Medium molecular weight heparin

Abstract

The present invention relates to reduced medium molecular weight heparin. The present invention further relates to the treatment of endotheliopathy, particularly reduced medium molecular weight heparin for use in the treatment of endotheliopathy. The present invention also relates to the synthesis of reduced medium molecular weight heparins.

Description

MEDIUM MOLECULAR WEIGHT HEPARINFIELD OF THE INVENTION

[0001] The present invention relates to reduced medium molecular weight heparin. The present invention further relatesto the treatment of endotheliopathy, particularly reduced medium molecular weight heparin for use in the treatment of endotheliopathy. The present invention also relates to the synthesis of reduced medium molecular weight heparins.BACKGROUND OF THE INVENTION

[0002] The vertebrate vasculature system consists of arteries, veins and capillaries. Blood flow through the vasculature is dynamic allowing for the maintenance of homeostasis through the delivery of essential elements such as oxygen and leukocytes to the tissues most in need. Blood flow is controlled through the dilation and constriction of the blood vessels. The endothelial cells which line the inside of the lumen of the vasculature act as a monolayer to form the endothelium; the endothelium sits upon a layer of smooth muscle cells. These smooth muscle cells either constrict or relax which results in constriction of the blood vessels (vasoconstriction) or dilation of the blood vessels (vasodilation), respectively. To reach sites of inflammation, leukocytes must pass from the blood through the endothelial cells to reach inflamed tissue. In the case of haemorrhage, blood flow can be controlled through thrombus formation. The regulation of vasoconstriction, vasodilation, vascular permeability, and thrombus formation are therefore crucial for the regulation of homeostasis.

[0003] The endothelial cells lining the blood vessel are more than simple constituents of the vessel wall. Endothelial cells produce and release vasoactive substances that relax and constrict blood vessels. For example, endothelial cells produce nitric oxide (NO) in response to sheer stress or stimuli, such as acetylcholine, histamine and thrombin. The NO then diffuses to the smooth muscle cells surrounding the endothelium to initiate vasodilation. Reactive oxygen species, which are released in response to inflammatory stimuli, can increase endothelial permeability and promote leukocyte adhesion to the endothelial cells via the expression of adhesion molecules. This serves to drive the influx of leukocytes to sites of inflammation. Moreover, the endothelium provides a surface for thrombus formation. Thus, it is the endothelial cells that play a crucial role in the regulation of homeostasis.

[0004] Endothelial dysfunction, or endotheliopathy, can therefore have dire consequences as blood flow, oxygen delivery, the immune response and, therefore, homeostasis are impaired. Endotheliopathy is characterised by decreased NO bioavailability. This can result in the increased expression of adhesion molecules on the endothelial surface, thereby initiating leukocyte recruitment to the vascular wall. Thus, inflammation of the endothelium, or endothelialitis, is observed in endotheliopathy. This can result in a defective lining of the blood vessels by the endothelium, resulting in the exposure of the subendothelial matrix to clotting factors in the blood. Consequently, platelet aggregation and thrombus formation occur, resulting in a potentially lethal blood clot.

[0005] Endotheliopathy may be caused by a number of diseases and is typically viewed as a symptom rather than a cause of disease. Consequently, treatments have focussed on targeting the causative disease rather than the endotheliopathy itself. As a result of this, treatments for endotheliopathy are lacking. However, it is now suggested that an underlying endotheliopathy may actually drive disease severity and morbidity and endotheliopathy plays a much larger role than previously thought. Therefore, treating the endotheliopathy and not just the causative disease may increase patient survival.

[0006] Herein, endotheliopathy and endothelialitis are used interchangeably. While endotheliopathy may be caused by a large number of diseases and / or conditions as described herein, endotheliopathy with reference to COVID-19 or SARS-CoV-2 will primarily be discussed herein. The skilled person will understand that this discussion is merely to provide an example and should not be considered limiting on the present invention.

[0007] In late 2019, in Wuhan, China a new beta-coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2, SARS-CoV-2) was identified, causing coronavirus disease 2019 (COVID-19). Thereafter, a rapid geographical progression of COVID-19 culminated in the WHO declaring a pandemic in March 2020 (1). The clinical manifestations of those infected with SARS-CoV-2 range from the asymptomatic patient to a more severe pneumonia, which can lead to acute respiratory distress syndrome (ARDS) and multi-organ failure. The majority of symptomatic patients will experience a mild-to-moderate form of the disease, which most commonly does not require hospitalisation (2-4). However, there is a cohort of patients that can progress to the more severe form of the disease, where evolution of symptoms / clinical manifestations can take up to 2 weeks, starting from an initial prodromal stage through to ARDS (3). It is now known that the subgroup of patients that become critical and require ventilation or extracorporeal membrane oxygenation (ECMO) have very poor outcomes with high rates of mortality that approach 90% (5).

[0008] Since the disease was first described it has affected more than 90 million individuals globally. The pathophysiological pathways remain unclear; accordingly, management is supportive. Diseasemodifying therapeutics which could be instigated whilst awaiting a specific anti-viral drug or vaccination are lacking. Several lines of evidence point towards endothelial dysfunction as a key pathophysiological mechanism in COVID-19. Prior to the current pandemic, markers of endothelial dysfunction have been shown to be correlated with disease severity and mortality in patients with sepsis (6-9). Recently Varga et al. (10) demonstrated a widespread endothelialitis that affected pulmonary, renal, gastrointestinal and hepatic vessels on post mortem examination of three patients with COVID-19. In one of the cases the authors reported 'most of the small vessels appeared congested' and in another case the patient died from bowel ischaemia with evidence of underlying endothelialitis.

[0009] Recently, two proposed haemostatic mechanisms have provided insight into an improved understanding of ARDS based on a molecular pathogenesis associated with endotheliopathy that promotes inflammation and coagulation disorder in sepsis and other critical illnesses (11-14) : one is the "two-activation theory of the endothelium" in which an endothelial pathogenesis activates the inflammatory pathway and microthrombotic pathway, whilst the other is a novel "two-path unifying theory" of haemostasis in which haemostasis initiates thrombogenesis and promotes micro-thrombogenesis, leading to vascular microthrombotic disease (VMTD) (11,13,15). These two theories are in congruity with one another since the endothelium contributes to initial haemostasis and triggers the molecular mechanisms of thrombogenesis. ARDS is often associated with sepsis from a variety of different causes and has been seen in severe acute respiratory syndrome (SARS) due to SARS-CoV (16), Middle East respiratory syndrome (MERS) due to MERS-CoV (17) and now COVID-19. Sepsis-associated ARDS often develops with other organ dysfunction such as encephalopathy (18), hepatic failure (19)(20), acute renal failure, and acute necrotizing pancreatitis (21). This multi-organ involvement suggests ARDS may not be the primary disease but is part of an on-going systemic pathogenic mechanism triggered by an infection or another critical illness.

[0010] On this basis the underlying physiologic alteration of multi-organ failure in sepsis and other critical illnesses is identified as circulatory dysfunction occurring as a result of an endotheliopathy associated VMTD (EA-VMTD) (14,15). Therefore, the infection triggers an insult to the endothelium, causing an endotheliopathy. This then results in disseminated microthrombosis (DIMT), which may trigger, for example, local hypoxaemia, systemic hypoxia, and / or ischaemia, and as mentioned earlier COVID-19 is now known to be associated with an endothelialitis (10).

[0011] A case series of COVID-19 pulmonary autopsies revealed that, alongside diffuse alveolar damage, numerous localised platelet-rich micro-thrombi and foci of haemorrhage were present in the lungs (22). The authors posited a pulmonary-localised thrombotic microangiopathy as key to the pathogenesis of COVID-19 with others also suggesting the micro-thrombosis is a critical driver in the disease process (23). These microcirculatory changes have been clearly demonstrated in the lungs, kidneys and the liver using contrast enhanced ultrasound (24,25). Similar findings have also been seen in the brain (26). Therefore, there is a growing body of evidence that COVID-19 appears to cause an endothelialitis and a diffuse and widespread microthrombosis.

[0012] Hypercoagulability and COVID-19 is now widely accepted and studies have shown abnormal levels of D-Dimers with higher levels associated with more severe disease and increased odds ratio of in-hospital mortality (27-30). Several case reports have noted acute pulmonary emboli in patients with COVID-19 pneumonia in the absence of major predisposing factors for venous thromboembolism formation (27,31,32). More recently Panigada et al. have shown that, in addition to raised D-Dimer levels, there was a marked increase in the levels of Factor VIII and von Willebrand factor (VWF) (33). An increase of over 500% in VWF and >350% increase in Factor VIII levels were reported by Escher et al (34) in relation to COVID-19. Furthermore, it has been demonstrated that patients with a thrombocytopaenia were at over 5-fold increased risk of severe disease and those with the lowest platelet counts were associated with the highest mortality (33,35,36) Therefore, both hypercoagulability and thrombocytopaenia appear to be harbingers of severe disease and mortality.

[0013] Von Willebrand Factor (VWF) is a multimeric plasma glycoprotein that plays a critical role in haemostasis and thrombosis mediating platelet adhesion to injured and activated vessels. It is synthesized only in megakaryocytes and endothelial cells (ECs) and it is interesting to note that SARS- CoV can directly infect both of these cell types (22,36).

[0014] The vast majority of VWF found in the plasma is derived from the VWF synthesised within the ECs, where it is stored within the Weibel Palade Bodies (WPB). Although restricted to ECs there aredifferences in the synthesis of VWF within the different vascular beds of the body, with the small vessels of the lung and brain expressing higher levels of VWF than similar sized vessels of the liver or kidney and higher levels in venous rather than arterial ECs (37). A major portion of the VWF stored in the WPBs of endothelial cells is made up of ultra-large VWF (ULVWF). These ultra-large VWF multimers are more adhesive than the smaller VWF multimers in the circulation (38). Upon secretion, ULVWF can spontaneously bind platelets. Inflammatory cytokines such as lnterleukin-1 and tumour necrosis factor (TNF)-alpha can trigger the exocytosis of WPBs with release of their contents. Thus, plasma level of VWF can be used as a marker of endothelial activation and vascular inflammation and raised levels of VWF have been shown to associate with ARDS and sepsis, and to correlate independently to mortality (39,40).

[0015] Upon secretion from ECs, the secreted VWF, which partly enters the circulation and partly binds to the endothelium, is sensitive to shear stress. This shear stress unfolds the VWF and exposes sites for platelet binding, self-association as well as for cleavage via the enzyme ADAMTS13. It has previously been shown these VWF molecules can self-associate into long 'strings' in the direction of flow, both arterial and venous, that bind to platelets and are adherent to the endothelium (41-43). A protease, ADAMTS13, cleaves VWF and ULVWF, perfusion of which over these platelet-VWF strings led to them being rapidly removed from the circulation (41). The ULVWF multimers released from the WPBs have a lower shear stress for unfolding and therefore may represent the initiating molecules for this self-assembly process which leads to hyper-adhesive strings capturing platelets. The binding of platelets to the VWF occurs via the GP lb receptor at the Al domain. The binding site for this receptor is usually not exposed when the VWF is in its globular form and therefore cannot bind to platelets. Once VWF unfurls, secondary to shear stress, the binding site is exposed and binds with high affinity to platelets. The binding of platelets to VWF may cause a conformational change leading to activation of the integrin GPIIbllla (also known as a2b|33) and promoting platelet-platelet as well as platelet-VWF cross binding. For this reason, the use of standard anti-platelet agents is likely to be ineffective (Aspirin or P2Y12 inhibitors) or only partially effective in mitigating this pathological process as was suggested by the cohort study of Tremblay et al (44).

[0016] This ability to form VWF-platelet rich thrombi in the microvasculature is the hallmark of acquired thrombotic thrombocytopaenic purpura (TTP) in which auto-antibodies to ADAMTS13 are present. It has also been shown that lnterleukin-6 (IL-6) can inhibit the cleavage of ULVWF - platelet strings (45). Furthermore, the synthesis of ADAMTS13, at least in cultured cells, is dramatically inhibited by a variety of cytokines including IL-6 and TNF-alpha (46). This suggests that the cytokine storm, and particularly IL-6, may propagate the microthrombosis. However, this also suggests that if intervention is implemented early and there is no spike in the release of cytokines the disease may be more manageable and the rapid deterioration in the clinical status of patients can be averted.

[0017] There is now a significant body of evidence to suggest that there is very marked imbalance in the VWF:ADAMTS13 ratio as well as in the levels of high molecular weight VWF multimers (equivalent to ULVWF) in COVID-19. As mentioned earlier very high levels of VWF have been shown previously with the earliest case report to mention this surge in the levels of VWF being that of Escher et al (34). Subsequently, Goshua et al. (47) demonstrated that reported marked elevations in plasma VWF concentrations in patients admitted with COVID-19 with increased levels associated with disease severity - mean VWF antigen levels of 5651199% vs 2781133 for those admitted to an intensive careunit (ICU) compared to those not admitted to ICU (p<0.0001). Next, Rauch et al. (48) looked at the progression of patients with COVID-19 in relationship to their admission VWF. Those with the highest VWF levels required greater levels of oxygen support whereas those patients that had normal VWF levels did not require admission to hospital nor supplementary oxygen (n=10).

[0018] Shortly after the Rauch et al. publication Ladikou et al. (49) showed an increase in the VWF antigen levels of patients with COVID-19 admitted to the ICU with a positive correlation seen in the VWF levels and the age of the patients. They reported a median VWF Antigen level of 350% however, and crucially, they also showed a markedly reduced level of ADAMTS13 (49.7%), suggesting loss of the VWF cleaving protease that ordinarily degrades large VWF multimers and reduces its activity. They speculated that excess release of VWF seen in COVID-19 patients leads to depletion of ADAMTS13 and contributes to the prothrombotic state. Further analysis of their data showed that median VWF levels were significantly higher in patients that died (477%) compared to the ones that remained alive (335%) (p=0.015).

[0019] Helms et al. (50) recently published a multicentre prospective cohort study in France, assessing thrombotic risk in COVID-19 patients, which showed that VWF and factor VIII were considerably increased. In conjunction with this data showing increases in VWF and reductions in ADAMTS13 there is further research to show that the VWF:ADAMTS13 ratio is substantially deranged. Huisman et al. (51) were the first to show a mean VWF:ADAMTS13 ratio of 8.5 (normal 0.5-2) from 12 patients admitted to the ICU. Subsequently, Mancini et al (52) demonstrated similar findings with an elevated von Willebrand Factor antigen (VWF:Ag) to ADAMTS13 activity ratio that was strongly associated with disease severity with the worst ratio, 8.3, seen in those patients that required high intensity care (intubation and mechanical ventilation) compared to those requiring low intensity care, 3.42 (p<0.001).

[0020] Most recently, Philippe et al. (53) published their results from a cohort of 208 patients admitted to two centres in Paris of whom 23 had only mild symptoms and were treated as outpatients. They found that only VWF:Ag scaled according to clinical severity, with levels significantly higher in critical patients (median 507%, IQR 428-596) compared to non-critical patients (288%, 230-350, p < 0.0001) or COVID-19 outpatients (144%, 133-198, p = 0.007). In a univariable analysis model a VWF:Ag level over 423% at admission was significantly associated with higher in-hospital mortality (OR 89.7 95% Cl 25.9-567.4, p < 0.001) which remained very significant in a multivariable analysis model adjusted on age, BMI, D-Dimer and C-reactive protein (CRP) (odds ratio, OR 25.6, 95% Cl 5.6- 198.2, p < 0.001). More importantly they showed that VWF high molecular weight multimers (HMWM) were significantly higher in critical patients (median ratio 1.18, IQR 0.86-1.09) compared to non-critical patients (0.96, 1.04-1.39, p < 0.001). Furthermore, the levels of HMWM (ratio) (OR 116, 95% Cl 10.2-1943, p < 0.001) was one of the most significantly associated with in-hospital mortality.

[0021] It is possible to develop a unifying theory that is triggered by an endotheliopathy and endothelia litis, which causes the release of VWF and ULVWF resulting in the formation of microthrombi. This then leads to hypoxia and the process can be accentuated by the 'cytokine storm' and release of IL-6, which inhibits and reduces the functions of ADAMTS13, resulting in a cascade of disseminated microthrombosis and multi-organ dysfunction and failure. It has also been suggested that this microvascular thrombosis at the pulmonary level is the origin of right ventricular dysfunction(54). This mechanism can account for many of the findings currently being observed including the high D-Dimer levels (high because of the huge levels of microthrombosis), high levels of Factor VIII and VWF (released from the WPBs in response to an endothelial insult), the microthrombosis and atypical ARDS picture being seen (55), as well as the widespread clinical picture of pulmonary, neurological and gastrointestinal symptoms. The endothelia litis and microthrombosis we suggest may also explain why patients with a pre-existing endotheliopathy and micro-arteriopathy (e.g., secondary to diabetes mellitus, hypertension, or obesity) are at increased risk of severe COVID-19 (29,56). Similarly, there is a rapidly growing body of evidence linking patients with low levels of ADAMTS13 and high levels of VWF with a variety of diseases that pre-dispose to a poor outcome after infection with SARS-CoV-2 and to its variable presentation (57-64). The use of standard anti-platelet medication (aspirin or P2Y12 inhibitors) is also likely to be ineffective given that the interaction between VWF and platelets activates the GP2b3a receptor. Although the inhibition of VWF-platelet binding via the GPlb receptor, using either caplacizumab or anfibatide, would be an attractive option and has been suggested (65) these drugs are not in widespread use and clinical experience with them is extremely limited. Similarly, they carry a significant haemorrhage profile.

