Methods for treating symptoms and disorders associated with lysosomal storage diseases

Abstract

This disclosure relates to a method of using a quinuclidine compound of formula (I), in combination with enzyme replacement therapy as needed, for the treatment or prevention of specific symptoms and conditions associated with lysate storage disorders. This includes supranuclear gaze palsy, including horizontal and vertical blinking gaze palsy, and cognitive deficits or gait disturbances, in patients with, for example, Gaucher disease or Niemann-Pick disease, type C. Pharmaceutical compositions comprising quinuclidine compounds used in these methods are also disclosed.

Description

[Technical Field] Cross-referencing of related applications This application is an international application that claims priority and interest in the following U.S. provisional applications: No. 62 / 800,996, filed February 4, 2019; No. 62 / 851,433, filed March 22, 2019; No. 62 / 894,167, filed August 30, 2019; No. 62 / 937,618, filed November 19, 2019; and No. 62 / 962,647, filed January 17, 2020, the contents of which are incorporated herein by reference in their entirety. This disclosure relates to a method of using quinuclidine compounds of formula (I), in combination with enzyme replacement therapy as needed, for the treatment or prevention of specific symptoms and conditions associated with lysate storage disorders. This includes supranuclear gaze palsy, including horizontal and vertical blinking gaze palsy, as well as cognitive deficits or gait disturbances, in patients with, for example, Gaucher disease or Niemann-Pick disease, type C. [Previous Technology] Lysosomal storage disease Lysole storage diseases (LSDs) are a group of approximately 50 rare inherited metabolic disorders caused by defects in lysosome function. Generally, patients with LSDs accumulate harmful amounts of substances in the lysosome due to a deficiency or defect of enzymes responsible for metabolic substrates, or a lack of enzyme activators required for proper enzyme function. Most LSDs are caused by a single enzyme deficiency or lack, usually an enzyme involved in lipid or glycoprotein metabolism. Some of the more common LSDs include Gaucher disease, Fabry disease, and Niemann-Pick disease (type C). Gaucher, Fabry, and Niemann-Pick are examples of sphingomyelin storage diseases. Each of these diseases is associated with a group of symptoms directly or indirectly caused by an underlying genetic defect. Therefore, the effectiveness of different treatment methods for these related symptoms or conditions is often unpredictable. Common symptoms across several types of LSD include saccadic eye movement, cognitive impairment, and gait disturbances such as changes in ataxia. These symptoms are particularly common in Gaucher disease (type 3) and Niemann-Pick disease (type C). LSD's instantaneous movement defect Several functional categories of eye movement exist, including saccades, smooth pursuit, optokinetic nystagmus (OKN), vestibular reflexes, and vergence, each controlled by different cortical, brainstem, and cerebellar nuclei networks. Dysfunction of the supranuclear saccade visual center in the brainstem results in supranuclear gaze palsy, also known as saccade-gazing palsy. "Supranuclear" refers to the defect location above the relevant cranial nerve nuclei in the midbrain (oculomotor nerve, trochlear nerve) or pons (external rotator nerve) of the brainstem. The oculomotor, trochlear, and external rotator nerves are the only cranial nerves controlling the small muscles of eye movement, and lesions in these nerves themselves do not cause conjugate gaze palsy. Eye blinking is the rapid, simultaneous movement of both eyes in the same direction between two or more fixed phases. It is the opposite of smooth tracking, in which the eyes move smoothly without jumps, typically when tracking a target within the visual field. Eye blinking serves as a mechanism for visual fixation, rapid eye movement, and fast-phase optomotor nystagmus. It is cortically controlled by the frontal oculomotor area of ​​the frontal cortex or subcortically by the superior colliculus (a region of the midbrain). Eye blinking is particularly important during reading and when scanning the immediate surroundings. Because the fovea, a high-resolution area of ​​the retina, is very small (approximately 1-2 degrees of the visual field), blinking is crucial for small targets within the resolving visual field. Skilled readers move their eyes on average every 250 milliseconds during reading, with each blink lasting 20-40 milliseconds, resulting in an average lateral movement of 7-9 words (range 1-20 words) of the gaze target. In humans, the peak angular rotation of the eye during a single eye blink can reach up to 900 degrees per second. An eye blink in response to an unexpected stimulus typically initiates in about 200 milliseconds and lasts between 20 and 200 milliseconds, depending on the amplitude. The amplitude of an eye blink is the angular distance the eye travels during eye movement. Eye blinks with the head stationary can have amplitudes up to 90 degrees, but in most cases, any gaze shift greater than 20 degrees is accompanied by head movement. During these gaze blinks, the eye first undergoes an eye blink to shift the gaze to the target, and while the eye remains focused on the target, the head follows more slowly. The latter is called the vestibular-ocular reflex (VOR), and it operates to slowly rotate the