and (IIa) involve an acidic carboxylic acid moiety, and in these cases, suitable and pharmaceutically permissible salts may include alkali metal salts, e.g., sodium or potassium salts; alkaline earth metal salts, e.g., calcium or magnesium salts; and salts formed with suitable organic ligands, e.g., quaternary ammonium salts.

[0109] The present invention, within its scope, includes the use of prodrugs of formulas (I), (Ia), (II), and (IIa). Generally, such prodrugs will be functional derivatives of compounds that can be readily converted into the required compounds in vivo. Accordingly, in the therapeutic method of the present invention, the term “administering” should encompass treating the various pathological conditions described using the specifically disclosed compounds or compounds that are converted into the specified compounds in vivo after administration to a patient. Conventional procedures for the selection and preparation of suitable prodrug derivatives are described, for example, in the literature [“Design of Prodrugs,” ed. H. Bundgaard, Elsevier, 1985] (the full text of which is incorporated herein by reference). Metabolites of compounds of formulas (I), (Ia), (II), and (IIa) comprise active species produced when these compounds are introduced into a biological environment.

[0110] The terms “administration” and variants thereof (e.g., “administering” a compound) mean providing a specific compound or a prodrug of such compound to a subject requiring treatment. Where a compound of formulas (I), (Ia), (II), and (IIa), or its pharmaceutically acceptable salt or its hydrate or prodrug is provided in combination with a second active agent (e.g., another antifungal and / or antibacterial agent useful for treating fungal and / or bacterial infections), “administration” and variants thereof are understood to each comprise the joint and sequential provision of said compound (or its salt, hydrate, or prodrug) and the other active agent.

[0111] As used herein, the term “composition” is intended to encompass not only products containing the specified ingredients but also any products resulting directly or indirectly from a combination of the specified ingredients.

[0112] "Pharmaceutical acceptable" means that the components of a pharmaceutical composition must be compatible with one another and must not be harmful to the recipient.

[0113] The term "subject" as used herein (or, on the other hand, referred to herein as "patient") refers to an animal that is the subject of treatment, observation, or experiment, preferably a mammal, most preferably a human.

[0114] The term “synergistic” refers to the effect of a compound of formula (I), (Ia), (II), or (IIa), or its pharmaceutically acceptable salt or hydrate or prodrug provided in combination with a second active antifungal agent to prevent, manage, or treat a specific disorder, the effect of which is superior, more advantageous, or more significant than the additive effect of the individual therapies. The synergistic effect of the combination of therapies may allow for the use of lower doses of one or more individual therapies and / or less frequent administration of the therapies to subjects with the disorder. The ability to use lower doses of the therapies or to administer the therapies less frequently reduces the toxicity associated with the administration of the therapies to subjects without reducing the efficacy of the therapies in the prevention or treatment of the disorder. Additionally, the synergistic effect may improve the efficacy of the agents in the prevention or treatment of the disorder. Finally, the synergistic effect of the combination of therapies may allow for the avoidance or reduction of adverse or unwanted side effects associated with the use of the therapies alone.

[0115] As used herein, the term “effective dose” refers to an amount of an active ingredient or medicine required by a researcher, veterinarian, physician, or other clinician to elicit a biological or medical response in a tissue, system, animal, or human. In one embodiment, the “effective dose” may be a therapeutic effective dose that alleviates the symptoms of a disease or condition being treated. In another embodiment, the “effective dose” may be a prophylactic effective dose to prevent the symptoms of a disease or condition being prevented or to reduce the likelihood of its occurrence. The term may also refer to an inhibitory effective dose of an enfumafungin derivative sufficient to inhibit (1,3)-β-D-glucan synthase and elicit the desired response thereby. The term may also refer to an amount of a second antifungal agent, such as a fungal activator, sufficient to inhibit fungal growth. The term may also refer to an amount of an enfumafungin derivative and a second agent (e.g., therapeutic effective dose, prophylactic effective dose, or inhibitory effective dose) sufficient to inhibit fungal growth and elicit the desired response thereby when administered in combination. When enfumafungin derivatives and a second antifungal agent are administered in salt form, references to the amounts of these compounds refer to the free acid or free base forms of the compounds.