[0022] Thus, there is a need for a treatment of endotheliopathy per se.SUMMARY OF THE INVENTION

[0023] Heparin is a naturally occurring, highly sulphated polysaccharide characterised by a wide molecular weight range of polysaccharide chains. Heparin acts at a variety of different ligands with varied actions. Heparin is a member of the glycosaminoglycan carbohydrate family and consists of repeating disaccharide units of GlcA|31-4GlcNAcal-4 with poly-disperse sulfation, N-acetylation and uronosyl epimerization. Heparin is highly heterogenous. Heparin may be isolated from natural sources, such as porcine intestine or bovine lung. Heparin isolated from natural sources contains polysaccharide chains with molecular weights ranging from about 3000 Da (g / mol) to about 30,000 Da (g / mol). This is known as unfractionated heparin (UFH or UF heparin). UFH can be enzymatically or chemically treated to deliver shorter polysaccharide chains. Heparinase I cleaves at the a-1,4 linkage between nonacetylated GlcNS6S and ldoA2S. Periodate treatment of UFH followed by alkaline elimination cleaves the polysaccharide chain at unsulfated uronic acid units. The products of the chemically or enzymatically treated UFH can be affinity purified to yield fractionated heparin where the molecular weight of the polysaccharides in each fraction can be readily determined. Low molecular weight heparin (LMWH) contains polysaccharide chains in the range of about 4000 Da (g / mol) to about 8000 Da (g / mol).

[0024] In 1991, it was first demonstrated that the intravenous administration of heparin to patients during open heart surgery induced the impairment of VWF-dependent platelet function, without changes in plasma VWF levels (66). This inhibitory effect of heparin on VWF-dependent platelet agglutination was not dependent on the heparin's affinity for anti-thrombin III, but was dependent upon the molecular weight of heparin. From later in vitro experiments, it was found that heparin bound to a specific amino acid sequence within the Al domain of VWF (residues 569 - 583), in which basic amino acids are regularly arranged. Heparin binding induced conformational changes in a peptide of this binding site (67). Heparin bound to both activated and inactivated VWF similarly, butdid not interfere with VWF binding to collagen. Since the platelet Gplb-binding domain (residues 524 - 542) is also located in the Al domain, it was suggested that heparin interferes with VWF binding to platelet Gplb both by steric hindrance and by inducing a conformational change of the domain that results in inhibition of platelets binding.

[0025] The structural specificity of the heparin that is responsible for binding to VWF, revolves around key disaccharide units - GlcNS6S-ldoA2S and ldoA2S-GlcNS6S. This structural unit, which is normally destroyed by heparinase I digestion, was successfully deduced by competitive binding assays using heparin fractions prepared by specific methods of depolymerization of heparin that produce fragments of predictable structure (68). Further, through the study using synthetic and structurally defined oligosaccharides, it was demonstrated that the assembly of more than 3 units of the disaccharide was crucial for the binding potency. Similarly, although fractionated heparins of lower molecular weight (6100 Da (g / mol)) have shown a higher affinity to binding to the VWF they were less able to inhibit VWF activity compared to UFH. This suggests that a minimum heparin molecular weight and molecular size is important in order to achieve steric hindrance.

[0026] Medium molecular weight heparins with specific disaccharide units (GlcNS6S-ldoA2S, also written as ldoA2S-GlcNS6S) can be produced from unfractionated heparins. These medium molecular weight heparins may have specificity towards inhibiting VWF-GPIb binding, hence stopping microthrombosis, but as they have little effect on anti-thrombin III they have little anti-coagulant effect. Thus, medium molecular weight heparins with a mass of about 11 000 Da (g / mol) may represent an ideal treatment option when considering the treatment of patients with pro-thrombotic states that are dependent upon increased VWF levels and endotheliopathies. Furthermore, the results of these earlier studies suggests that low molecular weight heparins are unlikely to work and target the GPIb receptor and that UFH, whilst it may contain the sugar moieties that can bind to VWF, is sub-optimal. Moreover, monitoring of UFH is difficult and the other fractions of UFH, e.g. the LMWH fractions, have anticoagulant effects which can result in dangerous bleeding events, which are unpredictable.

[0027] Of further interest is the fact that it has recently been shown thatSARS-CoV-2 binds to heparin sulphates and in particular requires the ldoA2S-GlcNS6S sugar moiety (74,75). This suggests that exogenous supply of these sugar moieties may inhibit binding to the endogenous heparan sulphates in the lungs and hence act as a potential prophylactic treatment. Taken together, a specialized medium molecular weight heparin (=11000 Da (g / mol)) with at least 3 units of the GlcNS6S-ldoA2S disaccharide may inhibit viral adherence and replication but also inhibit the microthrombosis triggered by the release of VWF secondary to the endotheliopathy caused by the virus.

[0028] As described herein, endotheliopathy may be associated with a number of diseases. As previously described the Inventors have found that medium molecular weight heparin can be used to treat endotheliopathy, particularly endotheliopathy in a patient having a high plasma von Willebrand factor level (WO 2022 / 238587; incorporated by reference herein).

[0029] The Inventors have now found that reduced medium molecular weight heparin as described herein can be used to treat endotheliopathy, particularly endotheliopathy in a patient having a high plasma von Willebrand factor level.

[0030] Thus, in a first aspect, the invention provides reduced medium molecular weight heparin (MMWH-Red). Preferably, MMWH-Red is prepared according to the second aspect of the invention.

[0031] The medium molecular weight heparin may be for use in treating endotheliopathy. The medium molecular weight heparin may inhibit von Willebrand factor (VWF). The medium molecular weight heparin may inhibit multimers of VWF, preferably ultra-large VWF. The medium molecular weight heparin may inhibit the binding of platelets to VWF.

[0032] As described herein, the invention also provides reduced medium molecular weight heparin for use in treating endotheliopathy.

[0033] In a second aspect, the invention provides a method of preparing reduced medium molecular weight heparin (MMWH-Red) comprising (a) dissolving unfractionated (UF) heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; (b) adding an oxidising agent to the first solution to provide a second solution; (c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a medium molecular weight heparin (MMWH) solution; and (d) incubating the medium molecular weight heparin with a reducing agent to produce MMWH-Red.

[0034] In a third aspect, the invention provides the invention provides reduced medium molecular weight heparin produced according to the following steps: (a) dissolving unfractionated (UF) heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; (b) adding an oxidising agent to the first solution to provide a second solution; (c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a medium molecular weight heparin solution; and (d) incubating the medium molecular weight heparin with a reducing agent to produce reduced medium molecular weight heparin.

[0035] In a fourth aspect, the invention provides a composition comprising reduced medium molecular weight heparin.

[0036] In a fifth aspect the invention provides reduced medium molecular weight heparin according to the first or third aspect of the invention, or MMWH-Red produced according to the second aspect, or a composition according to the fourth aspect of the invention for use in the treatment of endotheliopathy. Preferably, the patient has an endotheliopathy characterised by a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2. Alternatively or additionally, the patient may have an endotheliopathy characterised by a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0037] In an sixth aspect, the invention provides reduced medium molecular weight heparin according to the first or third aspect, or a MMWH-Red produced according to the second aspect, or a composition according to the fourth aspect for use in the treatment of a disease or condition in a patient, wherein the patient has an endotheliopathy characterised by a plasma von Willebrand factor to ADAMTS13 (VWF:ADAMTS13) ratio of at least about 2.

[0038] In a seventh aspect, the invention provides reduced medium molecular weight heparin according to the first or third aspect, or a MMWH-Red produced according to the second aspect, or a composition according to the fourth aspect for use in the treatment of a disease or condition in a patient, wherein the patient has an endotheliopathy characterised by a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0039] In an eighth aspect, the invention provides a method of treating endotheliopathy, the method comprising administering to a subject (patient) in need of treatment a therapeutically effective amount of reduced medium molecular weight heparin. Preferably, wherein the patient has plasma VWF:ADAMTS13 ratio of at least about 2. Preferably, wherein the patient has plasma VWF antigen:ADAMTS13 ratio of at least about 2. Typically, the MMWH-Red may be MMWH-Red according to the first or third aspect, MMWH-Red produced according to the method of the second aspect, or a composition according to the fourth aspect.

[0040] In an ninth aspect, the invention provides the use of the reduced medium molecular weight heparin for the manufacture of a medicament for the treatment of endotheliopathy in a patient. Preferably, wherein the patient has plasma VWF:ADAMTS13 ratio of at least about 2. Preferably the MMWH-Red may be MMWH-Red according to the first or third aspect, MMWH-Red produced according to the method of the second aspect, or a composition according to the fourth aspect.

[0041] In an tenth aspect, the invention provides the use of the reduced medium molecular weight heparin for the manufacture of a medicament for the treatment of endotheliopathy in a patient. Preferably, wherein the patient has plasma VWF antigen:ADAMTS13 ratio of at least about 2. Preferably the MMWH-Red may be MMWH-Red according to the first or third aspect, MMWH-Red produced according to the method of the second aspect, or a composition according to the fourth aspect.

[0042] In a eleventh aspect, the invention provides a kit suitable for preparing reduced medium molecular weight heparin, wherein the kit comprises: (a) unfractionated heparin; (b) an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0; (c) an oxidising agent; (d) a reducing agent; and (e) optionally, an inactivating agent.

[0043] For the avoidance of doubt, embodiments related to each aspect of the invention apply mutatis mutandis to the other aspects of the invention. Further aspects and embodiments of the present invention will be evident from the discussion that follows below.BRIEF DESCRIPTION OF THE DRAWINGSFigure 1 shows MMWH prepared at 4 °C compared to heparin treated at 37 °C, untreated heparin and a 11 kDa standard.Figure 2 shows MMWH prepared at 4 °C using only periodate compared to heparin treated with periodate then NaOH at 4 °C.Figure 3 Graph of molecular weight spread of prepared medium molecular weight heparin.Figure 4 Graph of activity of Low Molecular Weight (LMW) heparin, Unfractionated (UF) heparin and Medium Molecular Weight (MMW) heparin against Factor Ila.Figure 5 Graph of activity of LMW heparin, UF heparin and MMW heparin against Factor X.Figure 61H-NMR of MMWH-Red compared to MMWH.Figure 7 Ristocetin-induced platelet aggregation (RIPA) data for unfractionated (UF) heparin samples (UF sample 1 and 2), 3 medium molecular weight heparin (MMWH sample 1, 2, and 3) and reduced medium molecular weight heparin (MMWH-Red) obtained from three separate blood donors. Average values determined from experiments carried out in at least technical duplicate.Figure 8 The average percentage amplitude measured in a RIPA assay using blood from three separate blood donors for UF heparin, 3 MMWH samples and MMWH-Red. The control was a solution of sodium chloride. Each data point represents one biological repeat. Average values calculated from three biological repeats. The values were compared using a two-way ANOVA and p-values calculated using Tukey's multiple comparisons test. * = P < 0.05, ** = P < 0.01, *** = P< 0.001, **** = P< 0.0001. Figure 9 The average slope measured in a RIPA assay using blood from three separate blood donors for UF heparin, 3 MMWH samples and MMWH-Red. The control was a solution of sodium chloride. Each data point represents one biological repeat. Average values calculated from three biological repeats. The values were compared using a two-way ANOVA and p-values calculated using Tukey's multiple comparisons test. * = P < 0.05, ** = P < 0.01, *** = P< 0.001, **** = P< 0.0001.Figure 10 The average area under the curve measured in a RIPA assay using blood from three separate blood donors for UF heparin, 3 MMWH samples and MMWH-Red. The control was a solution of sodium chloride. Each data point represents one biological repeat. Average values calculated from three biological repeats. The values were compared using a two-way ANOVA and p-values calculated using Tukey's multiple comparisons test. * = P < 0.05, ** = P < 0.01, *** = P< 0.001, **** = P< 0.0001. Figure 11 Top panel - Percentage inhibition compared to the control for average amplitude measured in a RIPA assay with blood from three separate blood donors for UF heparin, 3 MMWH samples and MMWH-Red. Each data point represents one biological repeat. Average values calculated from three biological repeats. Bottom panel - - Percentage inhibition compared to the control for the slope measured in a RIPA assay with blood from three separate blood donors for UF heparin, 3 MMWH samples and MMWH-Red. Each data point represents one biological repeat. Average values calculated from three biological repeats.Figure 12 - Percentage inhibition compared to the control for area under the curve measured in a RIPA assay with blood from three separate blood donors for UF heparin, 3 MMWH samples and MMWH- Red. Each data point represents one biological repeat. Average values calculated from three biological repeats.DETAILED DESCRIPTION OF THE INVENTION

[0044] Throughout this specification, one or more aspects of the invention may be combined with one or more features described in the specification to define distinct embodiments of the invention.

[0045] In the discussion that follows, reference is made to a number of terms, which are to be understood to have the meanings provided below, unless a context expressly indicates to the contrary.

[0046] References herein to a singular of a noun encompass the plural of the noun, and vice-versa, unless the context implies otherwise.

[0047] Throughout this specification the word "comprise", or variations such as "comprises" or "comprising", will be understood to imply the inclusion of a stated element or integer, or group of elements or integers, but not the exclusion of any other element or integer, or group of elements or integers. The term "comprising" includes within its ambit the term "consisting" or "consisting essentially of".

[0048] The term "consisting" or variants thereof is to be understood to imply the inclusion of a stated element or integer, or group of elements or integers, and the exclusion of any other element or integer or group of elements or integers.

[0049] The term "consisting essentially of" or variants thereof is to be understood to imply the inclusion of a stated element, integer or step, or group of elements, integers or steps, and that further components may be present, but only those not materially affecting the essential characteristics of the formulation, composition, or compound.

[0050] The term "about" herein, when qualifying a number or value, is used to refer to values that lie within ± 5% of the value specified.

[0051] The terms "treatment" and "therapy" define the therapeutic treatment of a patient, in order to reduce or halt the rate of progression of a disorder or condition, or to ameliorate or cure the disorder or condition. Prophylaxis of a disorder or condition as a result of treatment or therapy is also included.

[0052] As used herein, the term "patient" preferably refers to a mammal. Typically, the mammal is a human.

[0053] von Willebrand factor (VWF) is a blood glycoprotein involved in haemostasis. VWF is a large multimeric glycoprotein present in blood plasma and produced constitutively as ultra-large VWF in endothelium (in the Weibel-Palade bodies), megakaryocytes (a-granules of platelets), and subendothelial connective tissue. The basic VWF monomer is a 2050-amino acid protein.

[0054] A disaccharide is a sugar whose molecules contain two monosaccharide residues.

[0055] A low molecular weight heparin is defined herein as a heparin with an average molecular weight of from about 4000 Da (g / mol) to about 8000 Da (g / mol). A medium molecular weight heparin is defined herein as a heparin with an average molecular weight of from greater than about 8000 Da (g / mol) to about 13500 Da (g / mol).

[0056] MMWH-Red as described herein does not comprise an aldehyde or comprises fewer aldehydes than MMWH produced during step (c) of the method of the second aspect. The presence of an aldehyde or lack thereof may be determined using 2,4-Dinitrophenyl Hydrazine test. MMWH- Red may not produce an orange-yellow precipitate with reacted with 2,4-dinitrophenylhydrazine or less orange-yellow precipitate than a corresponding amount of MMWH. Alternatively, the reduction of MMWH to MMWH-Red may be monitored by infra-red spectroscopy or1H-NMR.

[0057] MMWH displays a significant reduction in the activity as performed by the anti-Xa and anti-lla tests routinely performed on heparin. It is proposed that the oxidation of the glucuronic acid during the preparation of MMWH changes the binding capability of heparin to antithrombin (ATIII). Ristocetin-induced platelet aggregation (RIPA) tests of MMWH show an increased activity of MMWH, indicating that the von Willebrand Factor interaction of the heparin polysaccharide remains intact.

[0058] The two aldehyde groups on the glucuronic acid of the MMWH produced during preparation may in some circumstances be reactive. This reactivity can potentially decrease the stability of the oxidized polysaccharide over time. Additionally, it may interact with free amines on proteins when injected into the body. The latter would be through a Schiff base reaction with the free amines in the same way as glucose reacts with hemoglobin to form the well-known glycated hemoglobin commonly known as A1C.

[0059] Thus, in order to mitigate these potential side reactions, in a first aspect, the invention provides MMWH-Red in which these aldehyde groups are / have been reduced to hydroxyl groups. Preferably, MMWH-Red is prepared (produced) according to the method of the second aspect of the invention. The method of the second aspect achieves this by reducing MMWH (aldehyde form) to MMWH-Red (hydroxyl form) using a reducing agent in reduction step (d).

[0060] The term "reduced" in the context of reduced medium molecular weight heparin means that the aldehyde groups formed in MMWH by oxidation of one or more of (or a plurality of, or substantially all of, or all of) the glucuronic acid moieties (in step (c) of the method) are reduced to hydroxyl groups. The one or more (or a plurality, or substantially all, or all) glucuronic acid derived moieties in MMWH-Red have the following structure:

[0061] The one or more (or a plurality, or substantially all, or all) glucuronic acid derived moieties in MMWH have the following structure:Preferably, substantially all or all of the glucuronic acid moieties in MMWH are have this structure.