eye in the opposite direction to head movement in order to maintain visual focus on the retina. Because head movement is almost always minimal, the VOR must stabilize the gaze in almost all situations, especially during reading. Oculomotor gaze palsy may result from slowing of horizontal, vertical, or both eye blinks, and may or may not be limited in scope. The presence or absence of horizontal or vertical oculomotor palsy pathologically depends on the exact brain region involved. Gaucher disease (GD) is a rare, autosomal recessive lysate storage disorder. GD patients have a mutation in the GBA1 gene, which encodes glucocerebrosidase (GC), also known as β-glucocerebrosidase. This enzyme is responsible for breaking down glycosphingolipids into their components, such as glucocerebrosidase (GLC) into glucose and ceramides. Monocytes and macrophages have particularly high levels of GLC-containing lysates, and in GD patients, these cells enlarge and accumulate toxic concentrations of GLC. These so-called "Gaucher cells" accumulate in several organs, including bone, bone marrow, spleen, liver, lungs, and brain. Systemically, it causes splenomegaly, hepatomegaly, anemia, thrombocytopenia, leukopenia, osteoporosis, osteonecrosis, and other pathological abnormalities. Gaucher disease has three subtypes, differing in age of onset, severity, and the presence of neurological manifestations. Type 1 Gaucher disease (GD-1), GD without neurological involvement, is the most common type, with a median age of diagnosis of 28 years and a slightly shorter lifespan. In GD-1, GC enzymes retain some function, and no neurological involvement is present. Type 2 GD is acute neuropathic GD, diagnosed in infancy, involving severe neurological involvement, and usually results in death within the first two years of life. GC enzymes in type 2 GD patients are functionally reduced compared to GD-1. Type 3 GD is chronic neuropathic GD, diagnosed in childhood, involving progressively worsening neurological involvement, and lifespan typically does not exceed 30 years. Symptoms of GD-3 include spleen and liver abnormalities, fatigue, bleeding, convulsions, and supranuclear gaze palsy. Neurological manifestations in GD-3 patients develop gradually during the disease. One of the more debilitating characteristics is gaze palsy, a defect in the neural pathway controlling blinking. In the early stages of the disease, there is a gradual slowing of horizontal blinking. The disease progresses to complete horizontal blinking palsy and various degrees of vertical blinking palsy. VOR impairment may also occur in GD-3 patients. These disease characteristics have a profound impact on the quality of life of GD-3 patients and may hinder opportunities for education and employment. Existing treatments for GD-1 and GD-3 are limited to recombinant enzyme replacement therapy (ERT) using imiglucerase, velaglucerase, or taliglucerase, and substrate reduction therapy (SRT) using miglustat or eliglustat. See, for example, Lunawati L. Bennett & Chris Fellner, Pharmacotherapy of Gaucher Disease: Current and Future Options, P&T 43(5): 274-280, 309 (2018). Imiglucerase, a leading treatment, is a recombinant human GC derived from Chinese hamster ovary cells and administered via slow intravenous injection every 1-2 weeks (typically over 1-2 hours). It has been available in the United States since 1998. Veralucerase, another recombinant human GC analog derived from fibrosarcoma cell lines, was approved by the FDA in 2010. Tadalafil is similar, made using genetically modified carrot root cells, and has been approved since 2012. All of these treatments require intravenous administration in a hospital or other medical setting, and the recombinant enzymes cannot cross the blood-brain barrier, therefore they cannot treat the neurological symptoms of GD. Thus, while these ERT therapies have proven effective in treating GD-1 patients, they are only effective in treating the non-neurological symptoms of GD-3 patients. Substrate reduction therapy is an alternative treatment for GLC (glucocorticoid degeneration). This treatment aims to reduce GLC buildup by inhibiting the enzymes responsible for GLC synthesis. Glucoceramide synthase (GCS), also known as UDP-glucocorticamide synthase, is the enzyme that catalyzes the initial glycosylation step of ceramide to form glucocorticoid. GCS inhibitors have been recommended for the treatment of various diseases, including glucose-lipid storage disorders and lysolic storage disorders, including Gaucher's disease. See, for example, WO 2005 / 068426 (Actelion Pharm. Ltd.). Miglustat (Zavesca) is an iminoglucose GCS inhibitor. It is an N-alkylated imino sugar that binds at the enzyme's active site as a reversible competitive inhibitor of GCS. When developed for the treatment of neuropathic forms of GD, GD-2, and GD-3, it was only approved by the FDA for the treatment of mild to moderate GD-1, and only as second-line therapy (for patients who cannot receive ERT). Miglustat crosses the blood-brain barrier and was found to be ineffective in treating the neurological manifestations of GD-3 in clinical trials. Eliglustat is also a GCS inhibitor and is an analogue of ceramides. It is only approved by the FDA for the treatment of systemic symptoms in patients with GD-1. Niemann-Pick disease type C (NPC) is also a lysosomal storage disorder. Although its causes differ significantly from Gaucher disease, the overall outcomes are similar in some respects. NPC is caused by mutations