[0116] To prevent or treat fungal infections, a combination therapy comprising a first antifungal agent (optional, in salt or hydrate form) and a second antifungal agent, which are compounds of formulas (I), (Ia), (II), or (IIa), may be administered in any manner that causes contact between said activator and the site of action of said activator. The first agonist and the second agonist may be administered in any manner available for use in conjunction with a drug as individual therapeutic agents or as a combination of therapeutic agents. They may be administered alone, but may also be administered with a selected route of administration and a selected pharmaceutical carrier based on standard pharmaceutical practices according to typical practice. They may be administered simultaneously or sequentially over a portion or the entire duration of the antifungal therapy through any acceptable route of administration appropriate for the intended purpose. For example: the first agonist and the second agonist may be administered intravenously, orally, or topically; or one may be administered intravenously and the other orally; or one may be administered orally and the other topically; Alternatively, it may be provided by any combination of routes of administration as appropriate for the fungal infection being treated or prevented. For example: in the case of invasive aspergillosis, the preferred route of administration will be intravenous and / or oral; in the case of cutaneous fungal infections, both antifungal compounds may be administered topically, or one may be administered orally and the other topically; in the case of ocular fungal infections, both antifungal agents may be administered topically, or one may be administered intravenously or orally and the other topically.For example, compounds of formulas (I), (Ia), (II), and (IIa), and their pharmaceutically acceptable salt and / or hydrate forms and a second antifungal agent may be administered in the form of a unit dose of a pharmaceutical composition containing an effective amount of the compound and a conventional non-toxic pharmaceutically acceptable carrier, ajuvant, and vehicle, by one or more of the following routes: orally, parenterally (including subcutaneous injection, intravenous, intramuscular, intrasternal injection or infusion techniques), by inhalation (e.g., intranasal or buccal inhalation spray, aerosol from a metered dose inhaler, and dry powder inhaler), by nebulizer, ocularly, topically, transdermally, or rectally. Liquid formulations suitable for oral administration (e.g., suspensions, syrups, elixirs, etc.) may be prepared according to techniques known in the relevant art and may use a conventional medium, such as water, glycol, oil, alcohol, etc. Solid formulations suitable for oral administration (e.g., powders, pills, capsules, and tablets) may be manufactured according to techniques known in the relevant art and may use solid excipients such as starch, sugar, kaolin, lubricants, binders, disintegrants, etc. Parenteral compositions may be manufactured according to techniques known in the relevant art and typically use sterile water as a carrier, and optionally use other components, such as solubilizing agents. Injectable solutions comprising a carrier containing a saline solution, a glucose solution, or a mixture of saline and glucose may be manufactured according to methods known in the relevant art.

[0117] Further descriptions regarding a method suitable for use in preparing a pharmaceutical composition and a component suitable for use in said composition are in the literature [ Remington's Pharmaceutical Sciences , 20 th [Provided in edition, edited by AR Gennaro, Mack Publishing Co., 2000]

[0118] Compounds of formulas (I), (Ia), (II), and (IIa), and their pharmaceutically acceptable salt and / or hydrate forms, may be administered, for example, orally or intravenously, as a single dose or divided dose, in a dosage range of, for example, 0.001 to 1000 mg per kg of body weight of mammals (e.g., humans) per day. An example of a dosage range is 0.01 to 500 mg / kg of body weight per day as a single dose or divided dose orally or intravenously. Another example of a dosage range is 0.1 to 100 mg / kg of body weight per day as a single dose or divided dose orally or intravenously. In the case of oral administration, the composition may be provided in the form of tablets or capsules containing, for example, 1.0 to 1000 milligrams of the active ingredient, particularly 1, 5, 10, 15, 20, 25, 50, 75, 100, 150, 200, 250, 300, 400, 500, 600, 750, and 1000 milligrams of the active ingredient, for symptomatic adjustment of the dosage for the patient to be treated. Specific dosage levels and frequencies of administration for any particular patient may vary and will depend on various factors including the activity of the specific compound used, the metabolic stability and duration of action of the compound, age, body weight, general health, gender, diet, mode and time of administration, excretion rate, drug combination, severity of the particular condition, and the host receiving the therapy.