[0062] The MMWH may comprise a peak in the NMR spectrum corresponding to an aldehyde. The MMWH may comprises a peak in the NMR spectrum in region of 9-10 ppm. The MMWH may comprises a peak in the NMR spectrum in region of 9.20-9.30 ppm. The MMWH may have activity in a ristocetin-induced platelet aggregation assay comparable to that of UF heparin and little or no activity in Factor X analysis. The MMWH may reduce the amplitude observed in a RIPA assay compared to control and have less than 5 lU / mg activity in a Factor X analysis. The MMWH may have less than 5 lU / mg activity in a Factor X analysis.

[0063] The MMWH may be characterised by a molecular weight analysis. This may be performed by high pressure size exclusion chromatography (HP-SEC). The MMWH may have a ratio of Msooo-ieooo to M 16000-24000 greater than 2 and less than 10. The MMWH may be comprised of less than 10%, preferably less than 8% polysaccharide chains with a mass greater than or equal to 24000 Da. The MMWH may be comprised of between 2% and 8% polysaccharide chains with a mass greater than or equal to 24000 Da. The MMWH may be comprised of 21% or less polysaccharide chains with a mass between 16000 Da and 24000 Da. The MMWH may be comprised of between 14% and 21% polysaccharide chains with a mass between 16000 Da and 24000 Da. The MMWH may be comprised of between 12% and 31% polysaccharide chains with a mass equal to or less than 8000 Da.

[0064] The MMWH-red may not comprise an aldehyde peak in its NMR spectrum. The MMWH-red may not comprise a peak between about 9 and about 10 ppm corresponding to an aldehyde peak in its:H-NMR spectrum. The MMWH-red may not comprise a peak above background noise between about 9 and about 10 ppm corresponding to an aldehyde peak in itsJH-NMR spectrum.

[0065] The MMWH-red may not comprise a band corresponding to an aldehyde (C=O) in its infra-red spectrum. The MMWH-red may not comprise a band between about 1740 and about 1720 cm-1 corresponding to an aldehyde (C=O) in its infra-red spectrum.

[0066] The MMWH-red may comprise a ring opened-uronic acid with at least one hydroxyl group, preferably at least two hydroxyl groups. The medium molecular weight heparin may comprise a ring opened uronic acid with one hydroxyl group, preferably two hydroxyl groups. The structure of the MMWH-red may be analysed using mass spectrometry, for example electrospray ionization-mass spectrometry.

[0067] The MMWH-red may be characterised by a molecular weight analysis. This may be performed by high pressure size exclusion chromatography (HP-SEC). The MMWH-red may have a ratio of MSooo- leooo to M16000-24000 greater than 2 and less than 10. The MMWH-red may be comprised of less than 10%, preferably less than 8% polysaccharide chains with a mass greater than or equal to 24000 Da. The MMWH-red may be comprised of between 2% and 8% polysaccharide chains with a mass greater than or equal to 24000 Da. The MMWH-red may be comprised of 21% or less polysaccharide chains with a mass between 16000 Da and 24000 Da. The MMWH-red may be comprised of between 14% and 21% polysaccharide chains with a mass between 16000 Da and 24000 Da. The MMWH-red may be comprised of between 12% and 31% polysaccharide chains with a mass equal to or less than 8000 Da.

[0068] The reduced medium molecular weight heparin has an average molecular weight of from greater than about 8000 Da (g / mol) to about 13500 Da (g / mol), more preferably from greater than about 8000 Da (g / mol) to about 13000 Da (g / mol), more preferably about 9000 Da (g / mol) to about 12000 Da (g / mol), more preferably about 10 000 Da (g / mol) to about 11 000 Da (g / mol).

[0069] The MMWH-Red may comprise polysaccharide chains with an average molecular weight in the range of from greater than about 8000 Da (g / mol) to about 13500 Da (g / mol), preferably from greater than about 8000 Da (g / mol) to about 13 000 Da (g / mol), preferably about 10 000 Da (g / mol) to about 12 000 Da (g / mol).

[0070] The average molecular weight of the MMWH-Red may be determined by size exclusion chromatography as described herein.

[0071] The MMWH-Red may comprise at least three units of a GlcNS6S-ldoA2S (or ldoA2S-GlcNS6S) disaccharide. The GlcNS6S and ldoA2S monosaccharides are linked by an al-4 linkage between GlcNS6S and ldoA2S, i.e. GlcNS6Sal-4ldoA2S. For example, the MMWH-Red may comprise at least four units, preferably at least five units, preferably at least six units, preferably at least eight units, preferably at least ten units of a GlcNS6S-ldoA2S disaccharide. The MMWH-Red may comprise less than or equal to 25 units of the GlcNS6S-ldoA2S disaccharide, for example less than or equal to 20 units. The presence of the units of the GlcNS6S-ldoA2S disaccharide may be determined by an antibody, mass spectrometry, or inferred from chemical and enzymatical studies. The GlcNS6S-ldoA2S units may be ordered in succession.

[0072] "IdoA" is a-L-iduronic acid. "ldoA2S" is IdoA modified by the addition of an O-sulfate group at carbon position 2 to form 2-O-sulfo-a-L-iduronic acid. "GIcNS" is 2-deoxy-2-sulfamido-a-D- glucopyranosyl. "GlcNS6S" is 2-deoxy-2-sulfamido-a-D-glucopyranosyl-6-0-sulfate. An al-4 linkage is an alpha glycosidic bond between carbon-1 on one monosaccharide and carbon-4 on a second monosaccharide. A pi-4 linkage is beta glycosidic bond between carbon-1 on one monosaccharide and carbon-4 on a second monosaccharide.

[0073] The MMWH-Red may comprise UA2S-GlcNS6S, UA2S-GlcNS, UA-GIcNAc, wherein U may be iduronic acid (IdoA) or glucuronic acid (GlcA). The MMWH-Red may comprise at least about 60% UA2S- GlcNS6S, UA2S-GlcNS, and UA-GIcNAc. The MMWH-Red may comprise at least about 45%, preferably at least about 48%, preferably at least about 49%, preferably at least about 60% UA2S-GlcNS6S. TheMMWH-Red may comprise up to about 60%, preferably up to about 70%, preferably up to about 85% UA2S-GlcNS6S. The MMWH-Red may comprise at least about 4%, preferably at least about 5%, preferably at least about 6%, preferably at least about 10% UA2S-GlcNS. The MMWH-Red may comprise up to about 15%, preferably up to about 20% UA2S-GlcNS. The MMWH-Red may comprise at least 4%, preferably at least 5%, preferably at least 6%, preferably at least about 10% UA-GIcNAc. The MMWH-Red may comprise up to about 15%, preferably up to about 20% UA-GIcNAc. In some embodiments the MMWH-Red may comprise at least 49.2% UA2S-GlcNS6S, 5.4% UA2S-GlcN and 5.4% UA-GIcNAc. In some embodiments the MMWH-Red may comprise at least 82% UA2S-GlcNS6S, 9% UA2S-GlcNS and 9% UA-GIcNAc. The percentage composition of UA-GIcNAc comprised in the MMWH- Red may be enriched compared to unfractionated heparin.

[0074] "UA" is a uronic acid, which is a hexose with a negatively charged carboxylate at the 6-position. The uronic acid may independently be glucuronic acid or iduronic acid. "UA2S" is UA modified by the addition of an O-sulfate group at carbon position 2 to form 2-O-sulfo-uronic acid. "GlcA" is -D- glucuronic acid "GIcNAc" is 2-deoxy-2-acetamido-a-D-glucopyranosyl.

[0075] The MMWH-Red may comprise a chemical modification. The chemical modification may be selected from the group comprising N-acetylation, N-deacetylation, N-sulfation, O-sulfation, 2-0 desulfation, and complete desulfation.

[0076] There are few known methods of preparing MMWH and MMWH-Red. One example of a method of preparing medium molecular weight heparin is described in Poletti LF, Bird KE, Marques D, Harris RB, Suda Y, Sobel M. Structural aspects of heparin responsible for interactions with von Willebrand factor. Arterioscler Thromb Vase Biol. 1997 May;17(5):925-31. This method requires incubation at 37 °C and produces a wide variety of products ranging in molecular weight from 10600 g / mol down to 1900 g / mol.

[0077] Accordingly, there is a need for a reliable method of preparing MMWH-Red.

[0078] In a second aspect, the invention provides a method of preparing MMWH-Red. MMWH-Red does not comprise aldehyde groups, or comprises fewer aldehyde groups than MMWH. The method of the third aspect comprises the following steps: (a) dissolving unfractionated (UF) heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; (b) adding an oxidising agent to the first solution to provide a second solution; (c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a MMWH solution; and (d) incubating the MMWH with a reducing agent to produce MMWH-Red.

[0079] UF heparin may be obtained from bovine or porcine tissue, for example porcine intestine or bovine lung.

[0080] "Buffer" refers to a chemical which, in a solution, resists a change in pH when acid or alkali is added to the solution. Typically, a buffer solution (or buffer system) comprises a weak acid and its conjugate base, or a weak base and its conjugate acid.

[0081] Typically, a suitable buffer comprises an acid with a pKa value that lies within ±1 of the desired pH of the formulation. For example, if the desired pH of the formulation is about 7.0, a suitable buffer comprises a weak acid with a pKa value of from about 6.0 to about 8.0. If the acid of a buffer has more than one pKa value (i.e. each molecule of the acid is able to donate more than one proton), in order for the buffer to be suitable, at least one of the pKa values should lie within the desired pH range.

[0082] The weak acid and conjugate base (or weak base and conjugate acid) of the buffer are in equilibrium with one another. In accordance with Le Chatelier's principle (if a constraint, such as a change in concentration of a reactant, is applied to a system in equilibrium, the equilibrium will shift so as to counteract the effect of the constraint), addition of acid or base to the solution shifts the position of equilibrium in favour of the conjugate base or weak acid, respectively. Consequently, the concentration of free protons in the formulation (and thus the pH) is relatively unchanged.

[0083] Suitable buffer systems comprise an acetate salt and acetic acid (pKa = 4.75), a citrate salt and citric acid (pKa = 3.13, 4.76 and 6.40), and phosphoric acid (pKa = 2.14, 7.20 and 12.37), or mixtures thereof. Phosphate buffered saline may also be used. The pKa values cited herein are those reported at 25 °C in water. Typically, the buffer comprises only one of the pairs listed above, i.e. one acid and its conjugate base. The buffer may comprise an acetate salt and acetic acid, a citrate salt and citric acid, or a phosphate salt and phosphoric acid.

[0084] The pH is adjusted to ensure that the pH of the first solution is between from about pH 5.0 to about pH 9.0 because dissolving unfractionated heparin may result in the pH of the aqueous buffer solution changing.

[0085] Optionally, in step (a), the aqueous buffer solution is adjusted to between about pH 6.0 and about pH 8.0, more preferably to about pH 7.0. Typically, the temperature of the aqueous buffer solution in step (a) is from about -2 °C to about 4 °C. Preferably, the temperature of the aqueous buffer solution in step (a) is from about 0 °C to about 2 °C.

[0086] Typically, the aqueous buffer solution is a phosphate buffer, a citrate buffer or an acetate buffer, i.e. the buffering system is phosphate, citrate or acetate. Preferably, the aqueous buffer solution is a phosphate buffer, more preferably the aqueous buffer solution is a sodium phosphate buffer or a potassium phosphate buffer, i.e. the buffering system is sodium phosphate or potassium phosphate.

[0087] The buffering system in the aqueous buffer solution may be present at a concentration of from about 10 mM to about 100 mM, more preferably from about 20 mM to about 90 mM, more preferably from about 30 mM to about 80 mM, more preferably from about 40 mM to about 70 mM, more preferably from about 50 mM to about 60 mM. The buffering system in the aqueous buffer solution may be present at a concentration of about 50 mM.

[0088] The concentration of UF heparin in the aqueous buffer solution may be from about 0.5 mg / mL to about 10 mg / mL, more preferably from about 1 mg / mL to about 8 mg / mL, more preferably from about 1.5 mg / mL to about 6 mg / mL, more preferably from about 2 mg / mL to about 4 mg / mL. The concentration of UF heparin in the aqueous buffer solution may be about 1.5 mg / mL, more preferablyY1 about 1.8 mg / mL, more preferably about 2 mg / mL, more preferably about 2.5 mg / mL, more preferably about 2.7 mg / mL, more preferably about 3 mg / mL.

[0089] Alternatively step (a) may comprise dissolving UF heparin in an aqueous solution instead of an aqueous buffer solution. The aqueous solution may be water. The aqueous solution may consist of or consist essentially of water. Step (a) may comprise dissolving the unfractionated heparin (UF) in water. In this embodiment, disclosures in respect of the aqueous buffer solution apply equally to the aqueous solution.

[0090] The oxidising agent may be a periodate, for example sodium periodate or potassium periodate. Preferably, the oxidising agent is sodium periodate. Alternatively, or additionally, the oxidising agent may be a perchlorate, for example sodium perchlorate. Preferably, the oxidising agent does not comprise a perchlorate. Use of a perchlorate in combination with a periodate as the oxidising agent results in an increased level of sample breakdown to smaller molecular weight species.

[0091] The concentration of the oxidising agent in the aqueous buffer solution may be from about 1 g / L to about 10 g / L. Preferably, the concentration of the oxidising agent may be from about 2g / L to about 9 g / L, more preferably from about 4 g / L to about 8 g / L, more preferably from about 5 g / L to about 7 g / L. Preferably the concentration of oxidising agent is about 5.7 g / L. Preferably the concentration of the oxidising agent is 5.7 g / L and the oxidising agent is sodium periodate.

[0092] The molar ratio of UF heparin to oxidising agent may be from about 1:1 to about 1:200, preferably from about 1:2 to about 1:150, more preferably from about 1:10 to about 1:100, morepreferably from about 1:20 to about 1:50, more preferably from about 1:30 to about 1:40. Typically, the molar ratio of UF heparin to oxidising agent may be about 1:40 or typically the molar ratio of UF heparin to oxidising agent may be about 1:150.

[0093] The molar ratio of UF heparin to oxidising agent may be determined based on the estimated molecular weight of the canonical heparin disaccharide as opposed to the molecular weight of heparin. The estimated molecular weight of the canonical heparin disaccharide is 593.45 g / mol. This is used to approximate the number of moles of this disaccharide and therefore the uronic acid residues present in the sample.

[0094] For example, if it is desired to add 1 equivalent of NalO4based on uronic acid and 3 grams of heparin is used, the number of moles NaIC to add is 0.005 moles i.e. 3 divided by 593.45.

[0095] Thus, the ratio of UF heparin determined based on the estimated molecular weight of the canonical heparin disaccharide may be from about 1:0.5 to about 1:10, preferably from about 1:0.7 to about 1:8, more preferably from about 1:0.9 to about 1:5, more preferably from about 1:1 to about 1:2, more preferably from about 1:1.1 to about 1:2. Preferably, the ratio of moles of uronic acid present in the UF heparin to moles of oxidising agent may be 1:1.1.

[0096] Typically, the incubation temperature in step (c) is from about 0 °C to about 10 °C, more preferably from about 1 °C to about 9 °C, more preferably from about 2 °C to about 8 °C, more preferably from about 3 °C to about 7 °C, more preferably from about 4 °C to about 6 °C. Preferably,the incubation temperature in step (c) is about 4 °C. Typically, the incubating step (c) is carried out for from about 1 hour to about 48 hours, more preferably from about 4 hours to about 36 hours, more preferably from about 8 hours to about 30 hours, more preferably from about 12 hours to about 24 hours, more preferably from about 15 hours to about 20 hours, more preferably from about 16 to about 18 hours.

[0097] Incubation step (c) of the second aspect of the invention may be carried out in a laboratory fridge set at the required temperature. The laboratory fridge may be set at a temperature of from about 0 °C to about 10 °C, more preferably from about 2 °C to about 8 °C, more preferably from about 3 °C to about 7 °C, more preferably from about 4 °C to about 6 °C. Preferably, the laboratory fridge may be set at a temperature of about 4 °C.

[0098] The method of the second aspect may further comprise the step of inactivating the oxidising agent in the MMWH solution or in the MMWH-Red solution. The oxidising agent may be inactivated by the addition of an inactivating agent selected from the group consisting of: methanol, D-mannitol, glycerol, AAacetylmethionine, sodium sulfite, and combinations thereof. A particularly preferred inactivating agent is methanol or D-mannitol.

[0099] The molar ratio of the oxidising agent to the inactivating agent may be from about 1:1 to about 1:10, more preferably from about 1:2 to about 1:8, more preferably from about 1:3 to about 1:6, more preferably from about 1:4 to about 1:5. Typically, the molar ratio of the oxidising agent to the inactivating agent may be about 1:2 or about 1:4.

[0100] Reduction step (d) comprises incubating the MMWH with a reducing agent to produce MMWH-Red. Preferably, the reducing agent is a mild reducing agent. The reducing agent may be sodium borohydride (NaBH4), sodium cyanoborohydride (NaBH3CN), sodium triacetoxyborohydride (NaBH(OAc)3) or potassium borohydride ( KBH4).