in the NPC1 or NPC2 genes. NPC1 is a membrane protein that mediates the transport of intracellular cholesterol to its post-lysosomal destination. Specifically, NPC1 functions similarly to NPC2, enhancing cholesterol exit from the endosome / lysosomal compartment. In the lumen of the late endosome / lysosome, unesterified cholesterol released from low-density lipoprotein is transferred to the cholesterol-binding pocket of NPC1 via NPC2. Approximately 95% of NPC patients have the NPC1 mutation, while the majority of the remainder have the NPC2 mutation. One effect of this disordered cholesterol transport is the accumulation of cholesterol and glycosphingolipids (including GLC) in liver, spleen, and brain cells. One characteristic of NPC, like GD3, is the progressive development of supranuclear gaze palsy, including horizontal and vertical blink palsy. Another group of diseases and conditions often associated with blinking gaze palsy includes GM2-ganglioside storage disorders (such as Tay Sachs disease, Sandhoff disease, and AB variant GM2-ganglioside storage disorders). GM2 ganglioside storage disorder, similar to Gaucher's disease and lysolic storage disorder, is characterized by genetic defects in glycosphingolipid metabolism. GM2 ganglioside storage disorder is characterized by a deficiency in hexosamine A, the enzyme responsible for breaking down GM2 into GM3, and / or its cofactor GM2 activator protein. GM2 and GM3 are related gangliosides, part of the same metabolic pathway in glucocereamine, and are degraded into ceramides. Therefore, GM3 is produced through a stepwise process, starting with the conversion of ceramides to glucocereamine (via GLC), then to galactosyl-glucocereamine, then to GM3 (N-acetyl-α-ceramide-galactosyl-glucocereamine), and finally to GM2 (N-acetyl-galactosyl-N-acetyl-α-ceramide-galactosyl-glucocereamine). Pathological accumulation of GM2 is a marker of GM2 ganglioside storage disorder, which may therefore be improved by GCS inhibitors that inhibit the early synthesis steps of glucocorticoids. The pyridine compounds described in this paper [Figure] have activity as inhibitors of the enzyme glucosamine synthetase (GCS). These compounds have been shown to be generally used to treat lysolic storage diseases such as Fabry disease, Gaucher disease, and Niemann-Pick disease. See, for example, WO 2012 / 129084 and US2016 / 0361301. There is a real need in this technology for developing effective therapeutic agents to alleviate or manage neurological symptoms associated with Gaucher type 3, particularly blink movement deficits. [Summary of the Invention] This invention relates to a pyridine compound (compound 1) according to formula (I) [Figure]. [picture] Or, it may be a medically acceptable salt or prodrug, wherein: R1 is selected from hydrogen, halogen (e.g., fluorine), cyano, nitro, hydroxyl, thio, amino, C1-6-alkyl (e.g., methyl or ethyl), C2-6-alkenyl, C2-6-ynyl, C1-6-alkoxy, C2-6-enoxy, and C2-6-ynoxy, wherein the alkyl, alkenyl, ynyl, alkoxy, enoxy, or ynoxy is substituted as needed by one or more (e.g., 1, 2, or 3) groups selected from halogen, cyano, nitro, hydroxyl, thio, or amino. R2 and R3 are independently selected from C1-3-alkyl groups, which are substituted with one or more (e.g., 1, 2 or 3) halogens as needed, or R2 and R3 together form a cyclopropyl or cyclobutyl group, which are substituted with one or more (e.g., 1 or 2) halogens as needed. R4, R5, and R6 are each independently selected from hydrogen, halogen, nitro, hydroxyl, thio, amino, C1-6-alkyl, and C1-6-alkoxy groups, wherein the alkyl or alkoxy group is substituted as desired by one or more (e.g., 1, 2, or 3) groups selected from halogen, hydroxyl, cyano, and C1-6-alkoxy groups; and A is a 5- or 6-membered aryl or heteroaryl group, which may be substituted as required by one, two or three independent groups selected from halogen, hydroxyl, thio, amino, nitro, C1-6 alkoxy or C1-6 alkyl groups. In a first aspect, this application provides a method for treating or preventing supranuclear gaze palsy, including horizontal and vertical blinking gaze palsy, for any object in need of such treatment. The method comprises administering to the object an effective amount of a [Figure] pyridine compound as described herein, for example, a compound according to Formula I. In another aspect, this application further provides the use of the [Figure] pyridine compound as described herein for treating or preventing supranuclear gaze palsy, including horizontal and vertical blinking gaze palsy, and for the manufacture of a pharmaceutical product for treating or preventing supranuclear gaze palsy, including horizontal and vertical blinking gaze palsy. Further features and benefits of the compounds, compositions and methods disclosed herein will become apparent from the following detailed description (implementation methods). [Simplified Explanation of the Diagram] Figures 1 and 2 show the horizontal blink movement measured in five patients as described in Example 5 (Figure 1 shows patients 1-3 and Figure 2 shows patients 4-5). The blink amplitude and peak velocity were measured as the target moved horizontally from the center position at 15° (gray dot) or 30° (black dot) in a leftward or rightward direction. Rightward eye movement is represented by a positive peak velocity, while leftward movement is represented by a negative peak velocity. The gray shaded areas in each figure represent the normal peak velocity range at each specific amplitude.