[0119] A second antifungal agent, comprising but not limited to azole or amphotericin B compounds and pharmaceutically acceptable salts and / or hydrates thereof, may be administered, for example, as a single dose or divided doses in a dosage range of 0.001 to 1000 mg per kg of body weight of a mammal (e.g., human) per day (e.g., orally or intravenously), more preferably in a dosage range of 0.01 to 100 mg / kg per day orally or intravenously as a single dose or divided dose. Another example of a dosage range comprises voriconazole administered as a single dose or divided dose orally or intravenously in a range of 2 to 20 mg / kg per day. Another example of a dosage range includes amphotericin B administered intravenously in a range of 0.2 to 10 mg / kg per day as a single dose or divided doses. For oral administration, the composition may be provided in the form of, for example, tablets, suspensions, solutions, or capsules containing, for example, 1.0 to 500 mg of the active ingredient, particularly 50, 75, 100, 150, 200, 250, 300, 375, 400, and 500 mg of the active ingredient, for symptomatic adjustment of the dosage for the patient to be treated. Specific dosage levels and frequencies of administration for any particular patient may vary and will depend on various factors including the activity of the specific compound used, the metabolic stability and duration of action of the compound, age, body weight, general health, sex, diet, mode and time of administration, elimination rate, drug combination, severity of the particular condition, and the host receiving the therapy. For intravenous administration, the composition may be provided in the form of (e.g.) a solution or suspension containing 1.0 to 500 milligrams of the active ingredient, or in other acceptable pharmaceutical forms. For topical administration, the second antifungal agent is, for example, 0. per gram of product.It may be provided as (e.g.) a cream, solution, ointment, foam, powder, lacquer, emulsion, or other pharmaceutically acceptable form containing 001 to 900 milligrams of the active ingredient.

[0120] The antifungal activity of a compound can be demonstrated by various assays known in the relevant art, for example, the glucan synthesis inhibitory activity of a compound against fibrous fungi and Dermatophytes in the gravy microdilution assay (IC10 50 This can be demonstrated by ), minimum inhibitory concentration (MIC) and minimum effective concentration (MEC), or by in vivo anti-Aspergillus activity in mouse or rabbit models. It has been found that the compound of formula (I) provided in the example of U.S. Patent No. 8,188,085 generally provides an MEC against Aspergillus fumigatus in the range of < 0.03 to 32 μg / mL.

[0121] Examples

[0122] The following examples are merely for illustrating the invention and its implementation. These examples should not be construed as limitations on the scope or essence of the invention.

[0123] Combination test

[0124] Interactions between different drugs are described in various ways, such as synergistic, indifferent, or antagonistic. The evaluation of in vitro drug interactions is typically based on the "no interaction" theory, which considers the combined drugs indifferent because they are presumed not to interact with each other. If the observed effect of the drug combination is greater than predicted by the "no interaction" theory, a synergistic effect is claimed. On the other hand, if the observed effect is smaller than predicted, an antagonistic effect is claimed.

[0125] A checkerboard method was used to determine the interaction types between several antifungal agents against Aspergillus fumigatus, the most frequent fungus causing invasive disease in humans, and a representative compound of enfumafungin derivatives (SCY-078). The citrate salt of the said compound was used in this study.

[0126] The checkerboard method involves determining the percentage of fungal cell growth inhibition in the presence of different combinations of drugs. The percentage of growth inhibition is calculated by comparing it to growth in control wells containing only cells and no drugs. The assay was performed on 96-well microplates, where each column and each row contained two-fold serial dilutions of Drug A and Drug B at concentrations ranging from 0 to slightly higher than the Minimum Inhibitory Concentration (MIC). Each well contained a unique combination of the two drugs. Subsequently, the inoculum was added to each well, and growth was evaluated after 48 hours of incubation to determine the first well in which growth was inhibited. Following the checkerboard-based determination of the MICs of the combined antifungal agents, further analysis was performed using the Non-parametric Fractional Inhibitory Concentration Index (FICI), which is defined by the following equation:

[0127]

[0128] In the above formula, MIC-A and MIC-B are the MICs of drugs A and B, respectively. According to Odds' terminology (reference [Odds, FC 2003. Synergy, antagonism, and what the chequerboard puts between them. J. Antimicrob. Chemother. 52:1]), FICI values ​​of 0.5 or less are considered synergistic, FICI values ​​greater than 4.00 are considered antagonistic, and FICI values ​​greater than 0.5 to 4.0 are considered no interaction.