[0101] The mild reducing agent may selectively reduce aldehydes and ketones to alcohols in the presence of esters. In other words, the mild reducing agent reduces aldehydes and ketones to alcohols at a faster rate than it reduces esters to alcohols. The mild reducing agent does not reduce carboxylic acids, nitriles, and amides under normal conditions. Preferably, the mild reducing agent may be sodium borohydride (NaBH4).

[0102] Typically the reducing agent is used at greater than about 0.5 molar equivalents, preferably greater than about 1 molar equivalent, more preferably greater than about 2 molar equivalents, more preferably greater than about 3 molar equivalents, more preferably greater than about 5 molar equivalents relative to medium molecular weight heparin. Typically the reducing agent is used at less than about 15 molar equivalents, preferably less than about 12 molar equivalents, more preferably less than about 10 molar equivalents, more preferably less than about 8 molar equivalents, more preferably less than about 6 molar equivalents, more preferably less than about 5 molar equivalents relative to medium molecular weight heparin. The reducing agent may be used in amount of between about 0.5 molar equivalents and about 15 molar equivalents, preferably between about 1 molar equivalents and about 10 molar equivalents, more preferably between about 2 molar equivalents and about 6 molar equivalents. The reducing agent may be used in amount of from about 0.5 molarequivalents to about 15 molar equivalents, preferably from about 1 molar equivalents to about 10 molar equivalents, more preferably from about 2 molar equivalents to about 6 molar equivalents.

[0103]

[0104] Preferably, step (d) is carried out at from about 0 °C to about 30 °C, more preferably from about 10 °C to about 30 °C, more preferably from about 5 °C to about 25 °C, more preferably from about 10 °C to about 20 °C, more preferably from about 15 °C to about 25 °C, more preferably from about 20 °C to about 25 °C. Typically, step (d) is carried out at about 20 °C. typically, step (d) is carried out at room temperature. Typically, step (d) is carried out for from about 1 hour to about 24 hours, preferably from about 2 hours to about 16 hours, more preferably from about 3 hours to about 12 hours, more preferably from about 6 hours to about 10 hours.

[0105] The solvent for step (d) may typically be selected from the group consisting of methanol, ethanol, water, THF, or combinations thereof. Preferably, the solvent in step (h) is water.

[0106] The MMWH-Red may be purified by any suitable method known to the skilled person. Thus, the method may further comprise the step of purifying the MMWH-Red. For example, the MMWH- Red may be purified by exhaustive dialysis using phosphate buffer (pH = 7.0) or saline, a desalting column (e.g. Sephadex G-25 with phosphate buffer (pH = 7.0) or saline used as the mobile phase) or precipitation of the MMWH-Red.

[0107] Thus, the method of the second aspect may further comprise dialysing the MMWH solution in a dialysate to provide a dialysed MMWH sample, and / or dialysing the MMWH-Red in a dialysate to provide a dialysed MMWH-Red sample.

[0108] "Dialysis" or "dialysing" means the process of separating molecules in solution by the difference in their rates of diffusion through a semipermeable membrane, for example dialysis tubing. The sample for dialysis and a dialysate (or buffer) are placed on opposite sides of the semipermeable membrane. Target sample molecules (e.g. proteins, DNA or polysaccharides) that are larger than the membrane pores remain on the sample side of the membrane. Contaminants such as small molecules and salts can pass through the membrane into the dialysate, thereby reducing the concentration of contaminants in the sample to low levels. Changing the dialysate for fresh dialysate removes the contaminants that have passed from the sample to the dialysate. This allows more contaminants to diffuse from the sample into the dialysate.

[0109] Dialysis can separate small molecules such as salts, reducing agents, or dyes, from larger macromolecules such as proteins, DNA or polysaccharides. Dialysis can also be used to separate polysaccharides by molecular weight. The semipermeable membrane is typically made of a film of regenerated cellulose or cellulose esters.

[0110] Dialysis may be carried out by placing a dialysis tubing containing a sample in a dialysate. A "dialysate" is the fluid into which material passes from the dialysis tubing. The dialysate may be refreshed as often as necessary to achieve optimum separation. The dialysis may be carried out over a period of about 1 day to about 14 days, preferably about 5 days to about 10 days, preferably about 7 days. The dialysate may be refreshed about 1 time a day to about 10 times a day, preferably about2 times a day to about 5 times a day, preferably about 3 times a day. Typically, the dialysate is many times the volume of the sample, for example from about 2 to about 500 times the volume of the sample. The dialysate may be about 4 times the volume of the sample.

[0111] Typically, the dialysate is water. Optionally, the dialysate may comprise electrolytes such as sodium, potassium, magnesium, calcium, chloride, bicarbonate, lactate, glucose, amino acids, or combinations thereof.

[0112] The dialysing step may be carried out in 2 kD cut off tubing, for example provided by Spectra / Por®. The skilled person is aware of the appropriate tubing cut off size for different purposes. Alternatively, the dialysing step may be carried out in a dialysis device or dialyzer. Suitable dialyzers may be the Slide-A-Lyzer™, the Float-A-Lyzer, the Pur-A-lyzer, the D-Tube, and GeBAflex Dialyzers product lines.

[0113] The method of the second aspect may further comprise the step of isolating the MMWH from the dialysed heparin sample and / or isolating the MMWH-Red from the dialysed MMWH-Red sample. The MMWH and / or MMWH-Red may be isolated from the dialysed sample by freeze-drying, centrifuging, or filtration. Preferably, the MMWH and / or MMWH-Red is isolated from the dialysed sample by freeze-drying.

[0114] "Freeze drying" (also known as lyophilisation or cryodesiccation) is a drying process carried out at low temperature. Freeze drying generally involves reducing temperature and pressure to below the substance's triple point and removing the frozen solvent (e.g. water ice) by sublimation. For aqueous compositions, such as those disclosed herein, freeze drying may be carried out at temperatures of from about -20 °C to about -80 °C, preferably about -40 °C, and pressures of from about 1000 Pa (0.01 bar) to about 10 Pa (0.0001 bar).

[0115] The method of the second aspect may comprise precipitating the reduced medium molecular weight heparin to provide a reduced medium molecular weight heparin precipitate in a precipitation mixture. This precipitations step results in pure MMWH-Red. This precipitation step may be used as an alternative to dialysis described above.

[0116] Precipitating the reduced medium molecular weight heparin to provide a reduced medium molecular weight heparin precipitate in a precipitation mixture may comprise adding a precipitating agent to the reduced medium molecular weight heparin solution to provide a reduced medium molecular weight heparin precipitate in a precipitation mixture.

[0117] Preferably, the precipitating agent may comprise or consist of an alcohol or acetone.

[0118] Surprisingly, the precipitating agent precipitates the reduced medium molecular weight heparin. The precipitated reduced medium molecular weight heparin may then be isolated from the precipitation mixture, for example by filtration. Thus, the method may further comprise the step of isolating the precipitated reduced medium molecular weight heparin from the precipitation mixture.

[0119] This precipitation procedure advantageously results in a more efficient and high purity method for the production and purification of reduced medium molecular weight heparin than known methods. This results in highly pure material that does not need to be purified, for example, via a column.

[0120] Preferably, the precipitating agent is added to the MMW-Red solution to give a final concentration of the precipitating agent in the precipitation mixture of from about 50% v / v to about 90% v / v, preferably from about 55% v / v to about 80% v / v, and more preferably from about 60% v / v to about 75% v / v. Preferably the final concentration of the precipitating agent in the precipitation mixture is about 73% v / v. A precipitating agent (e.g. methanol) concentration of about 73% v / v results in a precipitate that settles well and can be isolated as an easily filtrable powder.

[0121] The alcohol may be a Ci to C3alcohol. For example, the alcohol may be methanol, ethanol, propanol, or isopropanol. Preferably the alcohol is methanol. Preferably, the alcohol is added to the MMWH-Red solution to give a final concentration of the alcohol in the precipitation mixture of from about 50% v / v to about 90% v / v, preferably from about 55% v / v to about 80% v / v, and more preferably from about 60% v / v to about 75% v / v. Preferably the final alcohol concentration in the precipitation mixture is about 73% v / v. For example, addition of 73 mt of an alcohol, e.g. methanol, to a 27 mt MMWH-Red solution provides a final alcohol concentration of 73% v / v MeOH in the precipitation mixture. An alcohol (e.g. methanol) concentration of about 73% v / v results in a precipitate that settles well and can be isolated as an easily filtrable powder.

[0122] The precipitate obtained is a handleable, filtrable powder which can readily be isolated by filtration and subsequently dried under vacuum.

[0123] During the addition of the precipitating agent, the temperature of the solution may be kept between about 0 °C and about 15 °C, preferably between about 5 °C and about 10 °C. The precipitation mixture may be stirred for from about 1 minute to about 30 minutes, preferably from about 5 minutes to about 25 minutes, more preferably from about 10 minutes to about 20 minutes. Preferably the precipitation mixture may be stirred for about 10 minutes. Following stirring, the precipitate is preferably allowed to settle.

[0124] In some embodiments, a salt is added to the MMWH-Red solution prior to precipitating the MMWH-Red. The step of precipitating the MMWH-Red may comprise adding a salt to the MMWH- Red solution followed by addition of the precipitating agent. As described above, the precipitating agent may consist of, consist essentially of or comprise an alcohol or acetone.

[0125] The salt may be a lithium salt, a sodium salt, ora potassium salt. Preferably, the salt is a sodium salt. The salt may be lithium chloride, sodium chloride, potassium chloride. Preferably the salt is sodium chloride.

[0126] The mass of salt added to the MMWH-Red solution is selected to result in a final salt concentration in the MMWH-Red solution of from about 0.5% m / v to about 3% m / v, preferably from about 1% m / v to about 2.5% m / v, and more preferably from about 1.5% to about 2% m / v. Preferably the concentration of the salt is about 1.8% m / v. For example, addition of addition of 0.9 g solid NaCIto a 50 mL MMWH-Red solution provides a NaCI concentration of 1.8% m / v. Most preferably, the salt solution comprises sodium chloride at a concentration of 1.8% m / v.

[0127] Following addition of the salt, the resulting solution may be cooled to from about 5 °C to about 20 °C , preferably from about 10 °C to about 15 °C . Preferably, the resulting solution may be cooled to about 15 °C. The precipitating agent may then be added.

[0128] If required, in the method of the second aspect, the MMWH intermediate in step (c) may be purified by precipitation to form precipitated MMWH, as described above. The addition of the precipitating agent may also function to quench any remaining oxidising agent. In this embodiment, reduction step (d) is carried out on the precipitated MMWH.

[0129] The method may include an alkaline elimination step following step (c). Alternatively, the method may not include an alkaline elimination step following step (c). Alkaline elimination may be carried out using an alkali salt such as, for example, sodium hydroxide, potassium hydroxide or lithium hydroxide. The alkaline elimination step may be carried out by addition of an alkali salt to increase the pH of the medium molecular weight heparin solution to about pH 10 to about pH 14, preferably about pH 12, for about 10 minutes to about 3 hours, preferably about 30 minutes, at about room temperature.

[0130] Preferably, the method does not include an alkaline elimination step. Preferably, the method does not include the addition of an alkali metal salt, for example an alkali metal salt such as NaOH, KOH or LiOH. Preferably, the method does not include the addition of NaOH, KOH or LiOH. Surprisingly, a method that does not include an alkaline elimination step or the addition of an alkali metal salt produces medium molecular weight heparin to prepare reduced medium molecular weight heparin as defined herein that displays very low activity against Factor Ila and / or Xa as compared to UF heparin and low molecular weight heparin.

[0131] MMWH and / or MMWH-Red may be characterised by NMR, disaccharide analysis, ristocetin- induced platelet aggregation (RIPA), Factor X analysis. This method is suitable for preparing MMWH- Red on the milligram, gram or kilogram scale.

[0132] Advantageously, the method of the second aspect provides MMWH-Red reliably, in good purity, and with reduced degradation.

[0133] The MMWH-Red prepared by the method of the second aspect has an average molecular weight of from greater than about 8000 Da (g / mol) to about 13500 Da (g / mol), more preferably from greater than about 8000 Da (g / mol) to about 13000 Da (g / mol), more preferably about 9000 Da (g / mol) to about 12000 Da (g / mol), more preferably about 10 000 Da (g / mol) to about 11 000 Da (g / mol).

[0134] The MMWH-Red prepared by the method of the second aspect of the invention may comprise polysaccharide chains with an average molecular weight in the range of from greater than about 8000 Da (g / mol) to about 13500 Da (g / mol), preferably from greater than about 8000 Da (g / mol) to about 13 000 Da (g / mol), preferably about 10 000 Da (g / mol) to about 12 000 Da (g / mol).

[0135] The average molecular weight of the MMWH-Red prepared by the method of the second aspect of the invention may be determined by size exclusion chromatography as described herein.

[0136] The MMWH-Red prepared by the method of the second aspect may comprise at least three units of a GlcNS6S-ldoA2S (or ldoA2S-GlcNS6S) disaccharide. The GlcNS6S and ldoA2S monosaccharides are linked by an al-4 linkage between GlcNS6S and ldoA2S, i.e. GlcNS6Sal-4ldoA2S. For example, the MMWH-Red prepared by the method of the second aspect may comprise at least four units, preferably at least five units, preferably at least six units, preferably at least eight units, preferably at least ten units of a GlcNS6S-ldoA2S disaccharide. The MMWH-Red prepared by the method of the second aspect may comprise less than or equal to 25 units of the GlcNS6S-ldoA2S disaccharide, for example less than or equal to 20 units. The presence of the units of the GlcNS6S- ldoA2S disaccharide may be determined by an antibody, mass spectrometry, or inferred from chemical and enzymatical studies. The GlcNS6S-ldoA2S units may be ordered in succession.

[0137] The MMWH-Red prepared by the method of the second aspect may comprise UA2S-GlcNS6S, UA2S-GlcNS, UA-GIcNAc, wherein U may be iduronic acid (IdoA) or glucuronic acid (GlcA). The medium molecular weight heparin prepared by the method of the second aspect may comprise at least about 60% UA2S-GlcNS6S, UA2S-GlcNS, and UA-GIcNAc. The MMWH-Red prepared by the method of the second aspect may comprise at least about 45%, preferably at least about 48%, preferably at least about 49%, preferably at least about 60% UA2S-GlcNS6S. The MMWH-Red prepared by the method of the second aspect may comprise up to about 60%, preferably up to about 70%, preferably up to about 85% UA2S-GlcNS6S. The MMWH-Red prepared by the method of the second aspect may comprise at least about 4%, preferably at least about 5%, preferably at least about 6%, preferably at least about 10% L)A2S-GlcNS. The MMWH-Red prepared by the method of the second aspect may comprise up to about 15%, preferably up to about 20% UA2S-GlcNS. The MMWH-Red prepared by the method of the second aspect may comprise at least 4%, preferably at least 5%, preferably at least 6%, preferably at least about 10% UA-GIcNAc. The MMWH-Red prepared by the method of the second aspect may comprise up to about 15%, preferably up to about 20% UA-GIcNAc. In some embodiments the MMWH-Red prepared by the method of the second aspect may comprise at least 49.2% UA2S- GlcNS6S, 5.4% UA2S-GlcN and 5.4% UA-GIcNAc. In some embodiments the M MWH-Red prepared by the method of the second aspect may comprise at least 82% UA2S-GlcNS6S, 9% UA2S-GlcNS and 9% UA-GIcNAc. The percentage composition of UA-GIcNAc comprised in the MMWH-Red may be enriched compared to unfractionated heparin.

[0138] The method of synthesis of M MWH-Red may consist of or consist essentially of the steps: (a) dissolving unfractionated (UF) heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; (b) adding an oxidising agent to the first solution to provide a second solution; (c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a MMWH solution; (d) incubating the medium molecular weight heparin with a reducing agent to produce MMWH-Red; and (e) purifying the MMWH-Red.

[0139] The method of synthesis of M MWH-Red may consist of or consist essentially of the steps: (a) dissolving unfractionated heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; (b) adding an oxidising agent to the first solution to providea second solution; (c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a medium molecular weight heparin solution; (d) inactivating the oxidising agent in the MMWH solution; (e) incubating the medium molecular weight heparin with a reducing agent to produce MMWH-Red; and (f) purifying the MMWH-Red.

[0140] The method of synthesis of MMWH-Red may consist of or consist essentially of the steps: (a) dissolving unfractionated heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; (b) adding an oxidising agent to the first solution to provide a second solution; (c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a medium molecular weight heparin solution; (d) inactivating the oxidising agent in the medium molecular weight heparin solution; (e) dialysing the MMWH solution in a dialysate to provide a dialysed MMWH sample; (f) incubating the dialysed MMWH with a reducing agent to produce MMWH-Red; and (g) purifying the MMWH-Red.

[0141] The method of synthesis of MMWH-Red may consist of or consist essentially of the steps: (a) dissolving unfractionated heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; (b) adding an oxidising agent to the first solution to provide a second solution; (c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a MMWH solution; (d) inactivating the oxidising agent in the MMWH solution; (e) dialysing the MMWH solution in a dialysate to provide a dialysed MMWH sample; (f) Isolating the MMWH from the dialysed heparin sample; (g) incubating the MMWH with a reducing agent to produce MMWH-Red; and (h) purifying the MMWH-Red.