Implementation Method

[2006] ), which assesses cerebellar ataxia across eight different attributes on a scale of 0-40. These eight attributes were gait, posture, sitting, speech impairment, finger tracking, nose-finger test, rapid hand roll, and heel-tibia gliding. The SARA ataxia scores of all six patients are shown in the table below: [picture] As shown in the table, 5 out of 6 patients had mild ataxia at baseline, with a mean SARA score of 2.8 (SD=1.2). The most common deficit at baseline was gait disturbance. Patient 5 was excluded due to low exposure to compound 2 and a substantially normal baseline ataxia score (only 0.5). Four of the remaining 5 patients showed improvement in ataxia at week 52 (mean improvement = -0.9; SD=3.2). Patient 4 had an increased ataxia score, from 3 at baseline to 7.5 at week 52. It should be noted that this significant deterioration was almost entirely due to changes in the "posture" scoring parameter (posture score = 1 at baseline and week 26; = 5 at week 52), and the patient complained of left knee pain at the time of examination. Furthermore, the subject had an injury to the big toe of the left foot prior to the examination; this injury was considered resolved 11 days after the examination. Excluding these outlier effects in patient 4, treatment with compound 2 resulted in a significant decrease in the mean SARA score at week 26, with a further slight improvement at week 52. The Trajectory Tracking Test (TMT) is used to assess patients' cognitive function. The TMT is one of the most widely used neuropsychological tests and is included in most test sets. The TMT is a diagnostic tool for assessing general intellectual and cognitive impairment (Tombaugh et al.

[2004] ; Cavaco et al.

[2013] ). In Part A of the TMT, subjects are asked to connect a set of numbers in ascending order. This task combines visual searching with general visual and motor speed. Part B presents an alternating sequence of numbers and letters. When connecting these in ascending order, subjects must actively switch between the two categories, but in alternating order. Therefore, this task is considered to include an executive function component because subjects must actively switch between categories when connecting the symbols (MacPherson et al.

[2017] ). TMT-A primarily assesses sensory and psychomotor speed. TMT-B more specifically assesses mental flexibility and adaptability. Subtracting the TMT-A score from the TMT-B score removes variables attributable to writing motion and visual scanning components of TMT-A. This resulting score reflects the unique task requirements of TMT-B. In a prescriptive study of TMT A and TMT B in a community population aged 18–89 years (n=911), the mean (SD) values ​​were 22.9 (6.9) for TMT A and 49 (12.7) for TMT B in the 18–24-year-old group (n=155) (Tombauch et al.

[2004] ). Conversely, in this study, the mean time taken by patients to complete trajectory A and trajectory B was 67.8 seconds (SD=60.3s) and 193.8 seconds (SD=197.0), respectively. At baseline, the mean time difference between completing trajectory B and trajectory A was 126.0 seconds (SD=142.9 seconds). This suggests that GD-3 patients in this study exhibited some degree of cognitive impairment at baseline. At week 52, the average time to complete trajectory A was 56.5 seconds (SD = 55.2 seconds) and for trajectory B it was 122.7 seconds (SD = 91.8 seconds). Four out of six patients showed a decrease in time to complete trajectory A, and six out of six patients showed a decrease in time to complete trajectory B. Patient 5 was excluded due to low levels of compound 2 exposure. Four out of six patients showed a decrease in TMT-A, and five out of five patients showed a decrease in TMT-B. At week 52, 5 out of 6 patients showed a decrease in presentation time (TMT B-TMT A). Individual results are shown in the table below. [picture] At week 52, the average difference between the time spent completing trajectory B and trajectory A was 66.2 seconds (SD = 54.3). Excluding patient 5, 4 out of 5 patients showed improvement in the difference between trajectory B and trajectory A at week 52, with an average improvement of -71.4 seconds (-31.6%) (SD 99.3 seconds (37.6%)). Neurological function was further assessed using functional magnetic resonance imaging (fMRI). Patient 2 was excluded because no fMRI data were collected at the week 52 meeting. Resting-state fMRI screening meetings were held at baseline screening, week 26, and week 52 visits. The contiguous group of four subjects (patients 1, 3, 4, and 5) was presumed to be eligible for the second phase analysis. As mentioned above, patient 5 was excluded due to possible non-compliance with study medication. The analysis was performed as described elsewhere (Smith et al.