[0129] Initially, each drug was diluted in either sterile distilled water or DMSO, depending on whether the drug was water-soluble or water-insoluble. Since SCY-078 is not soluble in water, a water-insoluble formulation was used.

[0130] The stock solution of SCY-078 was prepared in DMSO at 200 times the desired concentration for use in drug plates. Serial dilution of the stock solution was performed in DMSO to obtain 11 2x dilutions of the drug. Subsequently, to ensure that the amount of DMSO was consistent for all dilutions and that the DMSO did not limit the growth of the organism, the SCY-078 solution was diluted to 4 times the desired concentration in RPMI-1640 medium.

[0131] Two 96-well plates are required to perform the combination test. Using a multichannel pipette, 50 μl of the lowest concentration of the first drug (Drug A) was added to each well in Column 1 of the first plate (Plate A) and Column 1 of the second plate (Plate B; Column AD). Subsequently, 50 μl of the next highest working dilution of Drug A was added to each well in Column 2, and dilution was continued until all columns 1 through 11 were filled. Column 12 was left empty. 50 μl of the lowest concentration of Drug B was added to each well in Column D of Plate B. 50 μl of the next highest working dilution of Drug B was added to each well in Column C of Plate B, and dilution was continued until all columns through Column B of Plate A were filled. Column A of Plate A did not contain any Drug B. 50 μl of RPMI was added to column A and column 12 (wells A-12 contained 100 μl of straight RPMI).

[0132] Following the above, 100 μl of organic inoculum was added to all wells. Then, the plates were incubated for 48 hours, and visual readings were performed after incubation.

[0133] The purpose of this study was to determine whether combinations of SCY-078 with voriconazole, isavuconazole, or amphotericin B resulted in a combined in vitro antifungal activity exceeding the sum of the activities of each drug alone. The combination MIC test was performed using the aforementioned checkerboard assay.

[0134] substance

[0135] Test isolate: The following six clinical strains of Aspergillus (four are wild-type and two are resistant) were tested:

[0136] wild-type strain

[0137] A. Fumigatus ( A. fumigatus ) MRL# 20438

[0138] A. Fumigatus MRL# 28382

[0139] A. Fumigatus MRL# 28401

[0140] A. Fumigatus MRL# 28378

[0141] Resistant strains

[0142] A. Fumigatus MRL# 28383

[0143] A. Fumigatus MRL# 28500.

[0144] A. Fumigatus 28500 has a CYP51 mutation in F46Y.

[0145] Antifungal agents: The following combinations were tested:

[0146] SCY-078 + Voriconazole

[0147] SCY-078 + Isabuconazole

[0148] SCY-078 + Amphotericin B.

[0149] A. The *Fumigatus* strain was obtained from the Mycology Reference Library (MRL) at Case Western Reserve University School of Medicine (Case Western Reserve University School of Medicine; Ohio, USA). SCY-078 was manufactured by Avista Laboratories (Avista Laboratories; North Carolina, USA). Voriconazole, isavuconazole, and amphotericin B were supplied by a commercial distributor.

[0150] method

[0151] The initial MIC determination of individual antifungal agents was performed according to the Clinical and Laboratory Standards Institute (CLSI) M38-A2 standard for susceptibility testing of fibrous fungi.

[0152] Combination MIC tests were performed using the checkerboard test method in accordance with Center for Medical Mycology SOP A11.3. The checkerboard combination test method is a variation of the microdilution antifungal susceptibility test in which two test compounds are combined at various concentrations to determine whether they have a synergistic, antagonistic, or no effect on their respective MIC values.