[0142] For the avoidance of doubt, embodiments related to first aspect of the invention apply mutatis mutandis to the second aspect of the invention and embodiments related to second aspect of the invention apply mutatis mutandis to the first aspect of the invention.

[0143] As described herein, MMWH-Red inhibits von Willebrand Factor, and so is an appropriate active pharmaceutical ingredient (API) and drug product for the purposes of the invention.

[0144] Advantageously, MMWH-Red may display greater stability as an API and drug product compared to MMWH. Furthermore, MMWH-Red may reduce the potential for side reaction with excipients comprised in the drug product and MMWH-Red may reduce interactions with proteins and / or components in the blood in vivo.

[0145] MMWH-Red does not comprise an aldehyde or comprises fewer aldehydes than MMWH produced during step (c) of the method of the second aspect. The presence of an aldehyde or lack thereof may be determined using 2,4-Dinitrophenyl Hydrazine test. MMWH-Red may not produce an orange-yellow precipitate with reacted with 2,4-dinitrophenylhydrazine or less orange-yellow precipitate than a corresponding amount of starting material. Alternatively, the reduction of MMWH to MMWH-Red may be monitored by infra-red spectroscopy or ^-NMR.

[0146] MMWH-Red may be characterised by NMR, disaccharide analysis, ristocetin-induced platelet aggregation (RIPA), Factor Xa analysis.

[0147] In a third aspect, the invention provides MMWH-Red produced according to the following steps:(a) dissolving unfractionated (UF) heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution;(b) adding an oxidising agent to the first solution to provide a second solution;(c) incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a MMWH solution; and(d) incubating the medium molecular weight heparin with a reducing agent to produce MMWH-Red.

[0148] For the avoidance of doubt, embodiments related to first and second aspects of the invention apply mutatis mutandis to the third aspect of the invention.

[0149] In a fourth aspect, the invention provides a composition comprising MMWH-Red. Preferably, the composition is a pharmaceutical composition.

[0150] The pharmaceutical composition may comprise an excipient. The excipient may be selected from the group comprising solvents, co-solvents, buffers, stabilisers, antioxidants, preservatives, chelating agents, emulsifiers, flavourings, lubricants, suspending agents, tonicity adjusting agents, surfactants, solubilising agents, suspending aids, dispersion agents, humectants, thickeners, colouring agent, wetting agent, anti-foaming agent, viscosity modifier, sweeteners and combinations thereof.

[0151] The pharmaceutical composition may comprise an additional active agent, which may be an API. The additional active agent may comprise a composition of matter that has a physiological effect. The additional active agent may comprise low molecular weight heparin, or a MMWH or a MMWH- Red of a different disaccharide composition. The additional active agent may be selected from the group comprising farnesoid X receptor (FXR) agonist, a peroxisome proliferator-activator receptor (PPAR) agonist, aramchol, a caspase inhibitor, a galectin 3 inhibitor, a mitogen-activated protein kinase 5 (MAPK5) inhibitor, a fibroblast growth factor 19 (FGF19) agonist, a FGF21 agonist, a leukotriene D4 (LTD4) receptor antagonist, a niacin analog, an apical sodium bile acid cotransporter (ASBT) inhibitor, an apoptosis signal regulating kinase 1 (ASK1) inhibitor, an angiotensin converting enzyme (ACE) inhibitor, an angiotensin receptor blocker, a chemokine receptor inhibitor, a thiozolidinedione, a GLP- 1 analog, a biguanide, an HIV replication inhibitor, metoformin, an opiate, an anaesthetic, HMG-CoA reductase inhibitor, a nonsteroidal anti-inflammatory drug (NSAID), or any combination of these.

[0152] For the avoidance of doubt, embodiments related to first to third aspects of the invention apply mutatis mutandis to the fourth aspect of the invention.

[0153] As described herein, endotheliopathy may be associated with a number of diseases. MMWH- Red inhibits von Willebrand factor. The Inventors have found that MMWH-Red can be used to treat endotheliopathy, particularly endotheliopathy in a patient having a high plasma von Willebrand factor level.

[0154] When heparin is exposed to an oxidant (eg. IO4‘, periodate ion), the diol portion of the glucoronic acid is broken and two aldehyde groups are formed which as described herein results in MMWH. The result is a significant reduction in the activity as performed by the anti-Xa and anti-llatests routinely performed on heparin. It is proposed that this oxidation of the glucuronic acid changes the binding capability of heparin to antithrombin III (ATI 11).

[0155] However, the ristocetin-induced platelet aggregation (RIPA) test shows an unchanged or increased activity of the MMWH. This indicates that the von Willebrand factor interaction of the heparin polysaccharide remains intact and possibly enhanced.

[0156] As described herein, reduction step (d) means that the cyclic ring of the glucuronic acid monosaccharide is not reformed and the binding of the MMWH-Red to ATIII would be to be unchanged. However, the reduced MMWH would still maintain the interaction with the von Willebrand factor and be useful for the treatment of endotheliopathy.

[0157] Advantages of MMWH-Red include: Maintains von Willebrand activity of MMWH, greater stability as an active pharmaceutical ingredient (API) and drug product, minimal interaction with pharmaceutical excipients, reduced or no reaction with proteins and / or components in the blood in vivo, minimising side effects.

[0158] Hence, in a fifth aspect, the invention provides MMWH-Red according to the first or third aspect of the invention, produced according to the second aspect or a composition according to the fourth aspect of the invention for use in the treatment of endotheliopathy in a patient.

[0159] The MMWH-Red may inhibit von Willebrand factor (VWF). The MMWH-Red may inhibit multimers of VWF, preferably ultra-large VWF. The MMWH-Red may inhibit the binding of platelets to VWF.

[0160] Preferably, the invention provides MMWH-Red or a composition comprising MMWH-Red for use in the treatment of endotheliopathy in a patient. Preferably, the invention provides MMWH-Red according to the first or third aspect, or a MMWH-Red produced according to the second aspect, or a composition according to the fourth aspect for use in the treatment of endotheliopathy in a patient having a plasma von Willebrand factor antigen to ADAMTS13 ratio of at least about 2. Preferably, the invention provides MMWH-Red according to the first or third aspect, or a MMWH-Red according to the second aspect, or a composition according to the fourth aspect for use in the treatment of endotheliopathy in a patient having a plasma von Willebrand factor to ADAMTS13 ratio of at least about 2.

[0161] The patient may have a VWF:ADAMTS13 ratio of at least about 2, preferably of at least about 4, more preferably of at least about 8, more preferably of at least about 10. The patient may have a VWF:ADAMTS13 ratio greater than about 2, preferably greater than about 4, more preferably greater than about 8, more preferably greater than about 10. The patient may have a VWF:ADAMTS13 ratio of about 2-16, preferably about 4-12, more preferably about 6-10. A patient having a VWF to ADAMTS13 ratio of greater than about 8 typically indicates severe illness and often is indicative of a patient deteriorating towards death.

[0162] The patient may have a VWF antigen: ADAMTS13 ratio of at least about 2, preferably of at least about 4, more preferably of at least about 8, more preferably of at least about 10. The patient mayhave a VWF antigen:ADAMTS13 ratio greater than about 2, preferably greater than about 4, more preferably greater than about 8, more preferably greater than about 10. The patient may have a VWF antigen:ADAMTS13 ratio of about 2-16, preferably about 4-12, more preferably about 6-10. A patient having a VWF antigen to ADAMTS13 ratio of greater than about 8 typically indicates severe illness and often is indicative of a patient deteriorating towards death.

[0163] The level of VWF and ADAMTS13 in the patient may be measured using an ELISA. The ratio may be calculated as described by Huisman et al (Involvement of ADAMTS13 and von Willebrand factor in thromboembolic events in patients infected with SARS-CoV-2. Int J Lab Hematol. 2020 Oct;42(5):e211— 2). Briefly, the level of the VWF antigen may be determined in international units and the level of ADAMTS13 may be determined in international units and then the ratio of VWF antigen: ADAMTS13 determined.

[0164] Normal levels of plasma VWF are in the range of from about 50 III per dL to about 200 IU per dL. The mean level of plasma VWF in the general population is about 100 IU per dL. High levels of plasma VWF are those of about 200 IU per dL or more, for example from about 200 IU per dL to about 400 IU per dL, from about 225 IU per dL to about 375 IU per dL, from about 250 IU per dL to about 350 IU per dL, from about 275 IU per dL to about 300 IU per dL.

[0165] The patient may have a raised VWF antigen level of about 150% or more, preferably of about 175% or more, more preferably of about 200% or more, more preferably of about 300% or more, more preferably of about 350% or more, more preferably about 400% or more, more preferably of about 500% or more. The patient may have a VWF antigen level of up to about 600%, preferably up to about 700%, more preferably up to about 800%, more preferably up to about 1000%.

[0166] It is noted that levels of plasma VWF may be temporarily raised by infections, inflammation, trauma, and with physical and emotional stressors. Accordingly, the patient may have a non- temporarily raised plasma von Willebrand factor level, for example for at least about six hours, at least about 12 hours, at least about 18 hours or at least about 24 hours. Preferably, the patient may have a raised plasma von Willebrand factor level for at least about one day, at least about two days, at least about three days, at least about four days, at least about five days, at least about six days, or at least about seven days. Even more preferably the patient may have a raised plasma von Willebrand factor level for at least about one week, at least about two weeks, at least about three weeks or at least about four weeks. Yet even more preferably the patient may have a raised plasma von Willebrand factor level for at least about one month, at least about two months, at least about three months, at least about four months, at least about five months, at least about six months or at least about one year. The patient may have a raised plasma von Willebrand factor level for up to about one week, up to about four weeks, up to about two months, up to about four months, up to about six months, or up to about one year.

[0167] The MMWH-Red may have a mass of about 11 000 Da (g / mol). The reduced medium molecular weight heparin may comprise at least three units of the GlcNS6S-ldoA2S (or ldoA2S- GlcNS6S) disaccharide.

[0168] The endotheliopathy may be caused by any disease or condition. In particular, the endotheliopathy may be caused by COVID-19 (for example, acute COVID-19 or post-COVID-19 syndrome), infection, viral infection, acute respiratory distress syndrome (ARDS), cancer, bacterial infection, septicaemia, sepsis, cardiovascular disease, diabetes mellitus, trauma, in particular brain or head trauma e.g. traumatic brain injury, burns, inhalational injury, drugs and drug reactions, haematological conditions, subarachnoid haemorrhage (for example aneurysmal subarachnoid hemorrhage), aneurysmal diseases, stroke, brain parenchymal haemorrhage, radiation induced injury, ischemic stroke, pancreatitis, hepatological conditions, renal diseases, or chronic obstruction pulmonary disease (COPD), or combinations thereof.

[0169] The endotheliopathy may be caused by a viral infection, optionally wherein the viral infection is SARS-CoV-2. The endotheliopathy may be caused by cancer, in particular leukaemia, lymphoma, myeloma, or a solid organ cancer, such as colon cancer, breast cancer, brain cancer, lung cancer, pancreatic cancer, testicular cancer, prostate cancer, cervical cancer, liver cancer, or skin cancer.

[0170] The infection may be bacterial, fungal, or parasitic. The infection may be bacterial. The bacterial infection may be Actinomyces israelii. Bacillus anthracis, Bacteroides fragilis, Bordetella pertussis, Borrelia burgdoferi, Borrelia garinii, Borrelia afzelaii, Borrelia recurrentis, Brucella abortus, Brucella canis, Brucella melitensis, Brucella suis, Campylobacter jejuni, Chlamydia pneumoniae, Chlamydia trachomatis, Chlamydophilia psittaci, Clostridium botulinum, Clostridium difficile, Clostridium perfringens, Clostridium tetani, Corynebacterium diphtheriae, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Francisella tularensis, Haemophilus influenzae, Helicobacter pylori, Klebsiella pneumoniae, Legionella pneumophila, Leptospira species, Listeria monocytogenes, Mycobacterium leprae, Mycobacterium tuberculosis, mycoplasma pneumoniae, Neisseria gonorrhoeae, Neisseria meningitidis, Pseudomonas aeruginosa, Nocardia asteroides, Rickettsia rickettsii, Salmonella, Shigella, Spirochaetes Staphylococcus, Streptococcus, Treponema pallidum, Vibrio cholerae, or Yersinia pestis.

[0171] The infection may be fungal. The fungal infection may be Aspergillus, Blastomyces, Candida, Coccidioides, Cryptococcus neoformans, Cryptococcus gattii, Histoplasma, mucormycetes, Tinea cruris. Tinea corporis, or Tinea pedis.

[0172] The infection may be parasitic. The parasitic infection may be protozoan eye infection, Chagas' disease, leishmaniasis, toxoplasmosis, giardiasis, malaria, microsporidiosis, or Rhinosporidiosis. Preferably, the parasitic infection is malaria.

[0173] The viral infection may be SARS-CoV-2. SARS-CoV-2 is the virus responsible for the disease COVID-19. COVID-19 can result in ARDS. The endotheliopathy may be caused by SARS-CoV-2 infection. The endotheliopathy may be caused by COVID-19. The endotheliopathy may be caused by ARDS.

[0174] The endotheliopathy may be caused by cancer. The cancer may be leukaemia, lymphoma or myeloma. Alternatively, or additionally the cancer may be solid organ cancer, for example colon cancer, breast cancer, brain cancer, lung cancer, pancreatic cancer, testicular cancer, prostate cancer, cervical cancer, liver cancer, or skin cancer.

[0175] The endotheliopathy may be caused by haematological conditions, for example Thrombotic thrombocytopenic purpura, anaemia, or sickle cell disease.

[0176] The endotheliopathy may be caused by hepatological conditions, for example cirrhosis, hepatitis, nonalcoholic fatty liver disease (NAFL), nonalcoholic steatohepatitis (NASH), primary biliary cholangitis, and primary sclerosing cholangitis.

[0177] The endotheliopathy may be caused by sepsis.

[0178] Dysfunctional endothelial cells may allow for the passage of tumour cells circulating in the blood to pass into the tissues. Thus, treating the endotheliopathy may prevent the haematogenous spread of blood borne cancers. The treatment of the endotheliopathy may inhibit the haematogenous spread of cancer. The medium molecular weight heparin may inhibit the haematogenous spread of cancer.

[0179] Biomarkers of endotheliopathy may include raised von Willebrand factor (VWF) levels, ultralarge von Willebrand factor (ULVWF) levels, Factor VIII levels as well as other markers such as Syndecan 1, VWF antigen, VWF activity, VWF multimers, ADAMTS13 levels, platelet counts, VCAM-1, ICAM-1, P-selectin levels, VWF:ADAMTS13 ratio or VWF antigen:ADAMTS13 ratio. Preferably, a biomarker of endotheliopathy is the ratio of VWF:ADAMTS13 or VWF antigen: ADAMTS13.

[0180] The patient may have raised plasma von Willebrand factor (VWF) levels compared to a healthy control subject. The patient may have sustained high levels of plasma VWF compared to a healthy control. The levels of plasma VWF may be raised compared to a healthy control subject over a period of at least about one day, at least about two days, at least about three days, at least about four days, at least about five days, at least about six days, or preferably at least about one week. The levels of plasma VWF may be raised compared to a healthy control subject for a period of up to about one week, up to about four weeks, up to about two months, up to about four months, up to about six months, or up to about one year.

[0181] For example, the level of plasma VWF may be raised to at least about 50 nmol / L, preferably at least about 60 nmol / L, even more preferably at least about 70 nmol / L or yet even more preferably at least about 90 nmol / L. The level of plasma VWF may be raised to about 130 nmol / L, to about 150 nmol / L, or to about 200 nmol / L. The level of plasma VWF may be raised to at least about 50 nmol / L for at least about one day, at least about two days, at least about three days, at least about four days, at least about five days, at least about six days, at least about one week, at least about one month or at least about one year. The level of plasma VWF may be raised to at least about 60 nmol / L for at least about one day, at least about two days, at least about three, days, at least about four days, at least about five days, at least about six days, at least about one week, at least about one month or at least about one year. The level of plasma VWF may be raised to at least about 70 nmol / L for at least about one day, at least about two days, at least about three days, at least about four days, at least about five days, at least about six days, at least about one week, at least about one month or at least about one year. The level of plasma VWF may be raised to at least about 90 nmol / L for at least about one day, at least about two days, at least about three days, at least about four days, at least about five days, atleast about six days, at least about one week, at least about one month or at least about one year. The plasma VWF level may be measured using an Enzyme-Linked Immunosorbent Assay (ELISA).

[0182] Alternatively or additionally, the patient may have a plasma von Willebrand factor level of about 200 ID pr dL or more for at least about six hours, at least about 12 hours, at least about 18 hours or at least about 24 hours. Preferably, the patient may have a plasma von Willebrand factor level of about 200 ID pr dL or more for at least about one day, at least about two days, at least about three days, at least about four days, at least about five days, at least about six days, or at least about seven days. Even more preferably the patient may have a plasma von Willebrand factor level of about 200 IL) pr dL or more for at least about one week, at least about two weeks, at least about three weeks or at least about four weeks. Yet even more preferably the patient may have a plasma von Willebrand factor level of about 200 IL) pr dL or more for at least about one month, at least about two months, at least about three months, at least about four months, at least about five months, at least about six months or at least about one year.