[2009] ). The study found that subjects in the "matching" group exhibited enhanced connectivity across a wider range of brain regions compared to those in the non-matching group, with the most significant feature being a gradual increase in strength between the posterior and anterior regions. Anatomically, subjects in the matching group showed extensive and robust enhanced connectivity between the occipital-parietal structures and frontal, temporal, and limbic targets. In patient 5, the changes in connectivity were more moderate and spatially limited to proximal structures. Functionally, enhanced connectivity between the pre-set pattern and the medial frontal network was observed in every patient (except patient 5). This indicates that signals within these different networks become more cohesive, allowing for more efficient transfer of brain activity between cognitive reserves (posterior) and higher-order executive functions (anterior). Consistent localization of the interaction between resting state networks (RSNs) 2 and 3 ("cognitive-language-correct spelling" and "cognitive-spatial") and RSNs 8 and 9 (executive and left frontoparietal) was also evident. The spatial distribution of connectivity changes was more significant for patient 5, primarily reflecting overlap between the medial frontoparietal and frontoparietal networks. These two perspectives show that patients who fully adhered to the treatment protocol developed better cohesion between the posterior and anterior brain regions, making the entire brain more conducive to effective information transfer. Notably, patient 5 exhibited altered connectivity in a narrower location within the forebrain region, representing evidence of lower integrity of the treatment benefit. These results are summarized in the table below. Spatial analysis of connections between different brain anatomical regions was performed to define the correlation coefficients of the average intensity of degenerated voxels. These results show increased connections between the pre-specified pattern network and the executive function network in patients 1, 3, 4, and 6, but decreased in patient 5. [picture] Additionally, it was found that two patients experienced a decrease in spleen volume and an average increase in mean platelet concentration of 9.3% (range -8.2% to +45.3%) at week 52. All patients maintained the treatment target of a platelet count greater than 120 x 10⁹ / L. The increase in mean platelet concentration was observed in 3 out of 6 patients. There were no clinically significant changes in hemoglobin levels. Example 6: Pharmacokinetics of Compound 2 in Healthy Human Volunteers Two Phase 1 clinical trials were conducted to evaluate the pharmacokinetics, pharmacodynamics, safety, and tolerability of compound 2 in healthy human volunteers, with and without food. Compound 2 is also known as venglustat. Study 1 Study 1 is a 2-part, single-center trial in healthy adult male volunteers. Part 1 is a double-blind, randomized, placebo-controlled study of the safety, tolerability, and pharmacokinetics (PK) of compound 2 in a sequential, escalating single dose. Part 2 is an open-label, single-generation, randomized, 2-sequential, 2-period, 2-treatment crossover study of the PK of compound 2 with or without a high-fat diet. Part 1 of the study recruited and randomized 55 healthy men (placebo, n=14; 2-, 5-, 15, 25-, 50-, and 100-mg doses, n=6 each; 150-mg dose, n=5). Eight healthy men participated in Part 2. In Part 1, participants were randomly assigned to receive 2, 5, 15, 25, 50, 100, or 150 mg of Compound 2 (L-malate form) or a matched placebo after fasting for at least 10 hours on the morning of Part 1. In Part 2, participants were randomly assigned to receive a single oral dose of 5 mg of Compound 2 30 minutes after fasting (at least 10 hours before and 4 hours after administration) or a standardized high-fat breakfast (~815 kcal). After a 7-day clearance period, participants were cross-referenced to other conditions. In Part 1 of Study 1, blood samples were collected to measure the plasma concentration of compound 2 at the time of drug administration (0 hours) and at 0.5, 1, 2, 3, 4, 5, 6, 8, 10, 12, 16, 24, 48, 72, and 96 hours after administration. Urine samples were collected from 2 hours prior to drug administration to 48 hours thereafter for analysis of compound 2 concentration. In Part 2 of Study 1, blood samples were taken at 0, 0.5, 1, 2, 3, 4, 5, 6, 8, 10, 12, 16, 24 and 48 hours after administration to measure the plasma concentration of compound 2. From Part 1, it was found that after a single oral administration of compound 2 at doses ranging from 2 to 150 mg, the maximum plasma concentration (Cmax) occurred at a median time of 3–5.5 hours, after which the plasma concentration began to decrease exponentially with a geometric mean t1 / 2 of 28.9 hours. Increased exposure across the entire dose range was nearly dose-proportional: a 75-fold increase in dose resulted in increases of 97.3-, 89.2-, and 85.9-fold in geometric mean Cmax, AUClast, and AUCinf, respectively. PK results are shown in the table below (AUC = area under the time-concentration curve at the last measurable concentration or extrapolated to infinity; t1 / 2 = final half-life; CL / F = apparent total clearance of plasma; CV = coefficient of variation; SD = standard deviation; tmax = time to reach Cmax; Vss / F = apparent volume of distribution at steady state): [picture] [picture] Part 2 revealed that a 5 mg dose and a high-fat diet had no effect on compound 2 exposure compared to fasting. The median tmax was 6.00 hours regardless of whether food or fasting was administered. The geometric mean ratios for food / fasting were 0.92 and 0.91 in terms of Cmax and AUClast, respectively. Intra-subject variability (i.e., food versus fasting) accounted for less than half of the total subject variability. Study 2 Study 2 is a single-center, double-blind, randomized, placebo-controlled, escalating repeated administration study of compound 2 in healthy adult male and female volunteers to assess its safety, tolerability, pharmacokinetics, and pharmacokinetic properties. This study recruited and randomly assigned 36 healthy adults (19 men and 17 women) (n=9 in each group). Subjects were randomly assigned to receive a once-daily dose of 5, 10, or 20 mg of compound 2 (in the form of 5 mg L-malate capsules) or placebo for 14 days after fasting for at least 10 hours. Blood samples were collected for compound 2 plasma concentration