[0153] Antifungal agents were serially diluted twofold in RPMI medium to produce 11 different concentrations, which were then combined in the wells of microtitter plates. Two columns containing serial dilutions of each individual drug were included. All combination tests were performed in duplicate. The comparison of the MICs of the individual drugs with the MICs of the combined agents indicates their relative efficacy.

[0154] This interpretation followed the antimicrobial and chemotherapy guidelines to encourage a conservative interpretation of checkerboard combination data.

[0155] result

[0156] Table 1 shows the FICI scores and interpretations for SCY-078 in combination with isavuconazole against tested azole-susceptible and resistant A. fumigatus isolates (the test was run in duplicate). Against the tested susceptible isolates, the combination of SCY-078 and isavuconazole demonstrated synergy in all four tested isolates. Against the resistant CYP51 mutant A. fumigatus strain 28500 and resistant strain 28383, SCY-078 in combination with isavuconazole demonstrated no interaction.

[0157] Table 2 shows the FICI scores and interpretations for SCY-078 in combination with voriconazole against tested azole-sensitive and tolerant A. fumigatus isolates (the study was run in duplicate). Against the tested sensitive isolates, the combination of SCY-078 and voriconazole demonstrated synergy against all four isolates evaluated. When tested against tolerant A. fumigatus isolates, the combination of SCY-078 and voriconazole showed no interaction.

[0158] Table 3 shows the FICI scores and interpretations for SCY-078 in combination with amphotericin B against tested azole-sensitive and resistant A. fumigatus isolates (the test was run in duplicate). The combination of SCY-078 and amphotericin B demonstrated synergy against all evaluated sensitive isolates. Against resistant isolates, A. fumigatus 28383, SCY-078 in combination with amphotericin B showed no interaction. However, against the CYP51 mutant strain (A. fumigatus 28500), SCY-078 in combination with amphotericin B demonstrated synergistic activity.

[0159]

[0160] A. MIC values ​​for SCY-078 and isabuconazole alone against fumigatus, and MIC values ​​(μg / mL) for the combination of SCY-078 and isabuconazole, respectively. MICs were read at 48 hours, and each test was performed in duplicate.

[0161]

[0162] Azole-resistant strains

[0163] Table 2

[0164] A. MIC values ​​for SCY-078 and voriconazole alone against fumigatus, and MIC values ​​(μg / mL) for each case in combination with SCY-078 and voriconazole. MICs were read at 48 hours, and each test was performed in duplicate.

[0165]

[0166] Azole-resistant strains

[0167] Table 3

[0168] A. MIC values ​​for SCY-078 and amphotericin B alone against fumigatus, and MIC values ​​(μg / mL) for each case in combination with SCY-078 and amphotericin B. MICs were read at 48 hours, and each test was performed in duplicate.

[0169]

[0170] Azole-resistant strains

[0171] These data show that combinations of SCY-078, voriconazole, isavuconazole, and amphotericin B demonstrated synergistic activity against all tested wild-type Aspergillus fumigatus isolates. Individual combinations of SCY-078, voriconazole, isavuconazole, and amphotericin B demonstrated no synergistic activity or interaction against the tested azole-resistant Aspergillus fumigatus isolates. Importantly, no antagonism was demonstrated with these combinations.

[0172] In vivo research

[0173] A study was conducted to evaluate the efficacy of the combination of SCY-078 and isavuconazole. Isavuconazole is a second-generation antifungal triazole active against Aspergillus species. As previously mentioned, invasive pulmonary aspergillosis is a life-threatening infection in immunocompromised patients, particularly those with severe and long-term neutropenia resulting from myelotoxic chemotherapy for cancer treatment, and those receiving immunosuppressants to prevent rejection after organ transplantation or being treated for graft-versus-host disease (GVHD) after allogeneic bone marrow transplantation. A neutropenic rabbit model was selected for the above in vivo evaluation to further exemplify the effects of the SCY-078 and azole combination therapy in the relevant immunocompromised population.