[0183] Vascular endothelial function can be assessed in the coronary and peripheral circulations. Non-invasive tests for the assessment of coronary endothelial function include Doppler echocardiography where blood flow is measured in response to pharmacological or physiological stimuli. Other tests include positron emission tomography and phase-contrast magnetic resonance imaging. However, the gold standard test involves invasive quantitative coronary angiography to examine changes in diameter in response to intracoronary infusions of endothelium-dependent vasodilators such as acetylcholine. Assessment of the endothelium in the peripheral circulation includes brachial artery ultrasound and strain-gauge venous impedance plethysmography.

[0184] Binding of MMWH-Red to VWF may be assessed by a competitive binding assay. Heparin- Sepharose beads may be incubated with labelled VWF, for example125l-vWF, for a period of time to allow the labelled VWF to bind to the immobilized heparin. Varying concentrations of the MMWH-Red may then be added and the amount of displaced labelled VWF determined. Other methods to determine MMWH-Red binding to VWF may include surface plasmon resonance, biolayer interferometry, isothermal titration calorimetry, fluorescence polarisation binding assays, ELISA and microscale thermophoresis.

[0185] The inhibition of platelets binding to VWF may be assessed by ristocetin-induced agglutination of fixed platelets. Platelets may be incubated with the medium molecular weight heparin and citrate treated plasma (a VWF source). Ristocetin may then be added, and platelet agglutination then determined. The MMWH may fully inhibit VWF-induced platelet aggregation at a concentration of 15 pM when measured by a ristocetin-induced platelet aggregation assay. Other methods to determine the inhibition of VWF binding to platelets may include ELISA, fluorescence assisted cell sorting, dynamic light scattering, or flow chamber assays.

[0186] The MMWH-Red may have an average molecular weight in the range of greater than about 8000 Da (g / mol) to about 13 500 Da (g / mol), or greater than about 8000 Da (g / mol) to about 13 000 Da (g / mol), or about 10 000 Da (g / mol) to about 12 000 Da (g / mol). The MMWH-Red may comprise polysaccharide chains with an average molecular weight in the range of greater than about 8000 Da (g / mol) to about 13 500 Da (g / mol), or greater than about 8000 Da (g / mol) to about 13 000 Da (g / mol),or about 9000 Da (g / mol) to about 13 000 Da (g / mol), or about 10 000 Da (g / mol) to about 12 000 Da (g / mol). The average molecular weight of the MMWH-Red may be determined by mass spectrometry or size exclusion chromatography, for example.

[0187] The MMWH-Red may comprise at least three units of a GlcNS6S-ldoA2S disaccharide, for example at least four units, at least five units, at least six units, at least eight units, or at least ten units. The medium molecular weight heparin may comprise less than or equal to 25 units of the GlcNS6S- ldoA2S disaccharide, for example less than or equal to 20 units. The presence of the units of the GlcNS6S-ldoA2S disaccharide may be determined by an antibody, mass spectrometry, or inferred from chemical and enzymatical studies. The GlcNS6S-ldoA2S units may be ordered in succession.

[0188] The MMWH-Red may comprise at least three units of a ldoA2S-GlcNS6S disaccharide, for example at least four units, at least five units, at least six units, at least eight units, or at least ten units. The reduced medium molecular weight heparin may comprise less than or equal to 25 units of the ldoA2S-GlcNS6S disaccharide, for example less than or equal to 20 units. The presence of the units of the ldoA2S-GlcNS6S disaccharide may be determined by an antibody, mass spectrometry, or inferred from chemical and enzymatical studies. The ldoA2S-GlcNS6S units may be ordered in succession. The number of ldoA2S-GlcNS6S units may be tailored to provide a desired anti-VWF activity and / or standard anticoagulant activity.

[0189] The MMWH-Red may comprise UA2S-GlcNS6S, UA2S-GlcNS, UA -GIcNAc. The MMWH-Red may comprise at least about 60% UA2S-GlcNS6S, UA2S-GlcNS, and UA-GIcNAc. The MMWH-Red may comprise at least about 45%, preferably at least about 48%, preferably at least about 49%, preferably at least about 60%UA2S-GlcNS6S. The MMWH-Red may comprise up to about 60%, preferably up to about 70%, preferably up to about 85% UA2S-GlcNS6S. The MMWH-Red may comprise at least about 4%, preferably at least about 5%, preferably at least about 6%, preferably at least about 10% UA2S- GIcNS. The MMWH-Red may comprise up to about 15%, preferably up to about 20% UA2S-GlcNS. The MMWH-Red may comprise at least 4%, preferably at least 5%, preferably at least 6%, preferably at least about 10% UA-GIcNAc. The reduced medium molecular weight heparin may comprise up to about 15%, preferably up to about 20% UA-GIcNAc. In some embodiments the MMWH-Red may comprise at least 49.2% UA2S-GlcNS6S, 5.4% UA2S-GlcN and 5.4% UA-GIcNAc. In some embodiments the MMWH-Red may comprise at least 82% UA2S-GlcNS6S, 9% UA2S-GlcNS and 9% UA-GIcNAc. The percentage composition of UA -GIcNAc comprised in the MMWH-Red may be enriched compared to unfractionated heparin.

[0190] The treatment of endotheliopathy by MMWH-Red may inhibit the haematogenous spread of cancer. Human tumour cells can bind to VWF under shear flow conditions with both melanoma and colon cancer cells demonstrating this ability. The immobilized platelets, bound to the VWF, have been shown to mediate tethering, rolling, and the firm adhesion of different cancerous cell lines under flow shear stress. The VWF played a critical role in enabling this firm adhesion of the tumour cells to the immobilized platelets. The existing data suggests that VWF plays an important role in tethering cancerous cells. In addition, the VWF-Platelet binding that occurs as part of the normal thrombosis pathways may further act to allow the coalescence of tumour cells into the VWF-Platelet to form heteroaggregates of VWF+platelets+cancer cells which thereby help in the blood borne (haematogenous) spread of tumour cells. This process may at least in part be caused by the ability ofcancer cells to translocate to the vessel wall and thereby spread to other organs once the initial binding to VWF and Platelets has occurred. In addition, various cancers are known to cause an endotheliopathy with the resultant release of UL-VWF. By this mechanism, the tumour triggers the release of UL-VWF that then allows the tethering of platelets and tumour cells and the haematogenous spread of the cancer and the metastatic spread. This cancer induced endotheliopathy also results in an overall increase in the risk of thrombosis in patients with underlying malignancy. Therefore, any treatment aimed at treating an endotheliopathy and inhibiting the binding of platelets and / or tumour cells to VWF would serve a dual purpose of decreasing the risk of malignancy associated thrombosis and also reduce the risk of haematogenous metastatic spread.

[0191] The MMWH-Red may be administered by an administration method selected from the group consisting of: parenteral, subcutaneous, intravenous, intramuscular, intrathecal, intradermal, intraarterial, intraarticular, cutaneous, transcutaneous, subcutaneous, depot form, for example depot injection, intra-osseus, or inhalation. Preferably, the medium molecular weight heparin administration method is subcutaneous, intravenous or intramuscular. The administration method may be inhalation, optionally via a nebuliser.

[0192] Previous studies have looked at UFH as a nebulised agent in a variety of conditions. Small human studies indicate that nebulised UFH limits pulmonary fibrin deposition, attenuates progression of acute lung injury and hastens recovery (69). Early-phase trials in patients with acute lung injury and related conditions found that nebulised UFH reduced pulmonary dead space, coagulation activation, microvascular thrombosis, improved lung injury and increased time free of ventilatory support ( OTS). In a pre-pandemic double-blind randomised study in 256 critically ill ventilated patients, nebulised UFH limited progression of lung injury including acute respiratory distress syndrome and accelerated return to home in survivors. Thus, the MMWH-Red may be administered by inhalation via a nebuliser.

[0193] Heparin dosage is typically measured in "Howell Units". One unit of heparin (the "Howell unit") is an amount approximately equivalent to 0.002 mg of pure heparin, which is the quantity required to keep 1 ml of cat's blood fluid for 24 hours at 0 °C. The MMWH-Red may be administered at a bolus does of about 5000 units, followed by about 1200 to about 1600 units per hour optionally delivered by an infusion pump. The MMWH-Red may be administered at a dose of about 18 units / kg to about 5000 units / kg. Preferably, the MMWH-Red may be administered at a dose of about 100 units / kg to about 800 units / kg. Alternatively, the MMWH-Red may be administered at a dose of about 18 units / kg to about T5 units / kg. The MMWH-Red may be administered at a dose of about 5000 units, about 4000 units, about 3000 units, about 2000 units, about 1000 units or about 500 units every 12 hours. The MMWH-Red may be administered at a dose of about 5000 units every 12 hours.

[0194] The MMWH-Red may be administered at a dose of about 3 units to about 5000 units, for example from about 6 units to about 4000 units, from about 12 units to about 3000 units, from about 25 units to about 2000 units, from about 50 units to about 1000 units, from about 100 units to about 500 units, or from about 125 units to about 250 units. The reduced medium molecular weight heparin may be administered at a dose of about 18 unit / kg to about 5000 units / kg, for example from about 100 units / kg to about 4000 units per / kg, or from about 200 units / kg to about 800 units / kg. The reduced medium molecular weight heparin may be administered at a dose of about 18 units / kg toabout 75 units / kg. The dose may be given as a single dose or as a continuous dose. The dose may be given over a period of time. The period of time may be from about 1 month to about 12 months, for example from about 2 months to about 11 months, from about 3 months to about 10 months, from about 4 months to about 9 months, from about 5 months to about 8 months, from about 6 months to about 7 months. The period of time may be about 1 day to 7 days, about 2 days to about 6 days, about 3 days to about 5 days, about 4 days to about 5 days. The dose may be administered over about 1 hour to about 24 hours, about 2 hours to about 12 hours, about 3 hours to about 6 hours. The dose may be administered for the duration of the underlying endotheliopathy and raised VWF levels.

[0195] The MMWH-Red may be administered at a dose of about 0.01 mg / kg to about 10 mg / kg, for example at a dose of about 0.05 mg / kg to about 9 mg / kg, about 0.5 mg / kg to about 8 mg / kg, about 1 mg / kg to about 7 mg / kg, about 1.5 mg / kg to about 6 mg / kg, or about 2 mg / kg to about 5 mg / kg. The dose may be given as a single dose or as a continuous dose. The dose may be given over a period of time. The period of time may be from about 1 month to about 12 months, for example from about 2 months to about 11 months, from about 3 months to about 10 months, from about 4 months to about 9 months, from about 5 months to about 8 months, from about 6 months to about 7 months. The period of time may be about 1 day to about 7 days, about 2 days to about 6 days, about 3 days to about 5 days, about 4 days to about 5 days. The dose may be administered over about 1 hour to about 24 hours, about 2 hours to about 12 hours, about 3 hours to about 6 hours. The dose may be administered for the duration of the underlying endotheliopathy and raised VWF levels.

[0196] The MMWH-Red may be administered at a dose of from about 0.01 mg / kg, from about 0.1 mg / kg, from about 1 mg / kg, from about 5 mg / kg, from about 10 mg / kg, from about 20 mg / kg, from about 30 mg / kg, from about 50 mg / kg, from about 70 mg / kg, from about 80 mg / kg, or from about 100 mg / kg. The MMWH-Red may be administered at a dose of about 500 mg / kg or less, about 300 mg / kg or less, about 200 mg / kg or less, or about 100 mg / kg or less. The MMWH-Red may be administered at a dose of from about 0.01 mg / kg to about 10 mg / kg, preferably from about 0.2 mg / kg to about 10 mg / kg, from about 0.2 mg / kg to about 1.6 mg / kg. The MMWH-Red may be administered as a single dose or as a continuous dose. The MMWH-Red dosage amount may be dependent on the VWF antigen: ADAMTS13 ratio or the overall VWF levels. The skilled person would be able select a suitable amount for a patient based on the VWF antigen: ADAMTS13 ratio or the overall VWF levels.

[0197] The MMWH-Red may be administered at a dose of from about 0.01 mg / kg to about 10 mg / kg, from about 0.05 mg / kg to about 8 mg / kg, from about 0.1 mg / kg to about 5 mg / kg, from about 0.5 mg / kg to about 2 mg / kg, from about 1 mg / kg to about 1.5 mg / kg. The dose may be given as a single dose or as a continuous dose. The dose may be given over a period of time. The period of time may be from about 1 month to about 12 months, for example from about 2 months to about 11 months, from about 3 months to about 10 months, from about 4 months to about 9 months, from about 5 months to about 8 months, from about 6 months to about 7 months. The period of time may be from about 1 day to about 7 days, from about 2 days to about 6 days, from about 3 days to about 5 days, from about 4 days to about 5 days. The dose may be administered over about 1 hour to about 24 hours, about 2 hours to about 12 hours, about 3 hours to about 6 hours. The dose may be administered for the duration of the underlying endotheliopathy and raised VWF levels.

[0198] The MMWH-Red may be administered at a dose of from about 0.1 mg to about 5000 mg, from about 0.5 mg to about 2000 mg, from about 1 mg to about 1000 mg, from about 5 mg to about 900 mg, from about 10 mg to about 800 mg, from about 20 mg to about 700 mg, from about 30 mg to about 600 mg, from about 50 mg to about 500 mg, from about 75 mg to about 400 mg, from about 100 mg to about 300 mg, from about 125 mg to about 250 mg, from about 150 mg to about 200 mg. The dose may be given as a single dose or as a continuous dose. The dose may be given over a period of time. The period of time may be from about 1 month to about 12 months, for example from about 2 months to about 11 months, from about 3 months to about 10 months, from about 4 months to about 9 months, from about 5 months to about 8 months, from about 6 months to about 7 months. The period of time may be from about 1 day to about 7 days, from about 2 days to about 6 days, from about 3 days to about 5 days, from about 4 days to about 5 days. The dose may be administered over about 1 hour to about 24 hours, about 2 hours to about 12 hours, about 3 hours to about 6 hours. The dose may be administered for the duration of the underlying endotheliopathy and raised VWF levels.

[0199] The MMWH-Red may be administered at a dose of, for example about 1 international units ( I U ), about 2 ID, about 5 IU, about 10 IU, about 15 IU, about 20 IU, about 25 IU, about 50 IU, about 75 IU, about 100 IU, about 200 IU, about 300 IU, about 400 IU, about 500 IU, about 1000 IU, about 1500 IU, about 2000 IU, about 2500 IU, about 5000 IU, about 10 000 IU, about 20 000 IU, or about 25 000 IU. The dose may be given as a single dose or as a continuous dose. The dose may be given over a period of time. The period of time may be from about 1 month to about 12 months, for example from about 2 months to about 11 months, from about 3 months to about 10 months, from about 4 months to about 9 months, from about 5 months to about 8 months, from about 6 months to about 7 months. The period of time may be from about 1 day to about 7 days, from about 2 days to about 6 days, from about 3 days to about 5 days, from about 4 days to about 5 days. The dose may be administered over about 1 hour to about 24 hours, about 2 hours to about 12 hours, about 3 hours to about 6 hours. The dose may be administered for the duration of the underlying endotheliopathy and raised VWF levels.

[0200] The MMWH-Red may be administered at a dose of from about 1 IU to about 50 000 IU, from about 2 IU to about 25 000 IU, from about 5 IU to about 20 000 IU, from about 10 IU to about 10 000 IU, from about 15 IU to about 5000 IU, from about 20 IU to about 2500 IU, from about 25 IU to about 2000 IU, from about 50 IU to about 1500 IU, from about 75 IU to about 1000 IU, from about 100 IU to about 500 IU, from about 200 IU to about 400 IU, from about 250 IU to about 300 IU. The dose may be given as a single dose or as a continuous dose. The dose may be given over a period of time. The period of time may be from about 1 month to about 12 months, for example from about 2 months to about 11 months, from about 3 months to about 10 months, from about 4 months to about 9 months, from about 5 months to about 8 months, from about 6 months to about 7 months. The period of time may be from about 1 day to about 7 days, from about 2 days to about 6 days, from about 3 days to about 5 days, from about 4 days to about 5 days. The dose may be administered over about 1 hour to about 24 hours, about 2 hours to about 12 hours, about 3 hours to about 6 hours. The dose may be administered for the duration of the underlying endotheliopathy and raised VWF levels.

[0201] The MMWH-Red may be administered that is commensurate with the VWF antigen: ADAMTS13 ratio. For example, a patient with a high VWF antigen: ADAMTS13 ratio may be administered a higher dose of MMWH compared to a patient with a VWF antigen: ADAMTS13 ratio that is lower.

[0202] The MMWH-Red may be comprised in a pharmaceutical formulation. The pharmaceutical formulation may comprise an excipient. The excipient may be selected from the group comprising solvents, co-solvents, buffers, stabilisers, antioxidants, preservatives, chelating agents, emulsifiers, flavourings, lubricants, suspending agents, tonicity adjusting agents, surfactants, solubilising agents, suspending aids, dispersion agents, humectants, thickeners, colouring agent, wetting agent, antifoaming agent, viscosity modifier, sweeteners and combinations thereof. The pharmaceutical formulation may comprise an additional active agent. The additional active agent may comprise medium molecular weight heparin or low molecular weight heparin.