analysis as follows: Day 1, at 0, 0.5, 1, 2, 3, 4, 5, 6, 8, 10, 12, and 16 hours post-administration; Days 2-5, 8, 11, and 13, at 0 hours; Day 14, at 0.5, 1, 2, 3, 4, 5, 6, 8, 10, and 12 hours post-administration; and Days 15-17, at 24, 48, and 72 hours post-administration on Day 14. Urine samples were collected on Day 1 (0 hours post-administration) and continuing on Day 14 from 0 to 24 hours post-administration for compound 2 concentration analysis. Pharmacokinetic efficacy endpoints (plasma GL-1, GL-3, and GM3 concentrations) were assessed on Days 1-5, 8, 11, 13, and 14 at 0 hours post-administration; and on Day 15 at 24 hours post-administration on Day 14. In subjects receiving 5, 10, or 20 mg of compound 2 once daily for 14 days, plasma Cmax occurred at the median time of 2–5 hours post-dose on days 1 and 14. Ctrough values ​​peaked after day 5. Increased exposure to compound 2 within the 5–20 mg dose range was nearly dose-proportional: this 4–fold dose increase resulted in a 3.76– and 3.69–fold increase in geometric mean Cmax and AUC0–24 values ​​on day 14, respectively. The pharmacokinetic results of Study 2 are summarized in the table below: [picture] [picture] Following 2 doses of the 14 once-daily compounds, the 24-hour unchanged urinary excretion fraction (mean fe0–24) ranged from 26.3% to 33.1%, with no significant dose-related correlation. The mean CLR (0–24) ranged from 1.49 L / h to 2.07 L / h, approximately 3.18–3.86 times lower than the observed plasma CL / F. Plasma GL-1, GL-3, and GM3 levels in placebo patients remained similar to baseline, while in the overall 2-component dosing groups, plasma GL-1 and GM3 levels decreased from baseline in a time- and dose-dependent manner, as shown in the table below (assessment point for treatment ratios of glucosamine (GL-1), acetylsphingosine trihexoside (GL-3), and GM3 ganglioside (GM3) on day 15 in repeated escalation studies): [picture] The maximum sustained effect on GL-1 occurred on day 11 in the 5- and 10-mg groups and on day 8 in the 20-mg group. The mean calculated decrease in GL-1 from baseline on day 15 was 41.9%, 69.6%, and 74.6% in the 5-, 10-, and 20-mg groups, respectively. At baseline, one recipient of compound 2 at 5-mg had a GL-1 value below the lower limit of quantitation (LLOQ), and three, five, and nine recipients at day 15 in the 5-, 10-, and 20-mg groups, respectively. The maximum sustained decrease in GM3 starting on day 13 occurred in all compound 2 dosing groups. The mean plasma GM3 levels on day 15 were 42.7%, 49.4%, and 57.8% of baseline in the 5-, 10-, and 20- mg dosing groups, respectively. On day 15, one and two subjects in the 10- and 20- mg dosing groups, respectively, had GM3 levels below the LLOQ. In all compound 2 dosing groups, plasma GL-3 also decreased over time, but the variable and low baseline GL-3 values ​​decreased relative to the LLOQ-limited mean GL-3. In the placebo, 5-, 10-, and 20- mg dosing groups, 1, 3, 1, and 6 subjects, respectively, had GL-3 values ​​below the LLOQ at baseline, and 4, 9, 7, and 9 subjects, respectively, on day 15. The mean estimated decrease in plasma GL-1 attributable to compound 2 compared to baseline (90% CI) was 67.0% (54.4–79.7%), 74.4% (63.7–85.2%), and 76.3% (64.8–87.8%) in the 5, 10, and 20 mg dose groups (19.0, 47.5, and 69.9 ng / mL, respectively). in conclusion In these studies, compound 2 exposure (Cmax and AUC) in healthy subjects was nearly dose-proportional when administered as a single dose ranging from 2–150 mg or as repeated doses ranging from 5–20 mg once daily for 14 days. A high-fat diet had no effect on exposure in subjects receiving a single 5-mg dose compared to fasting. Steady state was reached within 5 days for repeated once-daily doses of 5–20 mg; age and sex did not affect cumulative effects. Although baseline GL-3 levels were too low to be used as a biomarker for pharmacokinetic analysis, pharmacokinetically, repeated once-daily doses of compound 2 reduced plasma concentrations of GL-1 and GM3 in a time- and dose-dependent manner, consistent with compound 2-mediated GCS inhibition. The dose-dependent reduction in GL-1 confirms the expected mechanism of action of compound 2: inhibition of GL-1 formation by ceramides via the GCS. In all studies, the safety profile was assessed by monitoring for treatment-related adverse events (TEAEs), including serious adverse events (SAEs), ECG monitoring, laboratory values, and physical examinations, for 10 days following the administration of the final study drug. No deaths, SAEs, severe TEAEs, or TEAs caused the study to be interrupted in any of these studies. No clinically relevant hematological or biochemical abnormalities were reported in any of these studies. Vital signs showed no significant changes compared to baseline in any of these studies. In single-dose escalation studies and food effect studies, ECG parameters showed no significant changes; in multiple-dose escalation studies, ECG parameters showed no statistically significant changes compared to mean baseline in recipients of any dose of compound 2, compared to placebo. It should be understood that while the invention has been described in conjunction with the specific examples above, the foregoing description and examples are intended to be illustrative and not to limit the scope of the invention. Other variations, advantages, and modifications within the scope of this invention will be apparent to those skilled in the art. Example 7: Clinical study of compound 2 in patients with Fabry disease method A three-year open-label study of compound 2 was conducted in young patients with typical Fabry disease to evaluate its long-term safety, pharmacokinetics, and exploratory efficacy in adult males with Fabry disease. Eleven participants were enrolled in this study, and seven completed all aspects of the study. All participants were confirmed by genotyping and residual α-galactosidase activity as low as detectable levels, and were diagnosed with typical Fabry disease (nine of the eleven participants had a meaningless mutation in the GLA gene). All participants had plasma lyso-GL3 levels of at least 65 ng / mL and had not previously been able to receive Fabry disease-specific treatment. The median age of the participants was 24 years (range 19–37 years). Patients were administered a daily oral dose of 15 mg of compound 2. Clearance of GL-3 deposits was monitored by biopsies taken at weeks 12, 26, 52, and 156, and was assessed semi-quantitatively using optical microscopy (focusing