[0174] method

[0175] In this study, 2.5 to 3.5 kg New Zealand white rabbits [Covance Research Products, Inc. (Denver, Pennsylvania, USA)] were used. Vascular access was established by the surgical placement of a Silastic tunneled central venous catheter. Cytosine arabinoside [Cytosar-U] 525 mg / m² 2Severe and persistent neutropenia (neutrophil concentration < 100 neutrophils / μL) was induced by administering it intravenously on days 1 through 5, and on days 8, 9, 13, and 14. Macrophage activity was inhibited by administering methylprednisolone [Solu-Medrol®; Pfizer (New York, USA)] 5 mg / kg on days 1 through 3. To prevent opportunistic bacterial infection during neutropenia, antibiotics were used (ceftazidim 75 mg / kg was administered intravenously twice daily; gentamicin 5 mg / kg was administered intravenously every other day; and vancomycin 15 mg / kg was administered intravenously daily).

[0176] Inoculum: In this study, NIH Aspergillus fumigatus isolate 4215 (ATCC number MY A-1163) obtained from a patient with fatal pulmonary aspergillosis was used. A. The Aspergillus fumigatus isolate was subcultured on potato dextrose agar slant [Remel Inc. (Baltimore, Maryland, USA)], incubated at 37°C for 24 hours, and then kept at room temperature for 5 days prior to use. On Day 2 (i.e., Day 1 after the first administration of cytosine arabinoside), the inoculum (2.5 x 10⁶) was examined under direct visualization. 8 The A. fumigatus conidia of dogs was administered into the trachea by crossing the vocal cords.

[0177] Antifungal therapy:As summarized in Table 4, the following six treatment groups were studied: a group receiving SCY-078 (SCY2.5) at 2.5 mg / kg / day; a group receiving SCY-078 (SCY7.5) at 7.5 mg / kg / day; a group receiving isavuconazole (ISA40) at 40 mg / kg / day; a group receiving SCY-078 at 2.5 mg / kg / day and isavuconazole (SCY2.5+ISA40) at 40 mg / kg / day; a group receiving SCY-078 at 7.5 mg / kg / day and isavuconazole (SCY7.5+ISA40) at 40 mg / kg / day; and an untreated control group (UC). Each group included 6 rabbits. The antifungal agents were administered intravenously once daily. The citrate salt of SCY-078 was used. In the group receiving antifungal therapy, this administration began 24 hours after tracheal inoculation and continued once daily for 12 days. Surviving rabbits in the treated group were sacrificed 24 hours after the last administration of the antifungal agent(s). Animals in the untreated group did not survive after day 8.

[0178] evaluation: Survival, pulmonary infarction, and galactomannan antigenemia (serological markers of Aspergillus infection) were evaluated as indicators of treatment response. After death or sacrifice, the lungs were weighed, and two blinded observers examined them for the presence of hemorrhagic infarct lesions typical of pulmonary aspergillosis. Blood was collected from each rabbit every other day to measure serum galactomannan concentrations. Serum galactomannan concentrations were determined by the Platelia® Aspergillus Enzyme Immunoassay (EIA) [Bio-Rad (Marnes La Coquette, France)] step-by-step immunoenzyme sandwich microplate assay method. The enzyme immunoassay data were expressed as serum GMI (galactomannan index) plotted over time.

[0179] Table 4

[0180] Treatment group

[0181]

[0182] result

[0183] Survival rates were significantly increased in animals treated with SCY7.5+ISA40 or SCY2.5+ISA40 compared to the group administered only SCY-078 (SCY7.5 or SCY2.5) or only isabuconazole (ISA40) (Fig. 1). Specifically, rabbits administered with SCY7.5+ISA40 or SCY2.5+ISA40 showed a survival rate of 83% (5 out of 6 in each group) by the scheduled sacrifice date (Day 13), whereas animals administered only ISA40 showed a survival rate of 32% (2 out of 6); animals administered only SCY2.5 showed a survival rate of 16% (1 out of 6); and there were no animals surviving by Day 13 in the group administered only SCY7.5 and the untreated control group. Lung injury markers (pulmonary infarction scores) demonstrated a similar response pattern (Fig. 2). Compared to animals treated with a single agent, serum galactomannan antigenemia was significantly reduced in animals treated with SCY7.5+ISA40 or SCY2.5+ISA40 (Fig. 3). The combination of SCY-078 and isavuconazole was more effective in reducing galactomannan levels than using either agent alone. Furthermore, the combination of SCY-078 and isavuconazole provided a more rapid reduction in galactomannan antigenemia than using either agent alone.