[0203] The pharmaceutical formulation may comprise an additional active agent. The additional active agent comprises a composition of matter that has a physiological effect. The additional active agent may comprise low molecular weight heparin or a medium molecular weight heparin or a reduced medium molecular weight heparin of a different disaccharide composition. The additional active agent may be selected from the group comprising farnesoid X receptor (FXR) agonist, a peroxisome proliferator-activator receptor (PPAR) agonist, aramchol, a caspase inhibitor, a galectin 3 inhibitor, a mitogen-activated protein kinase 5 (MAPK5) inhibitor, a fibroblast growth factor 19 (FGF19) agonist, a FGF21 agonist, a leukotriene D4 (LTD4) receptor antagonist, a niacin analog, an apical sodium bile acid cotransporter (ASBT) inhibitor, an apoptosis signal regulating kinase 1 (ASK1) inhibitor, an angiotensin converting enzyme (ACE) inhibitor, an angiotensin receptor blocker, a chemokine receptor inhibitor, a thiozolidinedione, a GLP-1 analog, a biguanide, an HIV replication inhibitor, metoformin, an opiate, an anaesthetic, HMG-CoA reductase inhibitor, a nonsteroidal antiinflammatory drug (NSAID), or any combination of these.

[0204] The MMWH-Red may comprise a chemical modification. The chemical modification may be selected from the group comprising N-acetylation, N-deacetylation, N-sulfation, O-sulfation, 2-0 desulfation, and complete desulfation.

[0205] In an sixth aspect, the invention provides MMWH-Red according to the first or third aspect, or a MMWH-Red produced according to the second aspect, or a composition according to the fourth aspect for use in the treatment of a disease or condition in a patient, wherein the patient has an endotheliopathy characterised by a plasma von Willebrand factor to ADAMTS13 (VWF:ADAMTS13) ratio of at least about 2.

[0206] In an seventh aspect, the invention provides MMWH-Red according to the first or third aspect, or a MMWH-Red produced according to the second aspect, or a composition according to the fourth aspect for use in the treatment of a disease or condition in a patient, wherein the patient has an endotheliopathy characterised by a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0207] Preferably, the disease or condition is selected from the group consisting of: COVID-19 (for example, acute COVID-19 or post-COVID-19 syndrome), infection, viral infection, acute respiratory distress syndrome (ARDS), cancer, bacterial infection, septicaemia, sepsis, cardiovascular disease, diabetes mellitus, trauma, in particular brain or head trauma e.g. traumatic brain injury, burns, inhalational injury, drugs and drug reactions, haematological conditions, subarachnoid haemorrhage(for example aneurysmal subarachnoid hemorrhage), aneurysmal diseases, stroke, brain parenchymal haemorrhage, radiation induced injury, ischemic stroke, pancreatitis, hepatological conditions, renal diseases, chronic obstruction pulmonary disease or combinations thereof. The endotheliopathy may be caused by a viral infection, optionally wherein the viral infection is SARS-CoV-2. The endotheliopathy may be caused by cancer, in particular leukaemia, lymphoma, myeloma, or a solid organ cancer, such as colon cancer, breast cancer, brain cancer, lung cancer, pancreatic cancer, testicular cancer, prostate cancer, cervical cancer, liver cancer, or skin cancer. Preferably, the endotheliopathy is caused by sepsis or septicaemia. Preferably, the endotheliopathy is caused by sepsis.

[0208] In some embodiments, the present invention provides MMWH-Red for use in the treatment of COVID-19 (for example, acute COVID-19 or post-COVID-19 syndrome) in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen :ADAMTS13) ratio of at least about 2.

[0209] In some embodiments, the present invention provides MMWH-Red for use in the treatment of infection in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2. The infection may be SARS-CoV-2.

[0210] In some embodiments, the present invention provides MMWH-Red for use in the treatment of viral infection in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2. The viral infection may be SARS-CoV-2.

[0211] In some embodiments, the present invention provides MMWH-Red for use in the treatment of acute respiratory distress syndrome (ARDS) in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0212] In some embodiments, the present invention provides MMWH-Red for use in the treatment of cancer in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2. The cancer may be leukaemia, lymphoma, myeloma, or a solid organ cancer, such as colon cancer, breast cancer, brain cancer, lung cancer, pancreatic cancer, testicular cancer, prostate cancer, cervical cancer, liver cancer, or skin cancer.

[0213] In some embodiments, the present invention provides MMWH-Red for use in the treatment of bacterial infection in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0214] In some embodiments, the present invention provides MMWH-Red for use in the treatment of septicaemia in a patient, wherein the patient has an endotheliopathy characterised by a plasmaVWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0215] In some embodiments, the present invention provides MMWH-Red for use in the treatment of sepsis in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0216] In some embodiments, the present invention provides MMWH-Red for use in the treatment of cardiovascular disease in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0217] In some embodiments, the present invention provides MMWH-Red for use in the treatment of diabetes mellitus in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0218] In some embodiments, the present invention provides MMWH-Red for use in the treatment of trauma in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2. Preferably, the trauma is brain trauma or head trauma, e.g. traumatic brain injury.

[0219] In some embodiments, the present invention provides MMWH-Red for use in the treatment of burns in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0220] In some embodiments, the present invention provides MMWH-Red for use in the treatment of inhalational injury in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0221] In some embodiments, the present invention provides MMWH-Red for use in the treatment of drugs and drug reactions in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0222] In some embodiments, the present invention provides MMWH-Red for use in the treatment of haematological conditions in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0223] In some embodiments, the present invention provides MMWH-Red for use in the treatment of subarachnoid haemorrhage (for example aneurysmal subarachnoid hemorrhage) in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0224] In some embodiments, the present invention provides MMWH-Red for use in the treatment of aneurysmal diseases in a patient, wherein the patient has an endotheliopathy characterised by a plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0225] In some embodiments, the present invention provides MMWH-Red for use in the treatment of stroke in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0226] In some embodiments, the present invention provides MMWH-Red for use in the treatment of brain parenchymal haemorrhage in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0227] In some embodiments, the present invention provides MMWH-Red for use in the treatment of radiation induced injury in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0228] In some embodiments, the present invention provides MMWH-Red for use in the treatment of ischemic stroke in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0229] In some embodiments, the present invention provides MMWH-Red for use in the treatment of pancreatitis in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0230] In some embodiments, the present invention provides MMWH-Red for use in the treatment of hepatological conditions in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0231] In some embodiments, the present invention provides MMWH-Red for use in the treatment of renal diseases in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2.

[0232] In some embodiments, the present invention provides MMWH-Red for use in the treatment of chronic obstruction pulmonary disease in a patient, wherein the patient has an endotheliopathy characterised by a VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen :ADAMTS13) ratio of at least about 2.

[0233] MMWH-Red for use in the treatment of endotheliopathy as defined in the fifth, sixth or seventh aspect of the invention are particularly advantageous as said heparins can inhibit the microthrombosis triggered by the release of VWF secondary to the endotheliopathy caused by any disease or condition. When the cause of the endotheliopathy is SARS-CoV-2, said MMWH-Red can additionally inhibit viral adherence and replication.

[0234] In an eighth aspect, the invention provides a method of treating endotheliopathy, the method comprising administering to a subject in need of treatment a therapeutically effective amount of MMWH-Red. Preferably, wherein the patient has plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen :ADAMTS13) ratio of at least about 2. Typically, the MMWH-Red may be MMWH-Red according to the first or third aspect, MMWH-Red produced according to the method of the second aspect, or a composition according to the fourth aspect.

[0235] In a ninth aspect, the invention provides the use of the MMWH-Red for the manufacture of a medicament for the treatment of endotheliopathy in a patient. Preferably, wherein the patient has plasma VWF:ADAMTS13 ratio of at least about 2 or a plasma von Willebrand factor antigen to ADAMTS13 (VWF antigen:ADAMTS13) ratio of at least about 2. Typically, the MMWH-Red may be MMWH-Red according to the first or third aspect, MMWH-Red produced according to the method of the second aspect, or a composition according to the fourth aspect.

[0236] Sepsis is the body's extreme response to an infection. It is characterised by a whole-body inflammatory state where as a result of immune response dysregulation, the immune system reacts to the infection by attacking the body's own tissues and organs. Consequently, cells in the body are destroyed through apoptosis or necrosis and intracellular material ends up in the blood stream.

[0237] Histones are intracellular basic proteins found in the nucleus of a cell. DN A wraps itself around histones to form chromatin, which is then itself tightly wound to facilitate the packaging of the long DNA molecule into the nucleus of the cell. Whilst known for its role in the packaging of DNA into the nucleus, chromatin (and its constituent histones) have also been shown to play a role in innate immunity. During infection, neutrophils release granular proteins and chromatin that together form extracellular fibres that bind Gram positive and negative bacteria. These neutrophil extracellular traps (NETs) degrade virulence factors and kill bacteria.

[0238] Circulating histones have been identified as mediators of damage in animal models of sepsis and in patients. These histones may enter the bloodstream as a result of intracellular material being released due to apoptosis or necrosis which occurs during sepsis, or via NET release in response to bacterial infection. Accordingly, histones may propagate the dysregulation of the immune system observed during sepsis. For example, histones are damage associated molecule patterns (DAMPs)which are sensed by toll-like receptors (TLRs). Activation of TLRs on innate immune cells by histones results in the release of pro-inflammatory cytokines, thereby exacerbating an already dysregulated immune response. In particular, TLR receptors on endothelial cells may be activated by circulating histones, which results in the induction of an immune response in the endothelial cells. Thus, the endothelium becomes inflamed and endothelialitis and endotheliopathy is observed.

[0239] Hence, the MMWH-Red as defined herein may bind to free histones whilst simultaneously inhibiting VWF, thereby treating sepsis. In an embodiment, the invention provides MMWH-Red for the treatment of sepsis, systemic Inflammatory response syndrome (SIRS), severe sepsis or septic shock in a subject (patient). In some embodiments, the subject has plasma VWF:ADAMTS13 ratio of at least about 2. In some embodiments, the subject has plasma VWF antigen:ADAMTS13 ratio of at least about 2.

[0240] The MMWH-Red as defined herein may be a complement cascade modulator.

[0241] The MMWH-Red as defined herein may be an immune modulator.

[0242] For the avoidance of doubt, embodiments related to each aspect of the invention apply mutatis mutandis to the other aspects of the invention. Further aspects and embodiments of the present invention will be evident from the discussion herein.

[0243] Every document cited herein, including any cross-referenced or related patent or application, is hereby incorporated by reference in its entirety unless expressly excluded or otherwise limited.

[0244] It will be appreciated that various modifications may be made to the embodiments shown without departing from the spirit and scope of the invention as defined by the accompanying claims.EXAMPLES

[0245] The invention will now be demonstrated by reference to the following non-limiting examples.

[0246] Unless otherwise mentioned, room temperature and pressure are 20 °C (293.15 K, 68 °F) and 1 atm (14.696 psi, 101.325 kPa), respectively. xperimental MethodsSize Exclusion Chromatography (SEC)

[0247] SEC is performed on a GEC Superdex75 (10 / 100) column on an Agilent 1200 HPLC system with variable wavelength UV monitor or GEC AKTA system with variable wavelength UV monitor. Themobile phase is 0.15M NaCI in water, which is passed through the column at 0.4 mL / min. The optical density is measured at 232 nm. SEC is performed with reference to an 11 kD standard.Freeze drying

[0248] Freeze drying (also known as lyophilisation or cryodesiccation) is a drying process carried out at low temperature. Freeze drying generally involves reducing temperature and pressure to below the substance's triple point and removing the frozen solvent (e.g. water ice) by sublimation. For aqueous compositions, such as those disclosed herein, freeze drying may be carried out at temperatures of from about -20 °C to -80 °C, preferably about -40 °C, and pressures of from about 1000 Pa (0.01 bar) to about 10 Pa (0.0001 bar).Method of MMW Heparin Manufacture1. Development Examples

[0249] Batches of 80 mg unfractionated heparin were dissolved in 50 mM sodium phosphate buffer adjusted to pH 7.0 (30 ml).

[0250] Samples were prepared with (A) 43 mg, ( B) 86 mg, (C) 173 mg or (D) 200 mg sodium periodate added to the heparin in sodium phosphate buffer solution. The resultant solutions were incubated at 4 °C for 16 to 18 hours or at 37 °C for 6 hours.

[0251] 200 pl aliquots were taken prior to dialysis for SEC. The remainder of the samples were dialysed against water in 2kd cut off tubing (Spectra / Por®, product number 132109; 7 Days : 3 changes per day / 4 volumes of water). The samples were then freeze dried at -40 °C and 10 Pa. The samples were then dissolved in water and analysed by SEC on Superdex® 75 SE (10 / 300) column in 0.15 M NaCI at 0.4mL / min on either a GEC AKTA system or an Agilent 1200 system.

[0252] The aliquots taken prior to dialysis were analysed by SEC on Superdex® 75 SE (10 / 300) column in 0.15M NaCI at 0.4mL / min on either a GEC AKTA system or an Agilent 1200 system showed significant amount of disaccharide-like material mixed with the reagent peak.

[0253] SEC on the samples was performed and calibrated by coeluting with a verified 11 kDa standard. The SEC analysis of samples following dialysis provided the following results: a. 37 °C incubation provided a sample that ran as a broad peak centred on Ka, 0.12 and resulted in degradation of the medium molecular weight heparin.b. 4 °C incubation provided a sample that ran as a narrower peak centred on Kav0.06 and a molecular weight of 11 kD.

[0254] Figure 1 shows MMWH prepared at 4 °C compared to heparin treated at 37 °C, untreated heparin and a 11 kDa standard.

[0255] Thus, incubation at 4 °C favours the formation of medium molecular weight heparin. Incubation at 37 °C primarily provides other products.

[0256] All investigated concentrations of sodium periodate provided the desired medium molecular weight heparin. The most active concentration of sodium periodate was (C) 173 mg per 30 mL of the heparin in sodium phosphate buffer solution (equivalent to the 8.6 g per 1.5 L used in the large scale process example described below).1.2 Perchlorate addition

[0257] Samples were prepared in accordance with (A) and (B) of the periodate method above (1.1). 732 mg per 30 mL of sodium perchlorate was added to samples (A) and (B) and the resultant solutions were incubated at 4 °C for 16 to 18 hours or at 37 °C for 6 hours.

[0258] The samples were dialysed against water in 2kd cut off tubing (Spectra / Por®, product number 132109; 7 Days : 3 changes per day / 4 volumes of water). The samples were then freeze dried at - 40 °C and 10 Pa. The samples were then dissolved in water and analysed by SEC on Superdex® 75 SE (10 / 300) column in 0.15M NaCI at 0.4mL / min on either a GEC AKTA system or an Agilent 1200 system.

[0259] SEC on the samples was performed and calibrated by coeluting with a verified 11 kDa standard. The SEC analysis of samples following dialysis provided the following results:

[0260] All samples (incubated at 4°C and 37°C) resulted in the production of material with a broader size range centred on Kav0.12. There was also a large increase in material at the Vtof the column (i.e. smaller species).

[0261] This examples shows that oxidation with a mixture of periodate and perchlorate results in an increased level of breakdown to smaller species compared to oxidation with periodate alone. Thus, oxidation with only periodate is a more efficient method of preparing high purity medium molecular weight heparin.1.3 Alkaline Elimination

[0262] Samples were prepared in accordance with (A) and (B) of the periodate method above at incubations of 4°C and 37 °C (1.1).

[0263] NaOH (2 M) was added to the samples to adjust the pH of the sample to pH 12. The samples were then incubated at room temperature for 30 minutes. Aliquots of these samples were analysed by SEC on Superdex® 75 SE (10 / 300) column in 0.15M NaCI at 0.4mL / min on either a GEC AKTA system or an Agilent 1200 system. SEC on the samples was performed and calibrated by coeluting with a verified 11 kDa standard.

[0264] This alkaline elimination resulted in further degradation with more defined peaks at KavS 0.331, 0.35, 0.4, and 0.54, and a large peak at Kav0.625.

[0265] Figure 2 shows MMWH prepared at 4 °C using only periodate compared to heparin treated with periodate then NaOH at 4 “C, which runs as a broad peak due to degradation. Accordingly, the preparation of high purity medium molecular weight heparin is impeded bythe inclusion of an alkaline elimination step as significant degradation is observed.2. Large Scale Process Example

[0266] UF Heparin (Heparin of Porcine mucosal origin; Iduron Catalog No. H EP001 / 100) (4 g; 2.7 mg / mL; average molecular weight 15 kDa) was dissolved in ice-cold (0 °C to 2 °C) 50 mM sodium phosphate buffer (1.5 L) adjusted to pH 7.0. Sodium periodate (8.56 g, 40 mmol) was added and the sample was incubated overnight at 4 °C. Following incubation, the sodium periodate was inactivated by the addition of D-Mannitol (30 g, 160 mmol).

[0267] The sample was then dialysed against water in 2kD cut off tubing (Spectra / Por®, product number 132109; 7 Days : 3 changes per day / 4 volumes of water). The sample was then freeze dried at -40 °C and 10 Pa to provide medium molecular weight heparin in a yield of 2.1 g.