on skin microvascular endothelial cells). The presence of GL-3 inclusions in each sample was independently scored by three pathologists using a four-point scale and graded according to Eng et al., N. Engl. J. Med. 345: 9-16 (2001) as 0 (absent / trace), 1 (mild), 2 (moderate), or 3 (severe). Individual scores for each patient at each time point were generated using a majority of the scores from the three pathologists. If a majority could not be generated, the median score was used (resulting in some fractional scores). GL-3, lyso-GL-3, GL-1, and GM3 were also analyzed in plasma samples at baseline and at weeks 12, 26, 52, and 156. Pain scores and abdominal symptoms were analyzed using the SF-36 scoring criteria at baseline and at weeks 12, 26, 52, and 156. Patients were assessed using the Short Form-36 (SF-36) questionnaire during multiple visits from baseline to week 156. This 36-item questionnaire measures eight different health dimensions: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health. Scores for each of the eight dimensions ranged from 0 (maximum disability) to 100 (no disability), with higher scores indicating better health. Furthermore, gastrointestinal symptoms, including abdominal pain, bloating, and bowel movements, were assessed using a revised inflammatory bowel disease severity scoring system. The questions asked as part of these assessments include: (1) whether the patient has had abdominal pain in the last 10 days, (2) the severity of the abdominal pain experienced in the last 10 days, using a scale from 0 (no pain) to 100 (not severe pain), and (3) how many days the patient has had abdominal pain in the last 10 days. result At week 156, five patients showed a 1-point decrease in skin GL-3 score, two patients had completely cleared GL-3 inclusions, one patient showed no change, and one patient had no sample available. During the 156-week study period, the mean plasma GL-1 level decreased by 69%, the mean plasma GM3 level decreased by 60%, the mean plasma GL-3 level decreased by 77%, and the mean plasma lyso-GL3 level decreased by 52%. Plasma GL-1 and GM3 showed a very rapid decrease in the first 2–4 weeks of treatment. All four measurements showed a sustained reduction in plasma load, which largely stabilized by week 52. The plasma and urine data are summarized in the table below: [picture] [picture] These results show that administration of compound 2 at 15 mg / day consistently reduced GL-1, lyso-GL-1, and GM3 in vivo in a holistic and gradual manner. In addition, data from a previously completed placebo-controlled Phase 3 trial of agalsidase β (Fabrazyme) were analyzed and compared (see Eng et al., N. Eng. J. Med., 345: 9 (2001)). Compared to agalsidase β, the historical control arm consists of data from the Phase 3 trial administered via agalsidase β. Patients treated with β were compared for changes in plasma GL-3 at multiple time points up to three years. Inclusion criteria and baseline characteristics were similar between the two studies. To enhance comparability, patients receiving compound 2 were matched with patients in the phase 3 study based on propensity score and baseline variables of age, plasma GL-3, sex, UPCR (<500 mg / g vs. 500-1000 mg / g vs. >1000 mg / g), and eGFR (<80 vs. 80 mL / min / 1.73 m2 [Figure]). For placebo comparison, 11 patients receiving compound 2 were matched with 19 patients, while agalsidase... The β comparison involved 28 patients. All patients in all three groups were male and exhibited elevated plasma GL-3, UPCR <500 mg / g, and eGFR [Figure] 80 mL / min / 1.73 m2. The mean age was similar across the three groups. The comparison showed that treatment with compound 2 for 26 weeks resulted in a significant decrease in plasma GL-3 compared to placebo, -3.62 μg / mL vs. -1.06 μg / mL (P < 0.0001). Compared to agalsidase β, treatment with compound 2 produced a similar decrease in plasma GL-3 at 52 weeks, with significant decreases at 104 and 156 weeks (p = 0.0351 at 104 weeks; p = 0.0081 at 156 weeks). Compared to agalsidase β... The plasma GL-3 level was 4.44 μg / mL in patients treated with β and 1.90 μg / mL in patients treated with compound 2 after 156 weeks. The detailed results of the skin GL-3 inclusion body score are shown in the table below (0 points represent no GL-3 inclusion bodies): [picture] [picture] [picture] [picture] [picture] In addition to evaluating GL-3 skin inclusions using optical microscopy, electron microscopy was used to estimate the volume fraction of GL-3 inclusions in endothelial cell cytoplasm using a masked interpreter. At least 50 images of superficial endothelial cell microvessels were obtained using an electron microscope at 7500x magnification. Differences between baseline and post-treatment values ​​at each time point were assessed using a two-sided t-test. The results are shown in the table below: [picture] These results show that administration of compound 2 at 15 mg / day consistently reduced the amount of GL-3 inclusions in the skin in an overall gradual manner. Generally, the results were more pronounced in superficial vascular endothelial cells compared to deeper vascular endothelial cells and other skin tissues. Of the nine patients, seven experienced improvement in overall body pain score (SF-36) at week 26, while three of the six patients showed improvement at week 156. Among patients with gastrointestinal pain at baseline, four out of five patients experienced a decrease in pain (abdominal pain) severity at week 26, and four out of four patients experienced a decrease at week 156. Five out of five patients experienced a decrease in the number of days with gastrointestinal pain at week 26, and three out of four patients experienced a decrease at week 156. The detailed results of the abdominal pain measurement are shown in the table below. [picture] These results show that administration of compound 2 at 15 mg / day consistently reduced abdominal pain and physical discomfort in a generally gradual manner. Furthermore, when the features or characteristics of this invention are described according to the Markush group, those skilled in the art should understand that this invention is also described according to any individual member or subgroup of the Markush group. All publications, patent applications, patents, and other references cited herein are expressly incorporated in their entirety as if they were individually incorporated. In case of conflict, this specification, including its definitions, shall prevail.