[0184] This study further demonstrated that the combination of SCY-078 and azole exhibited a more effective and synergistic effect in treating invasive pulmonary aspergillosis compared to either SCY-078 or azole alone in the aforementioned model.

[0185] Although the present invention has been specifically presented and described with reference to its preferred embodiments, those skilled in the art will understand that, from the perspective of this disclosure, various changes in form and detail may be made without departing from the scope of the invention as encompassed by the appended claims.

Claims

Claim 1 (a) a first therapeutic agent which is a compound of formula (II) which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazole-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenantro[1,2-c]pyran-7-carboxylic acid, or a pharmaceutically acceptable salt thereof; (b) Aspergillus (composed of a second therapeutic agent which is voriconazole or amphotericin B) Aspergillus A pharmaceutical combination for use in a method of treating or preventing Aspergillus infection in subjects requiring treatment or prevention of infection. Claim 2 A pharmaceutical combination according to claim 1, wherein the first therapeutic agent is a compound of formula (IIa) in which the first therapeutic agent is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[(2R)-2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazole-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenantro[1,2-c]pyran-7-carboxylic acid, or a pharmaceutically acceptable salt thereof: . Claim 3 A pharmaceutical combination according to claim 1 or 2, wherein the first therapeutic agent and the second therapeutic agent are present in an amount such that the pharmaceutical combination is effective for treating an Aspergillus infection in a subject requiring treatment for an Aspergillus infection. Claim 4 A pharmaceutical combination according to claim 1 or 2, wherein the first therapeutic agent and the second therapeutic agent are present in an amount such that the pharmaceutical combination is effective in preventing Aspergillus infection in a subject requiring prevention of Aspergillus infection. Claim 5 A pharmaceutical combination according to claim 1 or 2, wherein the first therapeutic agent and the second therapeutic agent are present in an amount such that they become a pharmaceutical combination effective for treating invasive pulmonary aspergillosis in a subject requiring treatment for invasive pulmonary aspergillosis. Claim 6 A pharmaceutical combination according to claim 1 or 2, wherein the first therapeutic agent and the second therapeutic agent are present in an amount such that the pharmaceutical combination is effective in preventing invasive pulmonary aspergillosis in subjects requiring prevention of invasive pulmonary aspergillosis. Claim 7 To a subject requiring treatment for invasive pulmonary aspergillosis, (a) a first therapeutic agent which is a compound of formula (II) which is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazole-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenantro[1,2-c]pyran-7-carboxylic acid, or a pharmaceutically acceptable salt thereof; (b) A pharmaceutical combination for use in a method of treating invasive pulmonary aspergillosis in the subject, comprising administering a pharmaceutical combination of a second therapeutic agent which is voriconazole or amphotericin B. Claim 8 In claim 7, a pharmaceutical combination in which the first therapeutic agent is a compound of formula (IIa) in which the first therapeutic agent is (1S,4aR,6aS,7R,8R,10aR,10bR,12aR,14R,15R)-15-[[(2R)-2-amino-2,3,3-trimethylbutyl]oxy]-8-[(1R)-1,2-dimethylpropyl]-14-[5-(4-pyridinyl)-1H-1,2,4-triazole-1-yl]-1,6,6a,7,8,9,10,10a,10b,11,12,12a-dodecahydro-1,6a,8,10a-tetramethyl-4H-1,4a-propano-2H-phenantro[1,2-c]pyran-7-carboxylic acid, or a pharmaceutically acceptable salt thereof: . Claim 9 A pharmaceutical combination according to claim 7 or 8, wherein the first therapeutic agent is administered sequentially with the second therapeutic agent. Claim 10 A pharmaceutical combination according to paragraph 7 or 8, wherein the first therapeutic agent is administered jointly with the second therapeutic agent.

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