[0268] The medium molecular weight heparin sample was then dissolved in water and analysed by SEC on Superdex® 75 SE (10 / 300) column in 0.15M NaCI at 0.4mL / min on either a GEC AKTA system or an Agilent 1200 system. The medium molecular weight heparin had an average molecular weight of 11 kDa with reference to a 11 kDa standard as shown in Figure 3.

[0269] As shown in Figures 4 and 5, the medium molecular weight heparin produced displayed very low activity against Factor Ila and / or Xa as compared to UF heparin and low molecular weight heparin. Thus, unlike UF Heparin or LMW Heparin, MMW Heparin does not affect Factor Ila or Factor Xa- mediated coagulation.

[0270] Factor Ila (also known as thrombin) acts as a serine protease that converts soluble fibrogen into insoluble strands of fibrin, as well as catalysing other coagulation-related reactions. Factor Xa is the activated form of the coagulation factor X. Factor X is an serine endopeptidase enzyme, which plays a key role at several stages of the coagulation system.

[0271] Heparin (unfractionated heparin) and its derivatives, e.g. low molecular weight heparin, bind to a plasma cofactor, antithrombin (AT), to inactivate several coagulation factors Ila, Xa, Xia and XI la.This inactivation of Factor Xa by heparins is termed "indirect" since it relies on the presence of AT and not a direct interaction with Factor Xa.

[0272] Activity against Factor Ila and Factor Xa can be measured using Kinetichrome Anti-lla Heparin Kit and Kinetichrome Anti-Xa Heparin Kit, respectively. Activity against Factor Ila and Factor Xa can be measured using other kit meeting the USP <208> or EP requirements.

[0273] Disaccharide analysis was carried out on the medium molecular weight heparin. The results are shown in Table 1 below.

[0274] UF Heparin of Porcine mucosal origin is used for the purposes of the example synthesis provided herewith. For the avoidance of doubt, other sources of UF heparin are suitable for use in the methods disclosed herein.Method of MMWH-Red ManufactureOxidation of Heparin

[0275] UFH heparin is oxidised as described above under Method ofMMW Heparin Manufacture part 2.Reduction of the Oxidized Heparin Example 1

[0276] To a solution of oxidised heparin (6 g) in 100 mL milli Qat room temperature was added NaBH4(300 mg). The resultant mixture was stirred for 4 hours at room temperature. The pH was then adjusted to pH 4 with hydrochloric acid and the reaction mixture stirred for 15 minutes. The pH was subsequently adjusted to pH 7 with sodium hydroxide. 2% m / v NaCI was added followed by MeOH to arrive at 73% v / v MeOH in reaction mixture. The methanolic reaction mixture was stirred for 10 minutes and the precipitate allowed to settle. The precipitate was then resuspended with methanol and collected by filtration. The product was dried in vacuo at room temperature overnight.Reduction of the Oxidized Heparin Example 2

[0277] Oxidised heparin (2.4 g) was dissolved in water (125 mL). NaBH4(2.06 g) was added and the reaction mixture incubated at room temperature for 4 hours. The pH of the reaction mixture was then adjusted to 7.02 with glacial acetic acid.

[0278] The sample was then dialysed against water in 2kD cut off tubing (Spectra / Por®, product number 132109; 3 Days : 2 changes per day / 4 volumes of water). The sample was then freeze dried at -40 °C and 10 Pa to provide reduced medium molecular weight heparin.

[0279] As shown in Figure 6, monitoring of the reduction reaction by1H-NMR shows that the aldehyde signal present in MMWH at ~9.25 ppm disappears during the reduction reaction to prepare MMWH-Red, the hydroxyl form, thus indicating preparation of MMWH-Red.

[0280] The MMWH-Red prepared according to the above method has a Factor Xa activity of <10 lU / mg. MMWH (intermediate in this process) has a Factor Xa activity of <5 lU / mg. Unfractionated heparin has a Factor Xa activity of 169.24 lU / mg. Reduced medium molecular weight heparin displayed a very low activity against Factor Xa as compared to unfractionated heparin and low molecular weight heparin. Thus, unlike UF Heparin or LMW Heparin, MMWH-Red does not affect Factor Xa-mediated coagulation.Testing in Ristocetin-induced platelet aggregation (RIPA) assay

[0281] Protocol according to "Recommendations for the standardization of light transmission aggregometry: a consensus of the working party from the platelet physiology subcommittee of SSC / ISTH", Journal of Thrombosis and Haemostasis, 2013, 11: 1183-1189.

[0282] Blood samples were taken from non-smokers not on any anti-platelet therapy (for example, aspirin). An anti-platelet therapy may also be known as a platelet agglutination inhibitor or a platelet aggregation inhibitor.

[0283] Blood was drawn, with no venostasis, from a donor into 109 mM sodium citrate solution (VACUETTE, 3.5 mL #454327, lot#A21013FQ.). The first 3 to 4 mL of blood drawn was discarded.

[0284] Blood samples were allowed to 'rest' at room temperature for 15 min before centrifugation. Platelet rich plasma (PRP) was prepared by centrifuging blood samples at 200 g for 10 min at 21 °C, without using brake. Platelet poor plasma (PPP) was prepared by centrifuging blood samples, from which PRP was removed, at 1500 g for 15 min at 21 °C.

[0285] An assessment of PRP quality was made by carrying out a platelet count of the PRP. Platelet count in PRP was 421 G / L. The platelet count of PRP samples was not (and should not be) adjusted to a standardised value with autologous PPP.

[0286] After centrifugation, PRP samples were allowed to sit at room temperature for 15 min before Light Transmission Aggregometry (LTA) studies were carried out. PRP was used to set 0% light transmission in the aggregometer. Autologous PPP was used to set 100% light transmission in the aggregometer. LTA studies were carried out at 37 °C. Before adding agonist, baseline tracings for LTAwere observed for oscillations and stability for at least 1 minute. The volume of agonist added for LTA was consistent, and never more than 10% of the total sample volume.

[0287] 5.2 mM H2O solutions of two UF heparin samples (UF Heparin 1 and UF Heparin 2), three MMWH samples (MMWH Sample 1, MMWH Sample 2 and MMWH Sample 3) and one MMWH-Red sample (MMWH-Red) were prepared.Ristocetin working solution:- 20 pL of Ristocetin stock (24 mg / mL ristocetin in saline).Sample working solution:-10 pL of 5.2mM sample solution was combined with 163 pL saline to provide a 300 pM working solution of each of the samples.RIPA protocol:360 pL PRP was diluted with Agrastat (5 pg / mL; 1 / 10, antagonist of GPIIIbllla). 20 pLof sample working solution or 20 pL saline (control) was added (giving a final sample concentration of 15 pM). The solution was stirred for 2 seconds and then incubated for 10 minutes at 37 °C without stirring. The solution was then incubated for 1 minute at 37 °C with agitation (baseline tracking). 20 pL of ristocetin working solution was added and the platelet agglutination measured.

[0288] Each experiment was carried out in duplicate. The amplitude, slope and Area under the curve (AUC) calculated by software.Results:

[0289] Both MMWH and MMWH-Red were found to lower the amplitude, slope and area under the curve measured to a greater extent than control (see Figures 7-10). Thus, MMWH-Red was also found to display inhibition in Ristocetin-induced platelet aggregation (RIPA), although less inhibition that MMWH (see Figures 11-12). This indicates that the von Willebrand Factor interaction of the heparin polysaccharide remains intact. Although MMWH-Red was less active in RIPA than MMWH, this differing RIPA activity between MMWH-Red and MMWH allows tunability of treatment.References1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020 20;382(8):727-33.2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet Lond Engl. 2020 15;395(10223):507-13.3. 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High von Willebrand factor levels increase the risk of first ischemic stroke: influence of ADAMTS13, inflammation, and genetic variability. Stroke. 2006 Nov;37(ll):2672-7.64. Bongers TN, Emonts M, de Maat MPM, de Groot R, Lisman T, Hazelzet JA, et al. Reduced ADAMTS13 in children with severe meningococcal sepsis is associated with severity and outcome. Thromb Haemost. 2010 Jun;103(6):1181-7.65. Bhogal P, Jensen M, Collins G, Spooner O, Makalanda L, Hart D, et al. Letter in response to: Coagulation markers are independent predictors of increased oxygen requirements and thrombosis in COVID-19. J Thromb Haemost. 2020;18(12):3382-4.66. Sobel M, McNeill PM, Carlson PL, Kermode JC, Adelman B, Conroy R, et al. Heparin inhibition of von Willebrand factor-dependent platelet function in vitro and in vivo. J Clin Invest. 1991 May;87(5):1787-93.67. Sobel M, Soler DF, Kermode JC, Harris RB. Localization and characterization of a heparin binding domain peptide of human von Willebrand factor. 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Claims

Claims1. A reduced medium molecular weight heparin.

2. A reduced medium molecular weight heparin, wherein the reduced medium molecular weight heparin has an average molecular weight of from greater than about 8000 Da (g / mol) to about 13500 Da (g / mol).

3. A method of synthesis of reduced medium molecular weight heparin (MMWH-Red), the method comprising the steps of: a. Dissolving unfractionated heparin in an aqueous buffer solution adjusted to between about pH 5.0 and about pH 9.0 to provide a first solution; b. Adding an oxidising agent to the first solution to provide a second solution; c. Incubating the second solution at a temperature of from about 0 °C to about 10 °C to form a medium molecular weight heparin solution; and d. incubating the medium molecular weight heparin with a reducing agent to produce reduced medium molecular weight heparin.

4. The method according to claim 3 wherein the reducing agent is a mild reducing agent.

5. The method according to claim 4 wherein the mild reducing agent is sodium borohydride.

6. The method according to any one of claims 3-5 wherein the method does not include an alkaline elimination step.

7. The method according to any one of claims 3-6 wherein the method does not include the addition of an alkali metal salt.

8. The method according to claim 7 wherein the alkali metal salt comprises NaOH, KOH or LiOH.

9. The method according to claim 8 wherein the alkali salt is NaOH, KOH or LiOH.

10. The method according to any one of claims 3-9, wherein the aqueous buffer solution is adjusted to about pH 7.0.

11. The method according to any one of claims 3-10, wherein the aqueous buffer solution is a phosphate buffer.

12. The method according to claim 11, wherein the phosphate buffer is a sodium phosphate buffer.

13. The method according to any one of claims 3-12, wherein the incubating step c. is carried out for from about 1 hour to about 48 hours.

14. The method according to any one of claims 3-13, wherein the incubation temperature is about 4 °C.

15. The method according to any one of claims 3-14, wherein the temperature of the aqueous buffer solution in step a. is about 0 °C.

16. The method according to any one of claims 3-15, wherein the oxidising agent is a periodate, preferably sodium periodate or potassium periodate.

17. The method according to any one of claims 3-16 wherein the method further comprises inactivating the oxidising agent in the medium molecular weight heparin solution.

18. The method according to claim 17, wherein the oxidising agent is inactivated by the addition of an inactivating agent selected from the group consisting of: D-mannitol, glycerol, N- acetylmethionine, sodium sulfite, and combinations thereof.

19. The method according to claim 17 or claim 18, wherein the oxidising agent is inactivated by the addition of D-mannitol.

20. The method according to any one of claims 18 or 19, wherein the molar ratio of the oxidising agent to the inactivating agent is from about 1:1 to about 1:10.

21. The method according to any one of claims 3-20, wherein the method further comprises dialysing the medium molecular weight heparin solution in a dialysate to provide a dialysed medium molecular weight heparin sample.

22. The method according to any one of claims 3-21, wherein in the dialysing step e. the dialysate is water.

23. The method according to any one of claims 3-22, wherein in the dialysing step e. is carried out in 2 kD cut off tubing.

24. The method according to any one of claims 21 to 23, wherein the method further comprises isolating the medium molecular weight heparin from the dialysed heparin sample.

25. The method according to any one of claims 3-23, wherein the medium molecular weight heparin has an average molecular weight of from greater than about 8000 Da (g / mol) to about 13500 Da (g / mol).

26. The method according to any one of claims 3-25, wherein the medium molecular weight heparin has an average molecular weight of about 11000 Da (g / mol).

27. The method according to any one of claims 3-26, wherein the medium molecular weight heparin comprises at least three units of a ldoA2S-GlcNS6S disaccharide.

28. Reduced medium molecular weight heparin (MMWH-Red) for use in the treatment of endotheliopathy in a patient having a plasma von Willebrand factor antigen to ADAMTS13 ratio of at least about 2.

29. MMWH-Red for the use according to claim 28, wherein the MMWH-Red inhibits von Willebrand factor, optionally wherein the MMWH-Red fully inhibits von Willebrand factor-induced platelet aggregation at a concentration of 15 pM when measured by a ristocetin-induced platelet aggregation assay.

30. MMWH-Red for the use according to claim 28, wherein the MMWH-Red inhibits multimers of von Willebrand factor, optionally wherein the von Willebrand factor is ultra-large von Willebrand factor.

31. MMWH-Red forthe use according to any one of claims 28 to 30, wherein MMWH-Red inhibits the binding of platelets to von Willebrand factor.

32. MMWH-Red forthe use according to any one of claims 28 to 31, wherein the MMWH-Red has average molecular weight in the range of greater than about 8000 Da (g / mol) to about 13 000 Da (g / mol), optionally wherein the MMWH-Red an average molecular weight of about 11 000 Da (g / mol).

33. MMWH-Red for the use according to any one of claims 28 to 32, wherein the MMWH-Red comprises at least three units of a ldoA2S-25 GlcNS6S disaccharide.

34. MMWH-Red for the use according to any one of claims 28 to 33, wherein the treatment of endotheliopathy inhibits the haematogenous spread of cancer.

35. MMWH-Red for the use in the treatment of a disease or condition in a patient, wherein the patient has an endotheliopathy characterised by a plasma von Willebrand factor antigen to ADAMTS13 ratio of at least about 2.

36. MMWH-Red for the use according to claim 35 wherein the disease or condition is COVID-19, infection, viral infection, acute respiratory distress syndrome, cancer, bacterial infection, septicaemia, sepsis, cardiovascular disease, diabetes mellitus, trauma, burns, inhalational injury, drugs and drug reactions, haematological conditions, subarachnoid haemorrhage, aneurysmal diseases, stroke, brain parenchymal haemorrhage, radiation induced injury, ischemic stroke, pancreatitis, hepatological conditions, renal diseases, chronic obstruction pulmonary disease, or combinations thereof.

37. MMWH-Red for the use according to claim 36 wherein the endotheliopathy is caused by viral infection, optionally wherein the viral infection is SARS-CoV-2.

38. MMWH-Red for the use according to claim 36 wherein the endotheliopathy is caused by cancer, optionally wherein the cancer is leukaemia, lymphoma, myeloma, or a solid organ cancer.

39. MMWH-Red for the use according to any one of claims 28 to 38, wherein the medium molecular weight heparin is administered by an administration method selected from the groupconsisting of: parenteral, subcutaneous, subcutaneous, depot form, for example depot injection, intravenous, intramuscular, intrathecal, intradermal, intraarterial, intraarticular, cutaneous, transcutaneous, intra-osseus, or inhalation.

40. MMWH-Red for the use according to claim 39, wherein the administration method is subcutaneous.

41. MMWH-Red for the use according to claim 39, wherein the administration method is intravenous.

42. MMWH-Red for the use according to claim 39, wherein the administration method is intramuscular.

43. MMWH-Red for the use according to claim 39, wherein the administration method is inhalation, optionally via a nebuliser.

44. MMWH-Red for the use according to any one of claims 28 to 43, wherein the MMWH-Red is administered at a dose of about 0.01 mg / kgto about 100 mg / kg, preferably about 0.01 mg / kg to about 10 mg / kg.

45. MMWH-Red for the use according to any one of claims 39 to 44, wherein the MMWH-Red is administered as a single dose or a continuous dose.

46. MMWH-Red for the use according to any one of claims 28 to 45 of the preceding claims, wherein the MMWH-Red is comprised in a pharmaceutical formulation.

47. MMWH-Red for the use according to claim 46, wherein the pharmaceutical formulation comprises an excipient.

48. MMWH-Red for the use according to claim 47, wherein the excipient is selected from the group consisting of solvents, co-solvents, buffers, stabilisers, antioxidants, preservatives, chelating agents, emulsifiers, flavourings, lubricants, suspending agents, tonicity adjusting agents, surfactants, solubilising agents, suspending aids, dispersion agents, humectants, thickeners, colouring agent, wetting agent, anti-foaming agent, viscosity modifier, sweeteners and combinations thereof.

49. MMWH-Red for the use according to any one of claims 46 to 48, wherein the pharmaceutical formulation comprises an additional active agent, optionally wherein the additional active agent comprises low molecular weight heparin.

50. MMWH-Red for the use according to any one of claims 28 to 49, wherein the MMWH-Red comprises a chemical modification.

51. MMWH-Red for the use according to claim 50 wherein the chemical modification comprises N-acetylation, N-deacetylation, N-sulfation, O-sulfation, 2-0 desulfation, complete desulfation, or combinations thereof.

52. A method of treating endotheliopathy, the method comprising administering to a patient in need of treatment a therapeutically effective amount of MMWH-Red, wherein the patient has a plasma von Willebrand factor antigen to ADAMTS13 ratio of at least about 2.

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