Claims

1. Use of a compound for the preparation of a medicament for the treatment or prevention of cognitive impairment and / or ataxia associated with lysate storage in human subjects with such need, wherein the subject has Gaucher disease Type 3 and the medicament is effective in: a) improving cognitive function or reducing cognitive impairment; or b) reducing the ataxia score on the Scale for the Reduction of Ataxia (SARA) by at least 0.5 points and / or effectively reducing the SARA score to between 0.00 and 3.00; and wherein the compound is (S)-pyridin-3-yl(2-(2-(4-fluorophenyl)thiazolyl-4-yl)propyl-2-yl)carbamate, or a pharmaceutically acceptable salt thereof.

2. As claimed in claim 1, wherein the compound is in the malate form of (S)-pyrido-3-yl(2-(2-(4-fluorophenyl)thiazolyl-4-yl)propyl-2-yl)carbamate.

3. As used in claim 1 or claim 2, wherein the ataxia is cerebellar ataxia, and wherein the ataxia is manifested by symptoms selected from the following: gait instability, weakness, incoordination, delayed reaction time, time discrimination disorder, speech disorder, swallowing disorder, hypotonia, distance discrimination disorder, distance discrimination disorder, hyperextension, alternating movement disorder, slurred speech, vocal cord fremitus, ataxia, postural maintenance reflex disorder, and combinations thereof.

4. As requested in item 3, wherein the subject has a baseline ataxia score of at least 0.5 on the Grade of Ataxia Scale (SARA) at the start of treatment.

5. As used in Request 1 or Request 2, wherein the cognitive function is not entirely dementia, and wherein the dementia is manifested by deficits in the following areas: visual search speed, processing scanning speed, psychological resilience and / or executive function.

6. As claimed in claim 1 or claim 2, wherein the drug is effective in reducing the SARA ataxia score by at least 1 point; or wherein the drug is effective in reducing the SARA score to between 0.00 and 2.

00.

7. As requested in Request 1 or Request 2, wherein the drug is effective in improving cognitive ability or reducing cognitive impairment, as assessed by Trajectory Tracking Test (TMT), the time spent completing the Trajectory Tracking Test (TMT) is reduced, and the time difference between the time of TMT-A and / or TMT-B is reduced (TMT-B minus TMT-A).

8. As used in Request 1 or Request 2, wherein TMT-A decreases by 5-20%, and / or TMT-B decreases by 25-30%, and / or [TMT-B minus TMT-A] decreases by 25-30%.

9. As requested in Request 1 or Request 2, wherein the subject is undergoing concurrent treatment with enzyme replacement therapy (ERT).

10. As claimed in claim 9, wherein the subject has been given enzyme replacement therapy before starting treatment with the compound, and / or the subject is transitioning from ERT therapy to treatment with the compound.

11. The use as claimed in claim 1 or claim 2, wherein the compound or a pharmaceutically acceptable salt thereof is administered systemically, and / or wherein the subject is given 1 mg to 150 mg of the compound.

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